We'll go ahead and get started because we have four speakers and just one hour, the sessions this year only an hour versus 90 minutes. So we're going to get started so that hopefully we have some time for questions at the end. But I think you'll really enjoy this. Let's make sure you're in the right place at section 204. So Changing Occupational and Environmental Challenges for Underserved Workers. And we had a great meeting last night that kind of better defining what that encompasses and next year we may have a new name even, so stay tuned. All right, so we're going to get started then right away and begin first of four presentations. I think you'll think you'll really enjoy it. It's a nice variety and some old friends and some new friends, not chronologically. And again, like we've done in the past, we dedicate our session to Workers Memorial Day. Sometimes that overlaps with the conference. That's on April 28th, as you all know, but that's coming and that's our dedication. Thank you very much and I'll step out of the way. Good morning. It's nice to be here in person. My name is Amy Liebman. I'm the Chief Program Officer at Migrant Clinicians Network and I oversee our programs dealing with worker health and safety, environmental justice and climate justice. And Alexis and I are going to do a joint presentation today and we're going to talk a little bit about farm workers and occupational health. We have nothing to disclose. We always wish we did, but we don't. All right. I'm going to start off with just a case study. I apologize if you guys have heard this before, but I think we have mostly new faces in here, but it's going to illustrate, I think, a lot of the aspects of farm worker health that we want to talk about today. So I'm going to start off with an injured paper mill worker in the state of Maine. He one day severed a flexor tendon on one finger. He was taken to the emergency department right away. He was seen. He had surgery. He was going to be out of work for a while, so he had workers cover the surgery and pay for the time away for his work. When he came back, some accommodations were made so he didn't have to do his regular duties. And then after three months, this paper mill worker was working. I'm not sure if I mentioned, but this worker also belonged to a union. In the same state of Maine, we have a broccoli worker. And so when you're cutting and picking broccoli, it's usually a colder time of the year. So it was very cold, and this worker was working so quickly, they actually, his hands were cold and he cut the tip of his finger off. He was dropped off at the emergency department and specifically told to make sure that he did not mention that this occurred at work. This worker did not have any insurance. He was given, they fixed the wound, he was given three days of pain meds. He wasn't able to work because he needed his fingers functioning to cut the broccoli. And we don't know what happened to this worker, but we know that he did not return to his work. So just keep this particular case in mind as we talk about the health of, and occupational health of farm workers. Just a little bit about where I'm coming from. I'm from the Migrant Clinicians Network, and our mission is to create practical solutions at the intersection of vulnerability, migration, and health. We've been around since 1984, and we are now all over the U.S., we're a national organization. I think we're the oldest clinical organization, and I'll use the word for underserved populations, but definitely for farm workers. So we're really proud of the work that we've done almost over four decades. Our work is multifaceted, it involves a lot of resource development, education for clinicians, community health workers, workers. We get involved in research projects to make sure that we're getting the best practices out on the front lines. We have a program that helps people that are migrating have a continuity of care for their medical home. We have a very significant focus on worker health and safety, that's my division, but we've trained thousands of workers via train-the-trainer model with community health workers. We also have a program called Witness to Witness, which is psychosocial support for health care providers that's been very important during COVID. And we're also involved with advocacy and making sure that our clinicians have a home and that they're able to network with their peers. That brief explanation of MCN, check out our website, but I'm going to hand it over to Alexis, who's going to take us through some policies. Thank you so much, and good morning, everyone. It's great to be here. My name is Alexis Gild, I am the Vice President of Strategy and Programs at Farmworker Justice. We are a national advocacy organization, we are based in Washington, D.C. And our mission is to seek to empower farm workers and their families to improve their living and working conditions, immigration status, occupational safety and health, and access to justice. And we are multifaceted, just like American Clinicians Network, and we work very closely with MCN. We engage in administrative and legislative advocacy, litigation, technical assistance, coalition building, and public education, and we have been around since 1981. So I wanted to kind of lay the groundwork for those of you who may not be as familiar