Social Determinants of Health – Contemporary Concerns in Medicine

Social Determinants of Health for Migrant Farm Workers

Migrant Workers picking strawberries Source: Unsplash¹

The healthcare system in the United States boasts some of the most cutting-edge technology and research, but this high quality of care is not evenly distributed. For minorities, such as Latinos living in rural areas, their health is controlled by social, economic, and political determinants. We have studied these social determinants of health in class, and learned that determinants are:

“The conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks.”
Healthy People 2030²

While I agree that the facts and statistics about the number of people affected are important to know, I would like to share a couple of stories that show the people hidden between all those numbers. I was reminded of them after having read the Nature article by Amy Maxmen which discussed how farm worker disparities are due to their social determinants of health.³

Working at a berry farm for three years was a wonderful opportunity because I got to learn about agriculture and work alongside 200+ workers from Mexico in order to harvest over 400 acres of strawberries, blueberries, blackberries, peaches, and muscadines. The work was not for the faint of heart because it required seven days work weeks in blistering humid Arkansas heat and resulted in millions of pounds of produce each season. This became even more challenging when the company limited workers’ contact with the outside world in an attempt to reduce the chances of the Corona virus running rampant in the small rooms that housed anywhere from six to fifteen people. It was amidst all the craziness that comes with harvesting crops, that I got to know some of the workers such as Rosita and Jose and realized just how many adversities they must overcome in order to receive medical care.

Overview look of lake and blackberry field Source: Lucero Chena⁴

Rosita, The Spokeswoman

If you ever need someone to control a group of over 200 rowdy adults with one word, Rosita is the one you call. She was the unofficial spokeswoman for all the workers and was the first to voice everyone’s concerns about the COVID vaccine when it was offered at the farm. All they were told was that if any worker wished they to receive the vaccine they could do so for free. This news though exciting for some was also troublesome for others because they wanted some more information before making a decision. A week before the vaccine was to be administered, I was tasked with asking everyone whether or not they wished to receive the vaccine but was warned by my supervisor to not offer my opinion or answer questions because I was not a medical professional and could be held liable if something were to happen. Rosita was the first to bombard me with questions, but at that time, all I was able to share was that physicians are required to inform a patient of any possible side effects and must sign an informed consent form.⁵ The only problem with that is that the doctor had sent said forms, but they were in English. It took a lot of research and persuasion before the company agreed to prepare a meeting in which a doctor would address the workers’ concerns and hand out a Spanish version of the possible side effects.

Rosita’s story is just one of millions that highlight how language, education access, and socioeconomic status play a role in a person’s health. There are many Non-English speaking migrants that are not comfortable going to the doctor out of fear that the appointment or medication may be too expensive or based on previous frustrations from trying to communicate with the doctor. Many Latinos who do not speak English are less likely to receive medical care⁶ or are less informed of the medical situation due to the language barrier.⁷

Lake scene from farm where I worked Source: Lucero Chena⁸

Jose, The Veteran

By my second year, I had become the farm medic and would treat any minor injuries or acquire medication during the first year when the farm was on lockdown. I would often help the workers before or after their shift, so it wasn’t surprising that Don Jose, a man who has been working at the farm for over twenty years, was there to greet me at six thirty in the morning as I opened up the store for the day. Cuts, scrapes, and bruises are common occurrences at a farm, but when Jose began to limp into the store to ask for pain medication, I knew that the situation was more serious than he was letting on. It took a lot of convincing and promises that he would not have to miss work before he finally explained that he had hit his leg had hit a nail on the edge of a trailer when he was loading boxes of fruit, and when he finally showed me his shin, I informed my manager of the situation. During his lunch break, he was taken to a clinic an hour away where the doctor informed the other farm interpreter that the wound on his shin had become infected and would need to be cleaned daily for two weeks before asking he schedule a follow up appointment. He was told to rest his leg for three days and keep it elevated to reduce the swelling, but Jose went back to work the next day after I disinfected his wound. He continued to work with his injured leg until the end of that harvesting season where he returned to Mexico to treat his wound.

