JOSEPH CAMPBELL*, a 54-year-old Jamaican man with many years of farm experience through the H-2A visa program, arrives to work for the season. The farm owner notices swelling on Mr. Campbell’s neck and calls our health center. As the primary care nurse practitioner working with the farmworker population at our health center, a collaborating participant in a New England voucher program, I make an urgent visit to the farm with a community health worker (CHW).

Mr. Campbell’s health history includes good general health with borderline hypertension well-controlled on enalapril. Mr. Campbell, a widower, doesn’t smoke or take illicit drugs; he drinks an occasional beer. His teenage and young adult children live in Jamaica.

Mr. Campbell is alert and oriented and tells us that he’s had the neck swelling for about 1 week; he reports no fever, sore throat, hoarseness, dysphagia, or pain. Our physical exam confirms this. We find his neck supple with marked swelling about 4.5 cm in diameter; no other upper body lymphadenopathy exists. Mr. Campbell’s oropharyngeal mucosa is pink and moist; he has no tonsillar enlargement, erythema, or exudate. His lungs are clear, and he has a regular heart rate and rhythm without murmurs.

We quickly refer Mr. Campbell to a surgeon (who agrees to bill us at state Medicaid program rates as required by the farmworker program) for biopsy, which confirms lymphoma. The local oncologist agrees to an urgent referral. She begins treatment while we work to get Mr. Campbell adequate insurance coverage. After learning about the care he’ll receive, the patient opts to remain in Massachusetts for treatment. We begin an application for the state Medicaid program on an emergency basis. We also notify the Jamaican Labour Liaison.

Meanwhile, the CHW schedules Mr. Campbell’s appointments and provides transportation. When the CHW can’t provide transportation, others step in to help, including the program manager at the health center and the wife of another farm owner.

The patient continues working for the first few weeks of treatment, but gradually the chemotherapy takes its toll. He has no energy for work, and no appetite. On several occasions, he’s admitted to the hospital for fever and dangerously low white blood counts. These events postpone his treatments.

For the duration of treatment, the farm owner allows Mr. Campbell to continue living in the accommodations provided for the farmworkers. In addition, knowing that Mr. Campbell’s family depends on his income, the owner continues to pay a small stipend. Mr. Campbell’s fellow workers encourage him to eat by offering what they’ve cooked, and employees of the health center donate books and puzzles to help alleviate boredom. In addition, the CHW collects clothing appropriate for his family back in Jamaica.

In the meantime, the patient qualifies for state Medicaid. Without it, he wouldn’t be able to pay for the chemotherapy or multiple hospitalizations, even with the New England voucher program’s assistance.

Mr. Campbell’s treatment, which lasts 6 months, ends just as the farmworker housing closes for the winter. He returns to Jamaica. He doesn’t return to the United States, but fellow workers from his home parish keep in touch and tell us that he’s well and has achieved full remission.

The voucher program paid for Mr. Campbell’s initial evaluations, the several home visits I made throughout his treatment, and the CHW’s services. Medicaid covered most costs.

Barriers to care for Mr. Campbell included initial lack of insurance coverage, transportation challenges, and unfamiliarity with the U.S. healthcare system. However, he had an established relationship with the health center’s farmworker program and he qualified for health insurance. In addition, he had access to transportation and a “village” to support him—his coworkers, the growers and their families, the CHW, a primary care nurse practitioner, the farmworker program manager at the health center, voucher program staff, local specialists, the hospital, and the Jamaican Labour Liaison.

Who are farmworkers?

The U.S. Department of Agriculture notes that agriculture contributes about $203.5 billion to the economy each year. According to the National Agricultural Workers Survey (NAWS), 56% of farmworkers are U.S. citizens or legal residents. Those who work through the H-2A visa program have taxes and Social Security deductions withheld, but many don’t claim refunds and can’t collect Social Security benefits.

Douglas reported that, during the COVID-19 pandemic, society became more aware of the essential nature of farmworkers; however, they don’t always receive protections. As a result, these workers contracted COVID-19 and died in higher numbers than the general population.

In their review article, Bloss and colleagues examined the literature on U.S. migrant and seasonal farmworker health and found only 1,083 relevant articles, scientific papers, theses, dissertations, and government reports from 1931 through 2020 (about 12 per year). The sources were primarily academic and scientific journals, and some simply provided chemical descriptions of various pesticides. Many were unlikely to have reached the providers who directly care for these individuals.

According to the National Center for Farmworker Health (NCFH), 15% of farmworkers identify as migratory, and 85% are non-migrant agricultural workers. They may work with vegetables, fruits, or nuts; with field crops; or in horticulture and greenhouses. Some work with multiple crop types.

