Before she steps into the shower to wash the day's chicken grease and smell from her body, she prepares her baby's bottle. The bottles and formula are laid out with care on the kitchen table in her single-wide trailer. The mobile home is neat and clean. There are two large sofas and a giant television in the living room. The walls are wood paneled, making the room dark and quiet.
Susana puts her blue work helmet away and pulls off her hair net. She cradles her baby. She is shy and unaccustomed to talking about herself. She does not smile as much as offer a sly little-girl grin, head tilted, brown eyes peering around their corners.
Susana, like many immigrant mothers working in the poultry industry, does not breast feed her baby. She doesn't have the time. "What happens is, because you have to go to work, it's harder to breast feed her and she gets used to it," Susana says, peering through a single black brush stroke of hair covering her face.
Susana and her baby have gotten used to a lot of things because of her job at the poultry plant. She's missed prenatal appointments so she could keep her job. She's missed appointments when she couldn't find a ride to the clinic. She's missed appointments because she doesn't make enough money. She's been confused at the clinic because she can't speak English. And, finally, because she is undocumented, she's worried she won't be able to claim the poultry company's maternity benefits.
Susana and her baby are not alone in facing enormous barriers in the way of good, affordable health care. Recruited and coaxed by poultry plants, Latino immigrant families have flooded Southern rural counties in the past six years. Their increasing numbers and special needs have strained health-care services in rural counties, forcing providers to adapt the way they administer care.
Poultry workers like Susana face many barriers to seeing a doctor, including, for many, their undocumented status. Other obstacles include the cost of care, the lack of transportation and not being able to speak English. Job conditions at poultry plants, such as limited sick leave and a demerit system for unexcused work absences, also conspire to frustrate access to care for workers. As a result, many of North Carolina's Latino immigrants, have, at best, only limited and conditional access to health care.
In the past few years, some new programs have been launched that have the potential to improve the situation (see "Taking the Initiative"). But advocates for Latino immigrants say much remains to be done to ensure that immigrant Spanish-speakers are able to get the health care they need.
Of all the obstacles to health care for both patient and health-care worker, none is more frustrating than not being able to communicate.
"Many other providers haven't stepped up to the plate in offering Spanish-speaking providers," says Dr. Barbara Rowland, medical director of Piedmont Health Services, which operates five community health centers, including one in Chatham County where Susana lives.
The lack of bilingual providers and interpreters forces many families to travel long distances to find health facilities that do provide them. Others rely on their English-speaking children for help--a solution health-care workers say is less than optimal.
"Any situation where a child is an interpreter is risky," says Elia Sustaita, one of six on-call interpreters for Chatham Hospital in Siler City. "They may not understand what's going on or have the vocabulary to explain what the doctor is saying."
The Chatham County Health Department's clinic in Siler City has three Spanish-language interpreters. "A lot of people will either move here or say they live here because we don't charge for interpreters," says Sue Fields, an obstetrics/gynecology nurse practitioner at the clinic.
Many other providers are not so generous. In a survey of 218 health providers in North Carolina--including all the state's health departments, community and migrant health centers, rural health centers, and rural hospitals--43 percent of the 168 providers who responded said they ask clients to bring their own interpreters. The survey was conducted in 1999 by the Raleigh-based North Carolina Center for Public Policy Research for its report, "Hispanic/Latino Health in North Carolina, Failure to Communicate?"
The Office of Civil Rights of the U.S. Department of Health and Human Services requires that any health-care facility receiving federal funds offer free translation services. But despite receiving federal funds, the recent survey found half of North Carolina's 87 health departments ask clients to bring their own interpreters.
Private physicians are also feeling the need to provide interpreters or bilingual staff to ease communication and improve health care. Dr. James Schwankl, a pediatrician in Siler City, says his Spanish-speaking clientele has grown since he added bilingual staff. He currently has two bilingual staff people and one bilingual nurse practitioner.
But while interpreters help, they don't solve all communications problems.
"We miss the cultural context," says Dr. Anuj Sharma, a physician who works at the Chatham County Health Department and Chatham Primary Care, a University of North Carolina health-care clinic in Siler City. There are certain words that can't be easily translated. "I explain things, but I am never sure if they understand what's going on," Sharma says.
Confusion can be a problem for both patient and doctor. "It's hard to establish a relationship with a doctor through an interpreter," says Rowland, of Piedmont Health Services. Interpreters are also costly. "If you have to translate, then that takes time and that reduces the number of people we can serve," she adds.