with farm workers. So there are approximately 2.4 million farm workers in the United States, around 4 million with their families. Now all the data that you will see from here on out, in this particular slide, is from the Department of Labor, and the Department of Labor does a survey biennially, and it's the best data we have on farm workers, but it does have its limitations. Farm workers are extremely hard to capture in terms of data. So everything I say is approximately likely underreported. So around 70% are foreign born, around 62% report Spanish as a primary language. There are a growing number of workers coming from indigenous communities in Mexico and Guatemala, and these workers speak indigenous languages such as Sreki, Mam, K'iche, Mixteco, and Spanish is actually their second language. So they may be not only limited English proficient, but limited Spanish proficient. Approximately half, 40%, 50%, some estimates are higher, are without work authorization. 20% live below the federal poverty level. But less than half have health insurance, and there is a growing number of workers coming on a program called the H-2A program, which is a temporary non-immigrant visa program for agricultural workers. You may have heard about this program. It is expanding rapidly. There is no cap on the number of workers. Employers bring the workers in. The workers are tied to the employer, which is very important because they lack agency in their workplace and in their living conditions. And this program continues to grow. It has more than doubled since 2016. So let's talk about the vulnerabilities of farm workers. There are multiple, as you can imagine. So real quickly, of course, there are the cultural and language differences, recognizing that many come from outside the U.S. or are foreign born. It's a low-wage job, which, of course, impacts their housing conditions, their ability to access food, their ability to access transportation, immigration status, particularly undocumented and H-2A workers, and then, of course, the migratory lifestyle, which means that continuity of care can be very challenging. But what I really want to focus on are the occupational risks. And farm work is an extremely hazardous job. It's a highly skilled job. And amongst the multiple risks that farm workers face in the field, there is heat, wildfire, extreme climate, pesticides, and then, of course, other musculoskeletal injuries and other injuries, falls from ladders, that farm workers face every day. There is a lack of regulatory protection for farm workers. And this dates back to when the Fair Labor Standards Act was first being implemented. They carved out farm workers, largely due to a compromise with southern senators. So just to be clear, this is rooted in racism, because at the time, many farm workers were black Americans. And so the exception for agriculture in the Fair Labor Standards Act is based and rooted in discrimination and racism and continues to be so to this day. Farm workers are not able to do collective bargaining. They don't have the right to collective bargaining. Child labor protections, you can be as young as 12 and work in the fields. There are no overtime protections federally for farm workers. And although there is some minimum wage protections in an amendment to the Fair Labor Standards Act, there is no requirement for small employers. And you'll see when we talk about OSHA standards that small employers are exempt. So workers' compensation varies from state to state. There is no national minimum for workers' compensation. OSHA, really, there are very few OSHA standards in the fields. The one prominent one is the field sanitation standard. This was promulgated in 1987. It essentially says that workers in the fields need to have access to handwashing stations, to toilets, and other sanitation supplies. It only applies to farms with fewer than 11 workers. And even though we may think that many farms are big farms, you know, many workers do work for quote-unquote small employers because they are employed by farm labor contractors who work with larger growers. And so even though it may not seem like many workers fall under this exemption, many workers actually do. And for all the other types of standards that farm workers are under, and there aren't that many more, it's really EPA that oversees it. So the one big standard, and Amy will talk more about it, is the worker protection standard, which is around pesticides. And it's EPA, not OSHA, which is important because OSHA has enforcement. And EPA is not really as enforcement heavy because it's under EPA, not Department of Labor. Also, there's no paid sick leave. There's limited protective equipment. There's lack of health insurance access. As you can see, very few standards, very few protections for farm workers in the fields. Workers' compensation. This is just to show that workers' compensation really varies by state. Not all states cover farm workers to the same extent that other workers are covered under workers' compensation, hence the story that Amy shared at the beginning. In Maine, as you can see, there's limited coverage for farm workers, and that's true for many other states as well. Worker protections. There's no federal HEAT standard. OSHA is currently in the process of putting together a rule, a proposed rule for a federal