Migratory farmworkers (citizens and noncitizens) who live in the United States year-round tend to follow one of three streams, depending on their home base: Florida, Texas, or southwest including southern California. Some move northward with the growing season of the various crops. Others move from their winter home to a fixed place for the entire growing season (such as in the orchards of Washington State). Labor contractors may provide transportation or workers may travel in caravans, with no guarantees of work, wages, or housing. Some settle into permanent residence along the stream or at their ultimate destination. (See What you should know about farmworkers.)

A subgroup of farmworkers come from various countries under labor contracts through the federal H-2A visa program. They arrive in the United States via a U.S. Department of Labor (DOL) program to perform seasonal agricultural work if their employers can demonstrate no U.S. citizens are available to take those jobs. These workers can’t change employers after they arrive, although some may come under multiple contracts. For example, they might work harvesting vegetables until early fall and then move to a different farm to harvest apples. The DOL sets wages and requires that growers supply a certain standard of housing. (See About the H-2A visa program)

What are their health concerns?

Farmworkers face many of the same health problems that everyone faces, including poor dental health, diabetes, hypertension, weight issues, mental or behavioral health conditions, and musculoskeletal problems. In addition, depending on their home country, some workers may have been exposed to tropical or infectious diseases not typically seen in the United States, experienced chemical exposure, or not received some immunizations.

Farmwork itself holds distinct health risks, including pesticide exposure, long hours with few breaks, heat exposure and related illnesses, lack of water and sanitary bathroom facilities, injury, prolonged exposure to noisy equipment, and overexposure to bright sunlight. In addition, crops themselves can cause illness.

Pesticide exposure can occur through inhalation or skin contact due to drift or residue. According to Goldman and colleagues, acute symptoms include nausea, vomiting, abdominal pain, blurred vision, muscle aches, respiratory distress, headache, dizziness, and confusion. Individuals may even experience loss of consciousness or death.

In the long-term, those exposed to pesticides have an increased risk of some cancers (non-Hodgkin’s lymphoma, brain, breast, gastric, pancreatic, and prostate cancers as well as childhood leukemia). Prolonged exposure can result in thyroid and other metabolic disorders, hormone and DNA disruption, and lowered fertility. Other diseases and conditions associated with pesticide exposure include neurodegenerative diseases like amyotrophic lateral sclerosis, Parkinson’s disease, and Alzheimer’s disease; balance problems; neuropathies; cognitive changes; and increased rates of attention deficit hyperactivity disorder, depression, and anxiety.

Long work hours with few or no breaks can impact a person’s overall well-being. Heat exposure and illness can result in acute kidney injury, chronic kidney disease, heat stroke and even death. According to Goldman and colleagues, farmworkers may limit their water intake if they lack access to water and sanitary bathroom facilities, resulting in dehydration, acute kidney injury, and chronic kidney disease. Symptoms of heat-related illness include flushing, increased sweating (and later, more ominously, cessation of sweating), heat cramps, weakness, fatigue, nausea, vomiting, dizziness, lightheadedness, fainting, dehydration, rhabdomyolysis, cardiac stress, heat syncope, heat exhaustion, heat stroke, convulsions, and even death.

Agriculture is one of the most dangerous occupations in the United States. According to the Bureau of Labor Statistics, farmworkers experienced 17,390 non-fatal injuries in 2018; 2,233 deaths occurred between 2012 and 2021. The use of heavy machinery, including tractors, and working on ladders increase the risk of falls and injuries. Repetitive motion, such as overhead reaching and heavy lifting, contribute to musculoskeletal conditions—sprains, strains, injury, and carpal tunnel syndrome. Prolonged exposure to noisy heavy equipment can cause hearing problems, and extensive time in bright sunlight with lots of dust can impact vision and increase the risk of cataracts.

Certain crops can cause specific illnesses, such as green tobacco illness, a form of nicotine poisoning. This occurs via transdermal absorption of nicotine through skin in contact with damp uncured tobacco plants. Fotedar and Fotedar note that symptoms include nausea, vomiting, headache, dizziness, cramps, pallor, chills, and increased sweating and salivation. These symptoms, in turn, increase the risk of heat-related illness. Even simple activities such as harvesting corn or cucumbers can lead to skin irritation from contact with cornsilk or the tiny hairs on cucumbers, especially for those with sensitivities who aren’t wearing gloves.

What impacts farmworker health?

Additional factors that impact farmworker health include climate change and social determinants of health.

Climate change and heat illness

Climate change continues to increase temperatures throughout the United States, especially in prime growing areas in the South, Southwest, and Southern California. These regions experience hotter summers, more heat waves, and greater humidity (from increased rain). Goldman and colleagues note that elevated heat and humidity increase pesticide volatility, raising associated risks. The combination of heat and the heavy physical labor required in agricultural work puts farmworkers at elevated risk for heat-related illness. This risk increases without adequate shade, rest, and water.