Rowland believes that bilingual providers are a better solution. Piedmont has five Spanish-speaking doctors at its Moncure Community Health Center in Chatham County. "If you have the bilingual staff, they will come," she says.
And come they have. Latinos, who made up only two percent of Piedmont's clients in 1989, now comprise 42 percent. "Our pregnant women are 75 to 80 percent Latina," Rowland says. "That corresponds to a huge number of visits."
hen it comes to improving access to health care, merely speaking Spanish is not enough. That's because many poultry workers are undocumented and work at local plants under an alias.
Susana's first concern when she found out she was pregnant was how she was going to keep her job. Susana is not Susana at the plant. She works under a different name there--her work name. How was she going to get maternity leave under her work name?
An unknown number of poultry workers are undocumented and find work using aliases and fraudulent documents. The different identities of workers and their fear of being discovered make administering health care difficult. While some health-care providers will accept an alias or look the other way, others will not. This puts up another roadblock for access to care for undocumented poultry workers who must find a hospital or clinic sympathetic to their situation. If they can't, they risk losing their jobs or not receiving benefits like maternity leave.
For pregnant women, the situation is even more fraught because they want their babies to be born with their real family names. Susana lost her first job at a poultry plant in Siler City when her alias was discovered. After six months, she found a new job at another plant in town. She needed a doctor to write her a medical note saying she was pregnant so she could get maternity leave and not lose her job again. The doctor needed to put her work name on the note, despite knowing her real name.
Going to the Chatham County health department was not an option.
"We, as a health department, have decided not to sign papers or fill out forms in another person's name," says Fields, the nurse practitioner. "That applies to insurance papers like short-term disability for being out of work or for maternity leave."
The health department sticks with whatever name patients present during their visit. Administrators will not falsify information if they learn of another name. "If they register under a certain name, that's who they are," says Wayne Sherman, the department's former director. "We felt, under a legal standard, that we would not falsify information."
Health department administrators say some workers have become so desperate that they have offered interpreters at the Siler City clinic $200 bribes just for the note.
Rowland of Piedmont Health Services says that since the poultry companies are responsible for employing undocumented workers, it's not her job to verify the immigration status or identity of her clients at the Moncure health center. "My job is to provide health care," she says.
Still, the widespread use of aliases has had a chilling effect on many providers who want to serve the immigrant population but are wary of the legal issues.
"That's what has a lot of doctors afraid to expand their services to immigrants," says Bill Lail, chairman of the Family Resource Center in Siler City. The center is a nonprofit agency created in 1994 by the health department to provide health and community education programs for immigrants.
In addition to access, the illegal status of many immigrants also affects how health-care providers administer care and the quality of care they give. With so many aliases floating around, providers say tracking patients can be a problem. And continuity of care also can suffer because doctors don't know what other doctors have prescribed for the same patient.
Aliases also affect private physicians like Dr. Schwankl, who says the different names make filing histories difficult. "It's an issue of confusion sometimes and frustration too," he says. But over time, his office has been able to manage the name issue.
Other health care providers have also learned to work around the problem.
"We can combine two charts," says Fields, of the Chatham Health Department. So when workers who are screened at the poultry plant for tuberculosis under their work name come to the health department and use their real name, "we create one chart with two names in them," she says.
nother challenge facing undocumented Latino workers is how to pay for health care. In North Carolina, a federal health-care loophole called "presumptive eligibility" has helped thousands of pregnant undocumented women receive care--if only for a short time, Susana received Medicaid during her first two months of pregnancy. Even though she is undocumented and thus, does not qualify for the program, she was able to get two months of covered care under "presumptive eligibility." The practice allows designated health providers to presume all pregnant women are eligible for two months worth of Medicaid coverage. Presumptive eligibility not only covers the patient, but also reimburses the health provider with Medicaid funds for the costs of administering care.
An analysis of "presumptive eligible" Medicaid recipients in North Carolina shows an explosive growth of Latinas using the program from 1992 to 1998. In 1992, according to the state Department of Health and Human Services, there were 53 Hispanic women on presumptive eligibility compared to 18 white women and nine black women. By 1998, the number of Hispanic women using presumptive eligibility increased to 3,046, the number of white women increased to 417, and the number of black women to 219.