HEAT standard. This started in 2021. We have not seen a proposed rule yet. Hopefully we will see it in the next who knows how many years, but OSHA can be quite slow in its rulemaking process. And there is also no federal wildfire standard, despite the fact that that's also becoming a larger hazard for farm workers. So in the absence of a federal HEAT standard, there are a handful of states who have put together a state standard. Of course, California was the first. Others are Washington, Oregon, California. Minnesota has an indoor HEAT standard, but it doesn't apply to outdoor workers. And then Maryland is pending. For wildfire regulations, no surprise. The three states that actually have a wildfire regulation are California, Oregon, and Washington. And Washington is in the process of finalizing its wildfire standards, its permanent wildfire standard. So with that, I will turn it back over to Amy to talk about the worker protection standard. Thanks, Alexis. I think we saw California, Oregon, and Washington up there quite a bit. One of the reasons that you have some better standards out west has to do with labor organizing. And in that Fair Labor Standards Act and the National Labor Relations Act, well, it was actually the National Labor Relations Act that prohibited farm workers from collective bargaining. A few states have since allowed that. And I think that has made a difference in some of our western states as to why they have some stronger protections. So as Alexis mentioned, the primary regulatory protection for farm workers comes from the EPA, and it's the worker protection standard. And it has to do with pesticides. And I literally have spent my entire career since 2001 addressing the worker protection standard, trying to improve it. And then once improvements have been made, trying to play goalkeeper to make sure that it doesn't get taken away. Basically, it's intended to reduce the risks of illness and injury to workers and handlers resulting in exposure to pesticides. It has a long history. In the 1970s, we actually sued. We wanted OSHA to protect farm workers. The judge said no. So EPA got off its butt and said, okay, we're going to put out a standard, and they put out a minimal standard in 1974. In 1990, there were some, or 1992, there were some revisions. And again, they were fairly weak. Again, amendments that, weak additions, but moving forward. And then in 2015, we did a ton of work after many, many years of advocacy with the EPA, and we had a comprehensive rule issued. So that was, you know, it's exciting to see a mountain move within your lifetime, and that actually did happen. But since then, it's been a battle to make sure that the worker protection stays as it is. The changes included an age limit for when children could go into a pesticide-treated field. Basically you can't, another basic part of the protection was you can't spray when you see people there, and that workers get training every year. I'm being a little bit facetious, but there are some really important protections that are in there that basically we can go in if there is an opportunity for enforcement to hopefully make some changes and get workers protected. And then most of the rules went into effect in 2017. Okay, the worker protection did leave out some important protections, colon esters monitoring, which is in Washington State, that was not part of the national standard. There's no national system for reporting, and that's a huge issue. We have no surveillance system. We have a haphazard approach with a sensor program out of NIOSH in 12 states. We get some good results from that, but again, it's haphazard. I just do want to point out that there is a national reporting line if pets get poisoned by the pesticides that you put on them. There is a number you can call, and the EPA as well as industry responds to that. But we've had some victories, and basically we've been able to keep the WPS as we put forth in 2015 as it is. There was a movement to try and get that age back down to 16, and I think we're seeing that in other industries right now. With child labor, we're trying to move the dial backwards. And that AEZ provision, that's the one that says you can't spray when you see a worker there. We've been able to keep that. And then most recently, there's another act, believe it or not, in 2022, Congress passed an act. And we were super excited to see that. There is a provision in there that says the industry needs to translate the labels. And it's a long, much longer session, but essentially EPA goes by the label. So basically, if you're not applying pesticides correctly because you're not following the label, there's an issue. So it's a problem that many of the people that are applying it and using it can't read it. So that was a big victory. I'm a little bit skeptical, but Alexis says to be hopeful. And then I'm just going to talk really quickly about the role of the clinicians, since you are all clinicians. And NCN essentially works hard. My job has been to sort of really look at the primary care setting and figure out what is it that clinicians can do. You guys all know the hierarchy of controls. The clinician says, where am I in this hierarchy? Well, you're at the injured patient usually, or the exposed patient. And so we do talk about, they actually do have a huge role in this, and