No federal standards regarding heat-related illness currently exist, although the Occupational Safety and Health Administration (OSHA) has proposed regulations to address heat injury and illness for both indoor and outdoor workers. These proposed regulations include free potable water and toilet/handwashing facilities within a quarter mile of an agricultural field. However, as Goldman and colleagues note, enforcement of existing hygiene and hydration standards remains fragmented, and overseer/farm owner pressure can prevent farmworkers from using them. Florida actually prohibits the establishment of heat and labor standards.

The increase in wildfires, some of which have been attributed to climate change, according to the National Oceanic and Atmospheric Administration, also directly affects the health and safety of farmworkers. Wildfires lead to decreased air quality, which increases the risk of respiratory and ocular symptoms; they also can exacerbate existing pulmonary conditions such as asthma and chronic obstructive pulmonary disease. The nature of their work prevents farmworkers from staying indoors in air conditioning during times of poorest air quality.

Social determinants of health

Social determinants of health—including poverty, housing, limited social interactions, discrimination, and lack of care continuity—also contribute to overall health.

Poverty. According to NAWS, 20% of farmworkers live in poverty, with a median family income of $20,000 to $24,999 per year. A position paper from the American Academy of Family Physicians outlines how poverty can lead to more chronic health conditions, substance use disorders, and mental illness, as well as increased exposure to toxic substances such as lead (due to inadequate housing), higher infant mortality, and increased stress. Poverty also can result in poor nutrition due to lack of access to affordable fresh produce and healthy lean meats.

Housing. Krieger and colleagues describe how substandard housing, which many farmworkers encounter, can lead to higher rates of asthma, lead poisoning, and mental health issues, such as depression, anxiety, and stress. Communal housing increases the risk of skin infections (including athlete’s foot, ringworm, and impetigo) and infectious diseases (such as influenza, tuberculosis, and COVID-19). Farmworker housing located far from the nearest town and lack of transportation prevent easy access to sources of nutritious food.

Limited social interaction. The National Farm Worker Ministry reports that because most farmworkers must work a 6-day week, and sometimes work on Sunday, they can’t attend religious services or participate in other social activities. According to Holt-Lunstead, social isolation can increase the risk for cardiovascular disease, type 2 diabetes, and depression. It also can lead to lower general health and well-being, including decreased cognitive function.

Discrimination. Many farmworkers face discrimination due to language, ethnicity, and race, and they may be vulnerable to crime, worker exploitation, and human trafficking. Meng notes that female farmworkers are vulnerable to sexual harassment and assault. Ultimately, discrimination may cause the farmworker to avoid expressing their true health needs or avoid seeking care altogether.

Care disruption. Migration itself disrupts care continuity; a farmworker may run out of prescription refills or need to “start from scratch” to establish themselves with a primary care provider at various locations. The Migrant Clinicians Network (MCN) Health Network serves as a repository of individual health records, which follow a worker throughout migration and back to their home country. Many use this free program (it receives funding from the U.S. government, philanthropic grants, and individual donations) to ensure continuity of care for tuberculosis and diabetes.

What are the barriers to care?

The transient nature of migrant work, lack of transportation, healthcare costs, language and culture, a complicated healthcare system, and literacy all present barriers to adequate healthcare.

Transience

Moving from area to area presents specific challenges related to making and keeping appointments. Even those who have an opportunity to receive care in one location may experience an interruption in treatment when they move to the next work assignment. In addition, because many of the areas where these individuals work have limited public transportation and most workers don’t have their own vehicles, traveling to an appointment can prove especially challenging.

Healthcare costs

According to NAWS, only 48% of migratory farmworkers report having health insurance. Most don’t have paid sick time, and they can’t afford to take time off. They may fear retaliation, deportation or job loss if they leave for an appointment. In conversations I’ve had with migratory farmworkers, I’ve heard, “I’m here to make money,” and “My boss won’t let me take time off.”

Language and culture

According to NAWS, 62% of respondents said that they’re Spanish-speaking, and 1% speak an indigenous language. Language differences can make it especially difficult to navigate the complicated U.S. healthcare system. Past negative experiences have led some farmworkers to distrust healthcare professionals. For example, some medical practices lack interpreters, which impedes communication between patient and provider. In addition, many cultures have different concepts of disease causation, such as “hot/cold” theory, which hinder the understanding of treatment recommendations.