Hispanic women made up 83 percent of all women on presumptive eligibility in 1998. The total number of Hispanic women on full Medicaid in North Carolina has also increased from 2,452 in 1992 to 26,940 in 1998.
The trend is most dramatic in rural North Carolina. Rural counties with poultry plants have seen an increase of Hispanic women on presumptive eligibility from 37 in 1992 to 1,464 in 1998, according to Health and Human Services. Hispanic women in rural poultry counties make up almost half of all Hispanic women on presumptive eligibility in the state. And Hispanic women in rural poultry counties account for 40 percent of all women on presumptive eligibility in North Carolina.
In the past, many county health departments did not offer presumptive eligibility to poor pregnant women because they normally qualified for full Medicaid benefits. But that changed when the state's Latino population began to increase and the number of undocumented pregnant women rose. Counties then began to ask the state to train them in presumptive eligibility.
"When they started seeing large numbers of undocumented folks and they knew those people might not be eligible if they made full application, they said, 'come and do a refresher training because we want to start this presumptive eligibility,'" says Lynda Dixon, former coordinator of the state's Baby Love program, which oversees Medicaid programs.
While it's not the responsibility of health departments or other providers to determine legal resident status when it comes to presumptive eligibility, Dixon says many providers know this population is undocumented and therefore not eligible to receive Medicaid.
A recent analysis of state Medicaid records backs them up. State records show the vast majority of poor Hispanic pregnant women on presumptive eligibility in North Carolina are undocumented. Of the 1,489 low-income Hispanic women identified as receiving presumptive eligibility in fiscal 1999, 1,479 were later identified as undocumented.
Studies show the majority of Hispanic pregnant women in other social service programs are also undocumented. A total of 1,518 Hispanic pregnant women--or 85 percent--were later identified as undocumented in a survey of a variety of public assistance programs including Work First and Medicaid for legal aliens. A closer look at Hispanic women and Medicaid programs in North Carolina reveals that 1,723 Hispanic women, or 96 percent, were either initially or later identified as undocumented in fiscal 1999. T
he impact of North Carolina's burgeoning Latino population has fallen hardest on county health departments and other community health providers that have seen their Medicaid-eligible population fall, while their undocumented or ineligible population has risen. As a result, they must absorb the cost of seeing more patients with no federal reimbursements.
"Health departments are left with the people who have no eligibility for Medicaid, which is the undocumented population, and in some counties, that's all that's left," says Dixon, the former Baby Love program coordinator.
As a result, health departments and community providers have had to be creative with the reimbursements they do receive for undocumented pregnant women. Some health providers bill "presumptively" for Medicaid at different times during a woman's pregnancy to maximize benefits and care.
The Chatham County Health Department, for example, waits until the last two months of pregnancy before billing for Medicaid. "They come in every week the last two months," says nurse practitioner Fields. Typically, if they have no health insurance, poultry workers pay a sliding scale fee at the health department. Administrators say most patients fall between zero and 40 percent on that scale.
Some area community health clinics also bill "presumptively" for pregnant workers. But while the federal loophole may be a way to get undocumented pregnant workers care, it's not helping those clinics meet their expenses.
It's a different situation when the children are born because newborns are automatically placed in the Medicaid program for 13 months--and health clinics can be reimbursed for that care. But babies don't often stay covered that way for long. Many Latino parents do not reapply for Medicaid after the initial 13 months. In 1999, Latinos made up only 11 percent of the Medicaid population in Chatham County, according to the county Social Services Department. The largest group of Medicaid users in the county were whites who made up 44.5 percent of all recipients.
Although many more poultry workers are now receiving health insurance benefits from their employers, an unknown number are unable to take advantage of it because they use an alias.
"Although they have health insurance at work, they're working under a different name," says Cynthia Joyce, nursing supervisor for the Chatham County Health Department. "When we access it and we see a different name, we can't use their insurance."
For the many Latino workers toiling in dangerous, low-wage jobs, lack of access to health-care insurance can have life-changing consequences.
Jorge will never be the same after his accident. While working as a cleaner at a chicken plant in Chatham County, he slipped and fell, spilling four buckets of cleaning chemicals and mixing them into a dangerous gas.
"I didn't feel anything," he says. "I was going to throw water on it when someone said, 'Run!' because it's dangerous gas."