Aside from the vulnerability due to language barriers and lack of access to education, farm workers also face physical, political, and economical barriers that prevent them from seeking adequate care. Many might wonder why Jose didn’t just inform someone of his injury immediately after it occurred. The reason for that is out of fear that his injury would put him out of work and cost him a lot of money to get it looked at. In the agriculture business, migrant workers are supposed to be paid a flat hourly rate and a piece rate pay, but there are many owners who violate these wage laws or decide to return the worker to their country if they are not picking quick enough.⁹ Farm owners are also not required to provide healthcare insurance for their workers because they are seasonal employees. All of these circumstances drive many workers like Jose to work through injuries instead of seeking medical care.¹⁰

Conclusion

Although I focused on the social determinants of health of two people and how their categories affected their healthcare outcomes, these determinants apply to everyone’s life. Research continues to show us the relation between the social determinants and the disparities in healthcare for minority groups such as Latinos. These disparities were especially brought under scrutiny during the COVID pandemic, but now having acknowledged that they exist, it is time to start work to eliminate these disparities and make healthcare more accessible for everyone. I know that when those changes do come, they will be because of people like Rosita and Jose, not because of some statistics we read somewhere.

Works Cited

¹Mossholder, Tim. “Strawberry Picking.” Unsplash, 21 July 2021, https://unsplash.com/photos/Kx060cRsmt0.

²“Healthy People 2030,” U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion, https://health.gov/healthypeople/objectives-and-data/social-determinants-health

³Maxmen, Amy. “Inequality’s Deadly Toll.” Nature News, Nature Publishing Group, 28 Apr. 2021, https://www.nature.com/immersive/d41586-021-00943-x/index.html

⁴ Chena, Lucero. “Lake and Blackberry Field View.” 6 June 2020.

⁵ Commissioner. “Pfizer-BioNTech Covid-19 Vaccines.” U.S. Food and Drug Administration, FDA, https://www.fda.gov/emergency-preparedness-and-response/coronavirus-disease-2019-covid-19/pfizer-biontech-covid-19-vaccines.

⁶Taira, D A. “Improving the Health and Health Care of Non-English-Speaking Patients.” Journal of General Internal Medicine, U.S. National Library of Medicine, May 1999, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1496581/#:~:text=Non%2DEnglish%2Dspeaking%20patients%20receive,care%20than%20English%2Dspeaking%20patients.

⁷Al Shamsi, Hilal, et al. “Implications of Language Barriers for Healthcare: A Systematic Review.” Oman Medical Journal, U.S. National Library of Medicine, 30 Apr. 2020, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7201401/#:~:text=Other%20studies%20found%20that%20among,a%20problem%20understanding%20their%20healthcare.

⁸ Chena, Lucero. “Gazebo Over Lake.” 6 June 2020.

⁹ Robinson, Erin, et al. “Wages, Wage Violations, and Pesticide Safety Experienced by Migrant Farmworkers in North Carolina.” New Solutions: a Journal of Environmental and Occupational Health Policy : NS, U.S. National Library of Medicine, 2011, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3291018/.

¹⁰Bail, Kari M., et al. “The Impact of Invisibility on the Health of Migrant Farmworkers in the Southeastern United States: A Case Study from Georgia.” Nursing Research and Practice, Hindawi, 1 July 2012, https://www.hindawi.com/journals/nrp/2012/760418/.

St. Matthew, Adam Smith, and Immanuel Kant: an Unempathetic and an Empathetic Justification for Expanding Rural Healthcare Access

Michael Murakami

As an accountant and economist by trade, the theological story I am most naturally drawn to is when Jesus calls upon Matthew the tax collector (soon to be St. Matthew, Patron Saint of Accountants) to join him in ministry. Jesus’ quote in Matthew 9:12, “It is not the healthy who need a doctor, but the sick”¹ was always memorable; knowing that sinners (the sick) could be drawn into and saved in the church by Jesus (the doctor) comforted me. Yet in modern society, this initially metaphorical line now applies in a very literal sense: many regions of the United States, like rural communities, are populated with “sick” people who are unable to receive treatment for a variety of reasons, such as time, cost, and access.