that has to do with reporting. And if they're not reporting, we have no idea what's happening in the fields. So there are 30 states that require pesticide reporting, but we have found clinic after clinic that we go to almost every time, half of the clinicians know whether or not there is a regulation in their state and know what to do. So we work to integrate that into the primary care setting. We work to link to occupational medicine specialists. It's not easy, as you can imagine, in terms of the burdens of primary care clinicians, but we work to look at the whole clinical system and what are the supports that can be done to help the exposed and injured patient. Some of you have been involved with this. We came up with a screening question to help recognize and identify occupational hazards, recognizing the real estate is so tight, and we have been fortunate to work with many health centers that put this into the electronic records, and hopefully it's still being used. But EPA cut our funding in 2017, so we're no longer involved with an intensive program looking at this, but hopefully we will get some funding with that revised PREA Act. I also just want to end with the fact that community outreach is a critical piece of farmworker health, and they're the eyes and ears and can be a really important part of the team. I think I'm out of time, but go ahead and visit MCN's website, migrantclinician.org, and go ahead and visit farmworkerjustice.org, and we have a huge amount of resources for you to explore. Hi, everybody. My name's Linda Forrest. I'm a professor at the University of Illinois, Chicago School of Public Health, and it's great to see old friends and new friends here. And kind of the main thing that I want to talk about today is the importance of community outreach. And I'm going to talk a little bit about that. And I'm going to talk a little bit about the importance of community outreach. 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And I'm going to talk a little bit about the importance of Illinois Chicago School of Public Health, and we partner with UIUC, which is our land-grant university that has the Ag School in Urbana-Champaign, and we're partnering now with the University of Florida and a bunch of other folks, so we want to partner with you too. I'll talk a minute about agricultural injuries, illnesses, fatalities, tell you about NIOSH Ag Centers, and you heard a lot about farm workers already, so I won't spend too much time on that kind of stuff and then tell you what we're doing at the center. So in terms of the number of fatalities, agriculture, forestry, fishing, and hunting are number three, but in terms of the rate of fatalities, ag is the highest, and it's been so for decades. So in terms of rates, ag, forestry, and fishing has the highest rate of work-related injuries, pretty much aligned with transportation and warehousing. This is all BLS data. And then in terms of the hazards, you know, we divide the hazards into the five categories, chemical, biological, physical, biomechanical, and psychosocial, and you can see the typical hazards up there that are related to farm work, pesticides you heard about. There are also fuels, lubricants, gases, organics, and dust. There are a lot of infectious agents, UV, heat, cold, dust, and trauma, everybody knows a lot about. And then in terms of psychosocial hazards, we categorize long hours, workplace harassment, low pay, wage theft in that category. There's a lot of time spent on tractor overturns, which is one of the biggest causes of fatalities in agriculture, but farm workers often are not the ones driving tractors. And then there are other typical exposures here. There are a lot of upstream issues, which you heard about already from my predecessors here on the podium, but when you think about how farm workers got to the United States and why they are in this situation, we need to think about induced migration and why people have to leave their homes to work in a different place. So there's labor migration, but also fleeing violence and poverty in those countries. We have this H-2A visa program, which is really, it's a great opportunity in one sense, but actually we have this because you can pay farm workers so little and make them do so much work that it's much more economical to get an H-2A worker than an American worker who will demand fair wages and social benefits. A lot of our free trade policies in the United States really unbalance the economics and commerce across borders, and so one of the reasons that farm workers have to come here is because we've undercut their agriculture with our policies in the United States. We also have an ostrich approach to immigration, and so nobody really wants to, we all know what's happening. We're all in collusion for it. We all want inexpensive meals at restaurants and childcare and eldercare, and we want excellent agriculture without paying for it. And so it really benefits us in the United States not to have an immigration policy. And then I'll let you ponder all the rest. So NIOSH has 12 centers for agricultural safety and health. We're the 12th just funded, and NIOSH has, thank you, thank you, NIOSH has these centers to do research, to do educational outreach and intervention programs, develop control technologies and so on. And you heard about farm workers, so