A Clinic in a Cornfield: Emory’s Farmworker Family Health Program
Despite its reputation as the “Peach State,” Georgia offers a wide variety of agricultural goods that get shipped all over the country. From peanuts to pecans, cucumbers to watermelon, and even corn, it is possible that something in your fridge came from one of the 42,000 farms operating across Georgia.1 Migrant farmworkers make up an estimated 73% of agriculture workers in the United States today.2 Since summer is the busiest harvest season, there is often an influx of H2-A workers, or temporary U.S. agricultural employees, to rural areas like Colquitt County, Georgia. Because Georgia summers can reach upwards of 90°F, and many harvest from sunup to sundown, six days a week, life for a farmworker is often difficult—and in many ways, dangerous.
The climate and the long hours put farmworkers at risk for several health issues, including heatstroke, chemical- and pesticide-related illnesses, burns, cancer, musculoskeletal disorders, traumatic injuries and more.3 Unfortunately, access to healthcare, including preventative care and health education, can be challenging for migrant farmworkers since many may struggle with a language barrier and lack transportation to nearby clinics. In addition, taking time off for the farmworkers means losing out on a much-needed paycheck. Since many of these farmworkers are seasonal and live in temporary housing on the farms, these critical issues are exacerbated by isolation. So, establishing a relationship and ensuring continuity of care with a healthcare provider is difficult.4
Recognizing the gap in access to health care paired with the increase in migrant farmworker numbers in the summer, faculty at the Georgia State University (GSU) School of Nursing took action in 1993 and founded the Farmworker Family Health Program (FWFHP). The idea was to create an interprofessional, in-country, cultural immersion service-learning experience for various students including nursing, pharmacy, physical therapy dentistry, and more to provide healthcare services to the farmworkers in Colquitt County and adjacent counties. A win-win situation, where underserved farmworkers gained much-needed access to care while students gained invaluable clinical experience outside of a typical clinical rotation setting. When GSU no longer could support the program Dr. Judith Wold, RN, ANEF, FAAN, Dean Emeritus of the GSU School of Nursing, brought the program to the Emory School of Nursing in 2001, where it continues to thrive today. Although she retired three years ago, Dr. Wold left the program in the capable hands of its current director, Erin Ferranti, Ph.D., MPH, RN, FAAN.
“It is amazing to see how much the program has grown since it started in 1993,” said Erin. “The program started with just six students, and this year we brought one-hundred-nine, which is smaller than normal because of the precautions we took due to COVID-19. It keeps getting bigger and bigger, but it remains as it began, interdisciplinary, collaborative and nurse-driven."
Since its inception, every June there is a mix of selected nursing, dental hygiene, physical therapy and pharmacy students who apply for the opportunity to make the trek to Colquitt County, GA. There, they spend two weeks providing healthcare and health education to the farmworkers in the counties surrounding the small town of Moultrie. This year, psychology students joined the mix to provide mental health care services.
“We're seeing more mental health issues amongst the whole population, but especially in the migrant farmworker population who are very isolated from the community to start. Many of them live on farms, and they don’t own cars so they can’t venture into town often. Throw in a pandemic, which isolates them further, and we decided to include psychology students to expand our scope of care for them,” said Erin.
In a traditional, non-COVID year, a total of about 150 students and faculty take part in the program. During the day, they focus on providing primary care for approximately 200 young children of the farmworkers, who participate in a summer program at a nearby day school. At night, the program caravans the students to one of many large farms in the surrounding areas and set up tent clinics near the housing for farmworkers. Over the course of the two weeks, the students provide care for an average of 100 adults per night.
“It is a priority that we offer comprehensive primary care, dental checks, and education where the population can easily access it,” said Laura Layne, MSN, MPH, RN, co-director of the FWFHP. “Not only does that mean geographically, but timewise as well. It is important to them to work as much as possible, so we offer our care during a time that it is most convenient for them.”
Laura first participated in the FWFHP program as a BSN student in 2004 alongside Dr. Wold, whom she credits as a mentor who strongly supported her passion for public health. Now, coming full-circle, Laura provides care alongside her nursing students, who get firsthand experience of life for a migrant farmworker in a non-traditional care setting, which they then carry with them into their careers.
“Many students will talk about how this experience has opened their eyes,” said Laura. “It is a life-altering experience that can influence the way they care for patients in the future in whatever area of nursing they pursue.” As a Spanish speaker herself, Laura said she felt privileged to converse with the farmworkers and hear their experiences firsthand. “They share stories of their sacrifice, and it is always humbling to hear how passionate they are to work in the U.S. so they can have better opportunities back in their home country.”