Background on Rural Communities

Social determinants of health (SDoH) impact rural communities by decreasing the healthcare access and utilization of residents. Some of the most common SDoH in rural areas relate to lower levels of income, education, health-related infrastructure, and health literacy as well as other determinants such as race, ethnicity, sexual orientation, and environmental impacts.³

To exemplify the impact of a SDoH, Elisabeth Rosenthal describes in her piece, Paying till It Hurts: The $2.7 Trillion Medical Bill,⁴ how patients with lower incomes suffer because of rising costs and doctor-patient information asymmetry. The example she uses is colonoscopies, where it is shown that pricing is not equal nor well understood, even by doctors. However, even worse, because of the specialized knowledge of the medical field, patients typically do not understand what procedures or checkups most efficiently diagnose or aid their issues and are cornered into what doctors prescribe. The fundamental problem that results is that the motivations of doctors can be fueled by popular, but misguided medical beliefs (in this case, that colonoscopies are the best method for the early detection of GI issues) or lobbying of medical firms (more often seen in pharmaceuticals). In either case, low-income and low-access patients are most impacted by ineffective and unnecessary testing because they are least able to afford or access further care.

Beyond lower financial access and utilization of medical care, geography plays a critical role in physically limiting the access of rural patients from doctors. According to a study comparing rural and urban specialty healthcare access by Melissa Cyr et. al., both urban and rural areas struggle with the availability and accommodation of healthcare, although rural areas are considerably worse off (a problem compounded by additional limiting factors) as seen in the infographic below.⁵ Here, Cyr et. al. shows the existence of a variety of significant barriers to healthcare access in rural areas.

A frequency chart of mentions of the hindrances of healthcare access from *Access to specialty healthcare in urban versus rural US populations: a systematic literature review*, Melissa Cyr et. al.⁵

This dramatic difference in access and utilization tangibly impacts the quality of life and longevity for rural and poorer communities. In his piece, Inequality and the Health-Care System in the USA, Samuel Dickman explores the lower quality of life and shorter life expectancies for low-income patients. He explains that chronic and acute conditions alike have higher prevalence with declining income (which is correlatable strongly to rural communities) as well as considerably lower life expectancy.⁶ These results exemplify how the negative outcomes associated with SDoH decrease the quality of an already shortened life.

The Role of Rural Communities in the United States

With an understanding of the existence of disparities and deficiencies in healthcare from the above pieces, one may ask why only a small segment of society pushes for changes to the status quo. A common response draws upon economics in a resource-constrained game; proponents believe that the tradeoff of additional healthcare being invested in densely populated areas will help more people than in rural areas. This utilitarian stance, although logical on the surface, lacks consideration for the whole picture when further analyzed. To understand an unempathetic, economic argument in support of expanding rural healthcare, one must understand the role of rural, especially farming, communities in the United States. In rural America, approximately one out of ten workers are in industries such as agriculture, fishing, and hunting which, although decreasing over time, comprises a large portion of the community and nationwide production.⁷

Open market and even Keynesian economists may argue that we should help rural communities in order to directly strengthen our food source, therefore bettering society. This stance stems from a belief that farming communities (and other rural industries, however, farming is a clear example) will become more productive with increased average levels of health and health outcomes. Adam Smith points to this idea in The Wealth of Nations, the foundational text in support of capitalism and market economies. He describes how “no society can surely be flourishing and happy, of which the far greater part of the members are poor and miserable.”⁸ Even in a true capitalist market economy (which the United States is not), Smith argues that those rich in money and/or other goods will only live in a flourishing society by ensuring a respectable minimum living threshold for its members. In this case, the reward of a “flourishing” society results from the positive externalities associated with more efficient, healthier farmers who create more food for everyone. Uplifting rural farming communities’ healthcare resources and overcoming existing SDoH from this economic perspective is not an emotion-based decision but rather a net-positive sum game and an economically sensible choice.