in Illinois there are 55,000, but our goal is to reach across all the states, of course, in the U.S. and work with all the states, and of course these guys' organizations are providing leadership for us and also connections to the people that we want to work with and I think need to work with all of us. And you heard all about the workers. So here's our center, whoops, here's our center, which this is kind of a typical NIOSH center which has an evaluation and planning core, research projects, and then communication and outreach. And we have a lot of partners and integral to our group besides UIC and UIUC are people from Legal Aid Chicago, which has an H-2A worker outreach program, and also Community Health Partnership of Illinois, which has six FQHCs in the northern half of the state of Illinois, and so they're equal partners in the program, and then UI Extension is doing a lot of work via UIUC. We have new recent partners, I told you about all these other folks, but we have new recent partners at the University of Florida that we've worked with in the past and they're doing heat-related illness work in the field with farm workers. So what do we want to do? We want to consolidate our center group and join the other ag center team, you know, family, if you will. We're in the middle of an environmental scan looking at all the players and policies, first in Illinois and then across the country. We're working on a network analysis to see how all these individuals and groups interact with each other, and we're trying to figure out how to count a farm worker's census, at least in our state first, and then perhaps more widely. We have two funded research projects, RP1 and 2, Research Project 1 and 2. One is to, we started with the NIOSH well-being questionnaire for industry and we're adapting that for farm workers specifically, so we're developing that questionnaire. We're about to do a translation and cognitive testing and then we'll deploy it in the field in Illinois and Florida probably, and then we'll try to deploy it more widely. And the second is we're trying to develop surveillance for injuries and illnesses among farm workers through clinics. So this is an informatics project that we're working on. And this is our logic model, so you can have the slides and read that. It says all the things I just said to you. And again, I really invite you to connect with us in any way you can. If you're working in clinics or companies that in any way touch farm worker health and safety and well-being, we're interested in connecting with you. Thanks. Good morning, everyone. My name is Brett Shannon. I'm an advanced trainee in occupational medicine from Australia, but I currently reside in Chicago working with Linda. And this morning, I'm going to talk about indigenous occupational health and specifically some of the research I've done on indigenous occupational injuries and illnesses in the US, Canada, New Zealand, and Australia. Again, like everyone else, I have no potential conflicts of interest to disclose for this presentation. But before I begin, I'd just like to acknowledge the traditional owners and indigenous peoples of the United States, Australia, New Zealand, and Canada, specifically we're in Philadelphia today. We're meeting on the Lenape tribes land. So I acknowledge them and their elders, both past and present. And if anyone doesn't know, these are the flags of the Aboriginal and Torres Strait Islander peoples of Australia. To give a bit of context to this talk, so I am indigenous Australian. My mom's family are from two islands off Brisbane, Stradbroke and Moreton Islands. We're off the coast of Brisbane in Southeast Queensland, if you're familiar with Australia. Since I was a teenager, I've worked in indigenous medical services in some sort of capacity before I did medicine. And before I left Australia in 2020, I was the chairperson of the Brisbane Aboriginal Medical Service. And this was the second largest indigenous medical service in Australia. We had about six or seven family medicine clinics. We had a nursing home. We had community housing. We had social emotional wellbeing services. We had transport services. We had a school. It was very multidisciplinary, comprehensive primary health care. In 2018, then I moved into occupational medicine. And my favourite part of occupational medicine is really working with workers who were injured in occupational injuries. In 2021, I was the runner up for our national return to work award for a complex mining injury. And I really love treating workers in that capacity. And then in 2021, I moved to Chicago to start my PhD at the University of Illinois in a number of topics related to occupational injury research. And one of those is indigenous occupational injuries. This whole journey really started in 2018 when I moved into the occupational medicine space. I was approached by insurers asking for help with indigenous claims. And what's interesting about this is no occupational health data in Australia captures race ethnicity. So there was no documented data. This was really frontline workers coming to me, realising that I've worked in both spaces and saying, hey, we need help. Our indigenous patients that are coming through the workers' compensation system, they're having a lot of difficulty transitioning through the claim process. They're