Chapter 12. Health & Safety
The unique medical risks facing an H-2A farmworker
Benito Serrano always knew there were health risks to going north for farmwork on the H-2A bus. But only in 2022, his eighth year in the program, did he learn the bus ride itself could be deadly.
The thirty-eight-year-old dad had been coming north since his oldest child, now nine years old, was just one. His second child is four. Benito arrived on April 8 after a two-day, two-thousand-mile bus ride from Mexico. He planned to work his usual seven months until November, for an employer not belonging to the North Carolina Growers Association, earning at least $12,000 over that time. If weather was good, he might earn $16,000 this year or more.
Benito arrived at his camp in Sampson County on a Friday. The next day, his back began hurting terribly—never in his life had he felt pain like this. And he was gasping for air. Something was wrong, he told a coworker with access to a camp vehicle. By that night, he was at the hospital where doctors made a diagnosis: He was suffering from pulmonary thrombosis. A blood clot had stopped blood flow to an artery in his lungs. Various conditions can cause a blood clot to form, but the timing of this one made it all but certainly due to sitting still on a bus for more than two days, traveling from his home in Mexico to a farm in North Carolina.
Fortunately, they caught this one before it got any farther. Blood clots afflict up to nine hundred thousand people in the United States each year, killing up to one hundred thousand. Benito would survive. But his journey to the United States this year would turn out to be an emotional and financial disaster.
At the hospital, doctors started Benito on a six-month regimen of drugs: Xarelto and Eliquis. He’d stay in the hospital for two weeks, then in his bed at camp for another two, missing a month of work. With no money for food or medicine, he relied on local health agencies and a non-profit to see him through the ordeal. Once the meds kicked in and the symptoms subsided, he went back to work.
I first learned about Benito indirectly, from someone who knew someone who had helped him. Months later, when I was finally able to track him down, I reached him on WhatsApp and introduced myself. He replied in typical texted Spanish, filled with abbreviations and phonetics and missing punctuation marks:
“Ola mucho gustusto estoy vien grasias a Dios si aki estoy en Carolina del Norte,” he told me. Hello, very nice to meet you. I’m fine, thank God. Yes, I am here in North Carolina.
I was relieved to learn Benito was back on his feet. But I would soon learn that, once he had recovered enough to resume work, Benito’s medical ordeal had evolved into a financial one. First, his wife and two young children had to get by without a month of his usual income. Fortunately, the health agencies had managed to cover the cost of his medicine: $1,600 per month. But there were also two hospital bills. He showed me one from UNC Hospitals for almost $8,000. There was also a second, smaller bill for additional care. A worker at one of the agencies who assisted Benito was helping him to apply for a reduction or elimination of those bills, but by the time Benito got back on the bus in November, between the lost wages and hospital bills, he had not earned one dollar this year. And that wasn’t the worst part.
“¿Cuál fue la parte más difícil de tu experiencia?” I asked him. What was the most difficult part of your experience?
“Es estar solo lejos de mi casa y de mi seres keridos,” he replied. It is being alone, far from my home and loved ones.
Copy that.
“¿Regresarás a los EEUU el año proximo para trabajar?” I asked. Will you return to the United States next year for work?
“Primero Dios y aber ke Pasa,” he wrote back. God willing and let’s see what happens.
And Roger that.
Benito did not have health insurance when his coworker delivered him to the emergency room. For job-related injuries and illness, he is covered by workers’ compensation insurance, which by law his employer is required to carry, but for medical needs outside work, he’s on his own.[1] One might argue, convincingly, that riding almost three days on a bus to perform a job would be considered job-related. It’s not like he was coming see the Grand Canyon. But there you are.
One person familiar with his situation told me Benito had had insurance in the past but gave it up. Paying the monthly premiums seemed to him a waste of money. It’s too bad he hadn’t signed up for health insurance with Juan Allen and Robert Martinez. If he had, his health insurance might have cost him nothing, and he very likely would not have gone home to Mexico with nearly $10,000 of medical debt.
Officially, Juan and Robert are ACA navigators at Access East, a nonprofit health care corporation based in the town of Greenville, smack in the middle of eastern North Carolina. The Affordable Care Act (ACA), known also as Obamacare for President Barack Obama, makes health insurance available to people who otherwise may not be able to afford it—people like H-2A farmworkers.