Complicated healthcare systems

The systemic hurdles associated with U.S. healthcare present various challenges. For example, a dental practice might require three visits to extract a tooth—one for X-rays, one for a consultation with the dentist, and one for the extraction—making treatment prohibitive. And because many healthcare settings offer appointments only during working hours, most farmworkers can’t access care.

In their home countries, access to a primary care provider and the ability to schedule routine appointments, as opposed to seeking care through emergency departments or urgent care facilities, may be limited or unavailable to some farmworkers.

Literacy

Rooney and colleagues note that health literacy correlates strongly with patient outcomes. Low health literacy is associated with more hospitalizations, increased use of emergency care, and reduced use of preventive care. If an individual can’t understand health information and discharge instructions, they’re less likely to follow through with recommendations, leading to poorer outcomes. Rooney and colleagues found that mean readability levels in patient forms and health information range from 11.2 to 13.8 grade levels; far above the 6th or lower grade reading level of most farmworkers.

What health services are available?

The federal government funds various health services open to farmworkers, but they aren’t always located near where they work. Federally Qualified Health Centers, for example, must provide care to all patients, regardless of insurance status. They offer a sliding fee scale for those without insurance based on the patient’s or family’s income. Migrant Health Centers specifically serve farmworkers, either through brick-and-mortar sites, mobile clinics, or voucher programs. According to Goldman and colleagues, both types of facilities serve about 20% of the farmworker population, with others receiving care from private offices, emergency departments, or lay healers, while some receive no care at all.

Voucher programs also serve a role. For example, one program contracts with health centers in Massachusetts and Connecticut to provide primary, preventive, dental, and behavioral health care, as well as pharmacy services to migratory and seasonal farmworkers and their families. A strong outreach component identifies and registers farmworkers, helps them apply for health insurance (if eligible), provides translation services, transports patients, and delivers prescriptions. Some of these agencies maintain extended hours to serve the farmworker population, others use mobile vans to provide services, and some have a primary care provider (nurse practitioner, physician assistant, or physician) who brings care to the different farmworker housing locations after work hours. Each agency gears their services to the farmworkers in their catchment area.

Even with the Affordable Care Act, costs may remain out of reach for many farmworkers. Those with work visas are eligible to buy insurance, but they may require help navigating the complicated application process. Undocumented workers are ineligible for federal healthcare programs like Medicaid.

What can nurses do?

Nurses who care for farmworkers have the opportunity to address their unique environmental risks and barriers to care, as well as increase cultural sensitivity and advocate for policy change and regulation enforcement.

Unique risks and barriers

Although no specific practice guidelines exist for farmworker health, the same practice standards and guidelines apply to these patients as to any others. However, nurses should pay special attention to the unique environmental risks faced by farmworkers, including pesticide exposure, musculoskeletal issues, and heat-related illness. History taking should include questions about occupational risks and exposures and danger signs flagged for the provider.

In addition, nurses can work to help these patients overcome barriers to care and address the social determinants of health that impact their overall well-being. They can help ensure the availability of appropriate interpretation services at all patient encounters and make referrals to community social service agencies for food assistance and legal aid. In addition, practices can help patients apply for available insurance or financial assistance, including medication assistance programs.

Cultural sensitivity

Increasing cultural sensitivity can improve the likelihood that patients will adhere to care recommendations. Nurses can expand their cultural sensitivity by participating in applicable continuing education programs and reading about the subject in books such as Fadiman’s The Spirit Catches You and You Fall Down. Care plans should reflect awareness that patients may need assistance in obtaining medications or lack access to affordable fresh produce and a safe space for physical activity. Nurses should provide education and discharge instructions in the patient’s language and at their literacy level.

Advocacy

In addition, nurses can advocate for policy changes and the enforcement of regulations that decrease the risks faced by migrant and seasonal farmworkers as well as the challenges they face in accessing care. At the organizational level, nurses can advocate for appropriate translation and instructional handouts. At the state and national level, they can educate their representatives on the need for improvement and enforcement of safety regulations and better funding for entities (healthcare and community service organizations) serving farmworkers. Nurses also can write letters to the editor of their local papers, recognizing the value of the work that farmworkers do.

Support and quality care

Farmworkers, who serve an essential role in the United States, deserve access to quality healthcare. They face unique health risks and barriers to care that require the support and advocacy of nurses and other healthcare professionals. Adapting assessments to meet those needs, implementing culturally sensitive care, and advocating for policies that ensure safer working conditions serve as just a few examples of the support we can provide.

*Name is fictitious.

Jeanne Allen is a family nurse practitioner retired from Holyoke Health Center in Holyoke, Massachusetts.

American Nurse Journal. 2026; 21(3). Doi: 10.51256/ANJ032606

References

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Keywords: farmworkers, farmworker health, public health