having poor treatment outcomes and really poor return to work outcomes. And the catalyst really was one of the workers resulted in the death of a worker that really shouldn't have died. So I did some meetings with these insurance companies and started these collaborations, but that was really what ignited some of this work for me. And I usually start these talks sharing some data about why we need to keep indigenous people employed, particularly in the United States, Canada, Australia, New Zealand. You can see the figures are quite shocking. So in those four countries, indigenous people have 21 to 37% less median personal income. They have a 9 to 28% lower labor force participation rate. The unemployment rate is 7 to 11% higher and multiple surveys come out each year showing there is still discrimination evident in the workforce in each of these countries. There's a lot of relevant indigenous health issues that we've dealt with in our family medicine clinics that kind of cross over into the occupational health space as well. If I give some data from Australia, for example, 74% of indigenous Australians are either overweight or obese. Daily smoking rates are 2.7 times that of non-indigenous Australians. Binge drinking is 1.8 times. Requirements to get a sleep study is two times. You're three times more likely to have diabetes and you're two times more likely to have high psychological distress. Yet we kind of separate these and keep indigenous health and family medicine and occupational health over here, but there is huge overlap in a lot of these issues and I'm sure a lot of you see these on a day-to-day basis. From this work, I collaborated with Australian researchers and U.S. researchers and we conducted a systematic review. The review was really to just get a comprehensive understanding of what research is out there on indigenous occupational injuries and illnesses in those four countries, map that literature and then provide some directions for research in the U.S. and overseas. Our methodology was quite rigorous. I'm not going to go through it here. Our study was published in the BMJ-OEM if anyone wants to look at it, but essentially we had three independent reviewers. We had reliability testing at level one, level two, level three screening. We had clear inclusion criteria. All our reliability testing was sound and the studies, they could be peer-reviewed or non-peer-reviewed, but they had to come from the four countries I listed. The workers had to be in those four countries and the study had to show some epidemiological data on indigenous occupational injuries and illnesses. I think from this slide, I just wanted to share from those four countries, the first study ever done was 50 years ago on any data on indigenous occupational injuries and illnesses. So in 50 years, we've only had 51 publications, peer-reviewed or non-peer-reviewed, that have any data whatsoever on indigenous occupational injuries and illnesses in four of the biggest countries in the world. So you can see there's a real paucity of any research out there. The other thing I'll note is out of those 51 publications, nearly half were published in the last decade, which is good, shows we are improving. Majority were peer-reviewed articles and majority actually did come from the United States. So nearly two-thirds of those papers came from the United States looking at Alaska Native American Indian worker health, which is good and coincides with, I don't know if anyone is familiar with the American Indian Alaska Native Worker Health Strategy, which was published by CDC this month. It's the first ever strategy of its kind, so that's really great to see. Unfortunately, a lot of these papers had a very small sample size of indigenous workers. So more than half of the papers had less than 100 indigenous workers as case participants. We looked at the predominant occupational exposures indigenous workers are being researched against and the predominant industries. You can see physical trauma was the main exposure that was examined, but this crossed over into a lot of different areas. A lot of these papers looked at things like drownings in Alaska Natives, looked at electrocutions, looked at farming and agricultural injuries in other areas like bison herding in indigenous tribes, looked at workplace violence in specific indigenous settings, looked at workplace burns. So lots of different areas of physical trauma. There were standard government reports that just looked at all exposures, and then there was a lot of papers from the Four Corners area, the Colorado Plateau area, that looked at uranium and other mining exposures in American Indians. And again, the main industries, as you probably expect, are mining, quarrying, and oil and gas, and then agricultural, forestry, fishing, and hunting. We did a rigorous quality assessment on each of the articles to see what the quality was and if we could share some of the incident rate ratios, and unfortunately, the quality was quite poor across the board, so 36 of the papers had a cross-sectional study design. It was really hard to delineate were the injuries occurring more in indigenous populations than non-indigenous populations, and after doing quality assessments, only five of the papers were reported as high quality. I created this diagram just to show some of the