Robert Martinez, thirty-eight, has spent much of his career as a bilingual medical interpreter. He grew up in New Jersey, which comes as little surprise to anyone noticing his subtle Jersey accent, before moving south when he was twenty-one. He’s been working at Access East since 2020. Juan Allen, fifty-eight, was born in El Salvador. He relocated to North Carolina in 2016 from California, where he had worked for the state’s mental health department for twelve years. When he got here, he knew next to nothing about ACA enrollment. Which forms should he use? How to complete them? What exactly did he tell farmworkers? And so on. Fortunately he found others to help him get up to speed in a hurry.
Beyond the basics, there were any number of logistical hurdles still to resolve. For example, once signed up with insurance, how were farmworkers to pay their monthly premiums? In many cases, these were on the order of seven dollars or nineteen dollars. One idea was to collect a season’s worth of premiums from a worker, then pay it each month on their behalf. Juan soon got resistance to the idea of handling a worker’s money like this—Access East is not a bank, after all. Eventually, Juan and Robert came up with a solution they use today. As with most health insurance, one of the determinants of a monthly premium is the deductible level, that is, how much the insured must spend out of pocket before the insurance company begins paying. The higher the deductible, the lower the premium. With ACA insurance, the premium drops all the way to zero at some deductible levels. Juan and Robert, after learning a farmworker’s income level and other basic facts, simply look up the zero-premium deductible and propose that to the worker. With nothing to lose and everything to gain, the farmworker almost always goes for it. They’ve signed up hundreds of farmworkers for health insurance this way, none of whom need even think about it unless and until they need to.
Juan and Robert do more for farmworkers than sign them up for insurance. They almost have to. One of the things Juan learned early on as an ACA navigator was this: If the first thing you do when meeting a farmworker is to try to sell them insurance, then you will be received as, well, someone trying to sell insurance. He was not getting many takers. So he decided to draw on the wide range of services available through Access East, and the network of other health care providers in the area he was getting to know, and instead ask farmworkers first about their health needs in general. If a worker needed medication, maybe insulin or gabapentin, he would arrange to get their prescription filled, then deliver it to a camp. Eventually, as workers got to know these guys, they were more receptive to hearing about health insurance.
Juan got to know a number of farmworkers and was always glad to help. But progress was slow. In 2017, his second year on the job, he had enrolled only fifty or sixty workers. He knew he would have to work through growers to get to more farmworkers. Knowing that many farmworkers are here by way of the NCGA, Juan asked some of them if they ever went to la asociación for medical needs. No, he was told bluntly, they did not. The workers Juan spoke with felt like the NCGA didn’t care about them.
“They hate us,” Juan paraphrased one worker telling him.
That didn’t sound right to Juan. He knew a woman with a connection to the NCGA, Roberta Bellamy, a medical family therapist and agricultural behavioral health consultant who has worked with the NCGA and the North Carolina Agromedicine Institute. Would she help set up a meeting? She did not hesitate.
Juan will never forget his first meeting with Jay Hill and Lee Wicker at the NCGA. “It was horrible,” he told me, reliving the awkwardness of that first encounter four years earlier. He doesn’t know how it happened, but he somehow gave the wrong impression. Jay and Lee seemed to want nothing to do with him and his ideas for working through the NCGA to access more workers. He recalls references to fears he might bring along union organizers or attorneys to speak with workers.
Juan left Vass discouraged, “like I was some bad guy,” he put it. So much for that idea.
Then, a few months later, the storm came. Hurricane Floyd swept through eastern North Carolina in October 2018, wreaking havoc by ruining crops and flooding labor camps. Along with countless other grower and farmworker service providers in the region, Juan helped as he could, bringing toothbrushes and other donations to camps. He’s still not sure how, but word got back to Jay and Lee at the NCGA that he was helping people at farms, and not just workers but growers too.
“The next time I went to talk with Jay,” he told me with a big smile on the verge of a laugh, “it was a different Jay.”
From then on, according to Juan, Jay began calling him for assistance when a grower reported a worker with a medical issue. Maybe it was a hernia, or high blood pressure, or something else. In one case, Juan told me, a farmworker with acute alcohol dependency suffered the delirium tremens, or extreme ethanol withdrawal, on the bus ride up from Mexico. Exhibiting the wild confusion and panic common to the condition, the new arrival was said to be drinking hand sanitizer for the alcohol content.