Yet, this economic argument does not feel satisfying, even to an economist like myself. Instead of uplifting communities for their intrinsic value, this action derives its motivation from how it benefits me and my community. Rather, it may be beneficial to consider shifting the argument away from the expected net societal value of healthcare expansion and towards viewing farmers as intrinsically valuable and deserving of better health outcomes. For this view, we turn to Immanuel Kant, who describes how we must:

“Act in such a way that you treat humanity, whether in your own person or in the person of any other, never merely as a means to an end, but always at the same time as an end.”
Immanuel Kant, The Metaphysics of Morals⁹

Rethinking Rural Healthcare

Therefore, more than a means to efficient food production, one ought to look at the problem of rural healthcare from the lens of helping the communities in and of themselves. This empathetic call for improved rural medical access stems from the societal obligation to help create access to foundational resources to highlight the inherent and divine dignity of every person. The conversation thus returns to the ministry that Jesus called Matthew the tax collector to join.

Theologically, the societal obligation to assist others for their intrinsic value appears prior to the Gospel of Matthew in the Old Testament, for Proverbs 31: 8-9 declares that we must “Speak up for those who cannot speak for themselves, for the rights of all who are destitute. Speak up and judge fairly; defend the rights of the poor and needy.”¹⁰ It is not just for privileged communities to look down upon lower average health outcomes in rural communities. Much the opposite. We as members of a privileged section of society are each called upon in the fight to assist rural areas by creating new opportunities for financially and geographically feasible healthcare access.

From all of these ideas, we find the final conclusion. It does not matter whether rural communities are viewed as a means to resources for the rest of society or end in themselves, for healthcare is not and has never been a net-zero sum game. Rather, all perspectives understand the positive-sum nature of increased healthcare and better medical outcomes for rural communities. What implementing this solution looks like in real life is not in my wheelhouse, I am just an economist after all. But in this fight, all members of society should and ought to support actions that help rural communities overcome the SDoH that plague the status quo.

Works Cited

1) “Bible Gateway Passage: Matthew 9 – New International Version.” Bible Gateway, www.biblegateway.com/passage/?search=Matthew+9&version=NIV.

2) “The Calling of Saint Matthew.” Artble, Artble, 19 July 2017, www.artble.com/artists/caravaggio/paintings/the_calling_of_saint_matthew.

3) “Rural Health Information Hub.” Social Determinants of Health for Rural People Overview, www.ruralhealthinfo.org/topics/social-determinants-of-health.

4) Rosenthal, Elisabeth. “The $2.7 Trillion Medical Bill.” The New York Times, The New York Times, 1 June 2013, www.nytimes.com/2013/06/02/health/colonoscopies-explain-why-us-leads-the-world-in-health-expenditures.html.

5) Cyr, Melissa E., et al. “Access to Specialty Healthcare in Urban versus Rural US Populations: A Systematic Literature Review.” BMC Health Services Research, vol. 19, no. 1, 2019, doi:10.1186/s12913-019-4815-5.

6) Dickman, Samuel L, et al. “Inequality and the Health-Care System in the USA.” The Lancet, vol. 389, no. 10077, 2017, pp. 1431–1441., doi:10.1016/s0140-6736(17)30398-7.

7) Staff, America Counts. “More Work in Education and Health Care.” Census.gov, 15 Sept. 2022, www.census.gov/library/stories/2017/08/rural-economy-not-completely-dependent-on-farming.html.

8) Smith, Adam. The Wealth of Nations. Seven Treasures Publications, 2009.

9) Kant, Immanuel. The Metaphysics of Morals. Bobbs-Merrill Education, 1965.

10) “Bible Gateway Passage: Proverbs 31:8-9 – New International Version.” Bible Gateway, www.biblegateway.com/passage/?search=Proverbs+31%3A8-9&version=NIV.