different health focus areas of some of the indigenous occupational research, and you can see it varied quite widely. If you think of it as a clock and you look at 12 o'clock, there was different chemical exposures, so there was PCV poisoning in Canadian indigenous workers that were doing site remediation in the far north. If you look at 3 o'clock, there was a lot of respiratory conditions that were examined, mesothelioma registries in Australia, in the Pilbara region, lung cancer, pneumoconiosis in the Four Corners region, then if you look at 6 o'clock, there was a number of infections that were examined. We had cryptococcus in a number of ranges in Australia that work in rural areas, and then on the left-hand side, you can see lots of the different trauma health outcomes that I sort of discussed there, but it just shows the array of areas of research that's required and the diversity in indigenous workers. For example, another paper that came up that I thought was quite interesting was heavy metal exposures in Nato-American jewelry makers in the United States, and it was just an incidental case, but things like that that require further exploration. And just to sum it up, really, this systematic review showed us of the existing research out there, it's generally quite poor quality, there's a really clear focus on physical trauma, and not many studies on psychological hazards, there was no evidence of examining culturally appropriate or equitable occupational injury and illness management for indigenous people, there was a real lack of uniform definition of indigenous populations in all four countries, there was inadequate sampling across the board, and there was a real lack of survey and qualitative methods utilized to examine indigenous injuries, and there was no evidence of characteristics of workers' compensation or occupational health service usage. And this has led to some of the policy recommendations. At the moment, we're working with different governments across those four countries, trying to begin capturing indigenous status in some of the occupational illness and injury datasets in the national health surveillance systems. We're looking at collaborating and doing research and trying to oversample indigenous persons in some of the research that's going on at the moment, and conducting secondary analysis of current occupational health datasets. And we're really trying to help expand the current research agenda, like 51 studies in four countries over 50 years, there's a lot of work to do in this area just to get some baseline data and get the lay of the land and figure out what's going on. So that's my current work at the moment, and I think that was it, and sorry it was short and sharp, but yeah. Thank you. Wow, you guys did great with time. First of all, I'd like to ask for a round of applause to all our speakers. Really well done. I think their presentations speak for themselves in terms of how their level of expertise in this field. You guys did so great. So we do have time for questions. This session was sponsored by the Section for Underserved Occupational Populations, so I'd encourage you to join if you're not already a member, and yeah, let's turn over for questions. Great presentation. I feel like I was meant to be in here. I just completed a thesis on creating a culture of safety among a culture of diversity. I work in the food manufacturing, so we have a lot of migrant workers, so this was really relevant, so thank you. A lot of the challenges we also face are employees getting trained in their proper dialect, so we have a lot of Somalian populations, and there are seven different dialects among the Somalian population as well, and when you had discussed employees being trained, you also mentioned while Spanish is not their first language, how do you ensure employees are being trained in their proper dialect among pesticides? I have another question too, I'm sorry, as well, sorry. I'll just do a quick piece on it. So one of the things that we didn't get into is that a lot of our immigrant workers that are in these high hazard industries, their education, their level of formal education is lower and their levels of literacy are lower. So oftentimes, even translation into their language can be challenging. That's not true across the board. So we try to really look at developing trainings that involve a lot of pictures, use fewer words, and then I did mention the community health outreach model and the importance of having peer trainers who speak the language and understand the different cultures and how an adult learner would respond to the information and really integrating that into the training is really critical as opposed to simply having training that might be in a language, it's got to be in a way that they understand it and present it in a way that they understand. Awesome. Thank you. And one more question. Along the lines of having a multicultural workforce, do you find that there are reporting problems as well with multicultural workforces in terms of having to report any issues when there's pesticides? Yeah, I think reporting is complicated. I think one reason, of course, is due to fear of employer retaliation. So many of the data that we have, including pesticide injury data, is, of course, underreported, especially because clinicians may not