Then came the pandemic. During the first season disrupted by Covid, in 2020, Juan and Robert were part of an ad hoc coalition of health care workers from numerous organizations doing all they could to help. Their key contributions that first year involved going to camps, wearing layers of personal protection and full masks on the hottest of days, to swab noses and get them to a lab in Chapel Hill. They rushed to get samples there before closing time at 11:30 p.m.
“Nobody knew back then how long the swabs would last,” Robert told me. So they didn’t want to hold onto them overnight.
In 2021, the second full year of the pandemic, focus shifted toward vaccinations. Soon, Juan and Robert began seeing workers as they arrived in Vass to sign them up for vaccinations. At first, workers received the one-dose Johnson & Johnson vaccine before going to their camp. When concerns arose about the efficacy of this vaccine, they switched to the two-dose Moderna vaccine. This greatly complicated the vaccination process, with only the first shot administered in Vass when workers arrived. For the second, they had to track down each worker at their camp, several weeks later, to coordinate their second shot.
The Covid pandemic turned the world upside-down for everyone on this planet, especially for anyone responsible for the health of anyone else. As elsewhere, in the world of H-2A farmworkers in North Carolina, those first two years were filled with fear, uncertainty, and total confusion. In my research for this book, I would hear the names of so many organizations that helped farmworkers in these dire times that I’m certain I can’t recall them all.[2] Nobody in any of these groups knew quite what to do. Everyone just did their best. And some saw it as more than just a challenge.
Beth Rodman at the state’s Agricultural Safety and Health Bureau saw it as an opportunity to partner through the emergency with numerous other agencies. The urgent collaboration on education, vaccination, and prevention—ASH would deliver nearly a million masks and infection control supplies—did more than get North Carolina’s agricultural community through the outbreak. It prepared them for the next one.
In 2022, with the pandemic impact beginning to recede, health care providers serving H-2A farmworkers in North Carolina could again think about this community’s more traditional health risks. Heat stress is at the top of this list. It can get dangerously hot in the crop fields, and due to climate change, heat extremes are expected only to worsen. It’s more than just the heat that puts our farmworkers at risk. It’s also the common misperception that, being from Mexico, our H-2A workers are accustomed to this heat and are therefore less sensitive than we are to its effects. The truth is that many of our migrating farmworkers live in areas of Mexico with milder climates than ours. Arturo López, for example, told me that the hottest it ever gets where he lives is 30 degrees Celsius, or 86 degrees Fahrenheit. In North Carolina, we often top 90 degrees Fahrenheit in the summer and occasionally top 100.
For workers arriving from the milder regions of Mexico, acclimation is the key. Beth Rodman, in a podcast on farmworker health, notes that most heat-related fatalities—a whopping 75 percent, in fact—occur in the first week that workers are here. Her department gets reports of heat illness every year. Some workers die. Other than needing to keep new arrivals out of extreme heat for a few weeks while their bodies acclimate, preventative measures are mostly common sense: Wear light clothing, drink eight ounces of water four times an hour, organize workers into pairs so workers can keep an eye on each other. And so on.
Exposure to pesticides is another special and obvious risk to the health of farmworkers. Nationally, billions of pounds of it are applied each year to crops that farmworkers must handle. A report by Farmworker Justice, a nonprofit based in Washington, DC, notes that thousands of workers are poisoned each year—more than twenty thousand in 2013. It also spells out remedies as obvious as those for avoiding heat stress: Provide better training, health monitoring, and safety precautions. Provide labels in Spanish. Create buffer zones around schools and residential areas to keep pesticides from drifting there.
A third pervasive health risk is more significant in North Carolina, the nation’s top tobacco producer, than in any other state. Workers know it as the Green Monster, an ailment resulting from the harmful absorption of nicotine through the skin. The colloquialism might sound like something from the TV show Sesame Street, but its other name, green tobacco sickness, is anything but charming. Here’s how medical researchers John May and Thomas Arcury summarize it:
[1] The H-2A program requires that employers provided workers’ compensation insurance. For other farmworkers, the employer is required to do so only if they have more than ten full-time, year-round workers. Hence, many non–H-2A farmworkers have no health insurance, even when they get sick or injured on the job.
[2] I did make a note of these: The North Carolina Agromedicine Institute; the state Department of Health and Human Services and Agricultural Safety and Health Bureau; the North Carolina Farmworker Health Program; the North Carolina Cooperative Extension; county health departments; the North Carolina Farm Bureau; the NCGA; Access East; the Episcopal Farmworker Ministry; the NC Farmworkers’ Project; and NC Field.