Daniel Smith, Ph.D., RN, CNE, is a faculty member and a nurse practitioner student at Emory University who also participates in the FWFHP. For Daniel, who grew up on a farm, traveling and speaking with the farmers face-to-face brought a deeper appreciation of many aspects--not just of where his food comes from but also of the challenging lives of the farmworkers and the struggle to receive or prioritize basic health needs in the hot fields.
“If you're working in the heat and sweating as much of these workers do, you need thirty-two ounces of water per hour,” said Daniel. “Two years or so ago, someone had passed away in the fields from heatstroke, and so they brought me in so we could perform a study about what migrant farmworkers knew about heatstroke and heat-related illness. In our research, we found out they’re only drinking around seventy-three ounces a day. While most of them had an idea about identifying heatstroke, they weren’t necessarily as aware of how to cool someone down. Now we work to teach them that if someone starts having a heat stroke in the field, how they can identify it and what to do in the interim until emergency medical services arrive.”
Among the barriers the FWFHP program aims to address, health literacy is central—regarding both preventative healthcare and recognizing when to seek medical attention for acute issues. For example, two summers ago, a gentleman who came for a check-up did not realize he had diabetes. With his measured blood sugar level of 500 mg/dL, far higher than the average 90 to 110 mg/dL, the FWFHP staff ensured he got emergency care.
“To them, being on these farms is very much a business deal, so they don’t always tend to their own healthcare needs,” said Erin. “They are here to make money and send it back home to their families—that is their priority. So, we operate in Moultrie with two main missions. We want to extend primary health care to these workers and provide education to prevent health issues from escalating.”
For many nurses, this is usually their first time seeing the invaluable presence of nurses outside a clinical setting. Nurses who are running the day-to-day, having a hand in everything from setting up clinics in cornfields, to hearing their patients’ stories, all the way to diagnosing and treating them.
“You only have one component when you're at the bedside, and in an acute care setting, you're solving for one immediate issue at a time,” said Erin. “Overall, as public health nurses, we do a much more comprehensive assessment just by being where the workers are. We assess their living conditions. We see what kind of food they're eating and have access to. We see where they live, work and play. We get to know who they are. By association, our students get to live and breathe the social determinants of health when they're participating in this program, and I think that is what's so valuable and why it's such an amazing learning experience for them.”
The Social Determinants of Health (SDOH) are a focal point that the FWFHP considers while caring for patients during its two weeks in Moultrie. For many students partaking in the program, SDOH is not a new concept, but by partaking in the program they are gaining unique insights into exactly how environmental conditions affect health, and they’re gaining a better understanding of why certain populations are struggling to maintain a healthy lifestyle.
“We're seeing living and working conditions that you would not be able to see otherwise, which really does impact their health. When we’re down there, we learn so much from them about the impact environment has on health and we can take those learnings into our future practices, wherever they may be,” Daniel said.
With a long-standing relationship between Emory University, the Georgia Department of Public Health and Ellenton Farmworker Health Clinic, the county’s existing, nurse practitioner led farmworker healthcare facility, the FWFHP has continued to expand both the services offered and its connection with community members.
“I think with a lot of service-learning trips, people come and go there one or two weeks, and then leave. However, this program has a very strong community partnership through the Georgia Department of Public Health, Southwest District 8-2. Part of that whole process is we can capitalize on our community connections because we've been partnering with this clinic since the program formed 28 years ago. We're no longer worrying about if we go in and find something that needs immediate attention,” said Daniel.
“When we pack up and go home, the Ellenton Farmworker Health Clinic outreach workers are the ones who make sure patients have transportation, to the emergency room and back to the farm and for follow-up visits,” Erin added. “Ellenton is the heart and soul of that community. We are there to enhance that and provide support during our two weeks there, and we are so proud to be able to serve such an underserved—and deserving—population.”
For nearly three decades, the FWFHP has adapted and evolved to meet the needs of the migrant farmworker population in Georgia, including bringing along a broad scope of allied health professionals to tackle areas like mental health and dental hygiene. But the desire to innovate and evolve is central throughout, especially if it means improving the lives of underserved populations. For example, Laura noted that she hopes the model can be expanded upon and tailored for other at-risk populations, while Daniel wishes to upscale the point of care testing for the group. Overall, nurse-led, clinical service-learning programs, like the Emory FWFHP, remain prime examples of how nurses are the leaders that break down healthcare barriers and address health inequities for all underserved and marginalized populations.
For more examples of nurse innovators and leaders answering the call for crucial healthcare leadership, especially amid a pandemic environment, check out our newly published research that aims to define a progressive path forward for nursing: Accelerating Nursing, Transforming Healthcare.
To learn more about the Emory University FWFHP click here.