Jorge didn't make it far. He got dizzy and collapsed. He woke in the hospital. The spill forced the evacuation of the entire plant, just as the first shift was starting. In all, 29 people were sent to the hospital.
Jorge, a former poultry worker, is still struggling with the aftermath. "My head hurts a lot, day and night," he says. There is blood in his urine, he can't stand up for more than a few minutes without becoming dizzy, and he has headaches. Jorge has not worked or been paid since the accident. He is two months behind on his rent and friends bring him food to eat.
He has filed for worker's compensation but says he doesn't care about the money: He just wants to get better. Jorge partially blames the company for not properly labeling the contents of the buckets he was working with. He says he didn't know they contained chemicals that are deadly when mixed.
For many Latinos who are injured on the job, the system is stacked against them--especially if they're undocumented.
"Usually when a worker gets injured they try and soft peddle the situation," says Robert Willis, an attorney who handles worker's compensation claims. "They steer you toward the short-term disability program, a non-worker compensation insurance program. Then they'll have you fill out a form that says the injury is not work related. And there goes your case."
Advocates for Latino workers say companies frequently use the state compensation system to keep employees working despite their injuries. So, a person who may be totally disabled with carpal tunnel syndrome is sent to a place like the box room where they can keep working until the statute of limitations for worker's compensation runs out. Then they're told to go back to the cutting line. When they can't work, they're fired.
"Time works against anybody in a poultry plant," Willis says. "If you get a work limitation they're always chipping away at the limitation."
Josephina received a work limitation when she slipped and fell in a chicken plant in Siler City and ruptured a disk in her spine. The doctor told her to work half the day sitting, and half standing. The company agreed to the limitation, but when Josephina sat down, she says a supervisor told her to keep working standing up. Eventually, she was fired for insubordination.
Many poultry processing plants do not pay for days off when their workers are sick. Salvador, a poultry worker in Chatham County, says he went two weeks without pay while doctors performed tests to determine if he had active tuberculosis.
"A lot of Hispanics are afraid to miss work so they don't come to the clinic until it is too late," says Lisa Munoz, a health outreach worker for the Duplin County Health Department. She knows of one little girl who has partial hearing loss because her mother waited to bring her daughter in for treatment of an ear infection.
Even with maternity excuses, many Latinas do not take their full leave. Susana says that the first poultry plant where she worked allowed 12 weeks for maternity leave--a month before delivery and two months afterward. But she went back to work because the company only paid 60 percent of her salary. "I came away with $160 a week," she says. Before that, she was making $365 with overtime.
The same is true of sick leave that some companies provide but which many workers are reluctant to take.
"The women take it upon themselves not to come in because they don't want to take two hours off," Munoz says. "Everything falls back to, 'I don't want to miss work because of the money.'"
hile there are many barriers to health care for Latino immigrants, sometimes just getting to the doctor can be the toughest one.
Juanita knows all about that. Her home is a trailer in Duplin County that she shares with five men who work for a local poultry plant. She cooks and cleans for them and in return, they let her stay in the company-managed trailer.
Juanita came to Duplin County in search of a new life. But she didn't know she was pregnant when she crossed the border. Now, she can't find a job and she has no idea how she will get to the hospital to deliver her baby. She is relying on the good will of her neighbors in the trailer park, which is located far from the nearest hospital in Kenansville.
"My plan is to ask for a ride around here," she says.
Juanita is a small woman. Her dark straight hair is long, falling to her waist. She has small eyes and a wide mouth with gold-capped teeth. She smiles and laughs easily despite her predicament. She says the men will not allow her to stay once the baby comes.
When pressed that it may be difficult to ask for or find a ride when in labor she responds, "Some people around here, they work during the day, and some work at night. And the ones who work at night can give me a ride because it's only a half hour."
Transportation to health-care facilities can be nonexistent for some food-processing workers and their families. Local health-care providers say women and children will often miss appointments or delay going to the doctor because there is no way to get there.
Many immigrant women do not know how to drive, says Lucia Merino, a social worker and former maternity care coordinator in Chatham County. "The women don't want to be a burden on the men," she adds. "They don't drive and the men don't teach them."
Some health-care providers have responded by creating their own transportation services. Moncure Health Center, for example, has a van that will pick clients up in the morning and drop them off in the afternoon.
Postscript: Juanita recently had her baby at the hospital in Kenansville. She was lucky enough to find a ride that day.