Over the course of the season, roughly one-quarter of tobacco workers are likely to experience at least some of the symptoms of green tobacco sickness. These include nausea, vomiting, abdominal pain, diarrhea, dizziness, palpitations, and headache. Most commonly noted are headache, dizziness, vomiting, and nausea occurring in the evening or night following a day of working with tobacco.
Making matters worse, there appears to be a dangerous synergy between green tobacco sickness and heat stress. I once saw a team of tobacco workers exiting a field. Most were covered head to toe in protective clothing, including plastic bags to minimize skin contact with tobacco leaves, which only amplified the heat. They may not have known about the risk of heat illness and how dressing that way made it worse. But clearly, they knew all about the Green Monster.
Arturo knows all about the risk of absorbing extreme levels of nicotine through his skin, especially when leaves are wet. Indeed, it was at the top of his list when I asked him, near the end of the season, what changes he would most like to see to improve working and living conditions for H-2A farmworkers like himself.
“Más que nada mejores condiciones en el trabajo como por ejemplo siempre tener impermeables y botas de hule para cuando hay mucha agua por las mañanas en el tabaco.”
More than anything, better conditions at work such as always having raincoats and rubber boots for when there is a lot of water in the morning on the tobacco. Such rainwear would keep the dew on green tobacco leaves from getting onto their clothing and into their skin.
Second on his list?
“También que permitan usar guantes para evitar enfermedades en la piel por los quimicos.”
Also, that they allow the use of gloves to avoid skin diseases due to chemicals.
Arturo shared with me a photo of his right hand. There is a scarred area, about the size of a half dollar, at the base of his thumb. He referred to it as one of his quemadas del tabaco verde, or green tobacco burns. They started appearing two years ago, he told me. He wants to wear gloves, and has asked about it, but was told the grower does not permit them because it interferes with their ability to remove suckers. These are the shoots that grow out of the stem of a tobacco plant at the base of its giant leaves, removed by hand along with flowers at the top of each plant. Arturo thinks he can top and sucker just as well wearing gloves as he can bare-handed. But his grower doesn’t allow gloves. So that’s that.
Some H-2A farmworkers experience medical issues entirely unrelated to farmwork. Late one afternoon, I got a call from a number I didn’t recognize. I almost never answer these, but this one I did.
“Hello?”
A man began speaking in Spanish. As always, I struggled to follow what he was saying. Still I could tell this wasn’t a junk call. He spoke as if he knew me—maybe I had met him on camp outreach. The man apologized for bothering me but had a question, something about returning to the United States.
“No entiendo todo lo que dijiste,” I finally said to him. I don’t understand everything you said. “¿Puedes mandarme un texto?” I asked. Can you send me a text?
Minutes later, my phone buzzed, telling me I had a new message on WhatsApp. This too was in Spanish but, without the pressure of a real-time conversation, I had no trouble translating.
Javier Suárez was indeed an H-2A farmworker at a camp I had been to—I would never learn which one—but he was not at any camp now. He was back home in Mexico, recuperating from surgery. Like Benito Serrano, he had been working in North Carolina this season when he began experiencing pain, in this case on the right side of his belly, near his waistline. The pain was so intense he could not sit or lie down. A coworker got him to a hospital where they performed an emergency removal of his appendix. It was a complete success, but the doctors told him he should rest for a few weeks. Preferring to do that at home, he got on a bus and went back to Mexico to rest with his family.
Now, he felt better and wanted to come back to finish the season. But he feared he would be stopped at the border, even with his H-2A visa, because the hospital had sent him a $770 bill for the surgery, reduced from $1,400. He appreciated the discount but still did not have the money. Would the border officials demand payment of the hospital bill before letting him through, he wondered?
I had no knowledge or authority to answer his question. Nonetheless, I told him not to worry about it. Naturally, this was a serious matter to Javier, and I treated it that way in delivering my advice. Still, I smiled at the thought of our Department of Homeland Security being so wired into our health care system that they would know an H-2A farmworker owed a few hundred bucks to a hospital for an appendectomy a few weeks earlier. Javier clearly gave more credit to our nation’s information systems than I do.
I checked in with him the following week. He was back at work in North Carolina. Everything at the border went fine.