understand that the injury itself is related to pesticides. It's one issue. That's the clinical side. But when it comes to the worker side, the challenge is that there's a real fear of employer retaliation. And so many workers are reluctant to share any kind of violations, any kind of injuries or illnesses they may sustain at work because they're worried that they may be fired or that the employer may call immigration. And so that's a real fear. And so that is really the primary cause of under-reporting. I feel a lot more comfortable on my thesis submission now. Thank you. Also, I know Linda talked about getting that surveillance system together. The need for surveillance and really understanding what's happening is challenging on all kinds of levels so that reporting is critical. So MCN has been coordinating a group of 17 different farm worker organizations across the country and has come up with sort of a community-based approach for farm workers and community organizations to gather some of that data in a safe environment. And so we're really trying to think of that community space to be able to do that. And it's in its infancy, but it's something that could potentially complement what you're doing, but really looking at all these different challenges we have with reporting, because as we know in public health, if we don't have surveillance, we don't understand what the problem is. Hi, I'm Diane Waugh, OCDAC from DC area. I had a question for Dr. Frost. On one of your slides, you were listing some of the areas you're working on. It said biomarkers of stress, but it went by real fast, so I don't know what you're doing, so could you please talk about that? Yeah, the study hasn't gotten funded, so it didn't get funded in the first go-around, may not in the second go-around, but we were going to, it was a biological anthropologist looking at stress biomarkers and immunologic stress biomarkers, so looking at lipopolysaccharide stimulation of the immune system, and cytokines and interleukins and some of the other typical stress biomarkers, and that was going to be, those are the health outcome, biomarkers of health outcomes, and we have our survey tool, and we were going to look at different farm worker groups, but it hasn't gotten funded, so I don't know what we're doing on that front. Hi, good morning. Thank you for a great presentation. Faiz Bojani, Health Solutions 21st Century and University of Texas Professor in Environmental and Occupational Health. So, I was struck by the commonalities and similarities between the health impact findings that you mentioned in Australia for the aboriginal people. I've read the same thing about the Intuit and Iroquois Indians in Canada, Native Americans, the Maori people in New Zealand, and I can go back to my medical school whereby I've read some of the same findings impact obesity, diabetes, substance abuse, et cetera, right? So, I think by this time of 20 or 30 years, we know that the problems of aboriginal people or native people are similar, if not exactly the same with cultural nuances, right? My question is, I have not seen a cross country or intercontinental collaboration to do something about it in terms of partnerships. Are there any partnerships that are actually in place that take some action to do something about these inequities or we keep on going to identify the same equities over and over again for three or more decades now? Thank you. Thank you for the question. I think there are collaborative organizations like PRODUC, the Indigenous Doctors Association, and they do mainly policy and advocacy work. In terms of research partnerships, to be honest with you, very little that I've seen or experienced and I'm trying to build those relationships with Canadian researchers, New Zealand researchers, Australian researchers. Coming to these conferences is a great way to do that. But yeah, there is a long way to go and like you said about those Indigenous health outcomes, I think the issue now is we're seeing really stringent pre-employments. Obviously, Australia, we have a huge mining workforce and then the health requirements for some of these roles are getting stricter and stricter and then that precludes a lot of Indigenous people from employment in these areas and that's probably gonna get stricter and stricter in the next decade or two decades as well. So that's why I'm trying to work in both areas and bring them together and show that we really need to introduce occupational health into Indigenous family medicine and collaborate a bit further and try and improve some of these outcomes and get people employed at the same time. But thank you for the question. Thank you. It was a great presentation, Zal, Kathy Fagan. I have a quick question that actually you already started to answer, Amy, about the surveillance and getting information to the electronic record. Are you working with NIOSH and the Occupational Data for Health? Have you connected with them on that? I'm not familiar with that other than the sensor systems that are funded by NIOSH. So maybe you could tell us what that is. Well, we'll have a phone call. I'll have a Zoom with NIOSH because they've been working on this for a long, long time. Eileen Story was kind of the frontier woman on that. And so, yeah, AOEC, we'll get that on the agenda. Good morning, great talk. Couple of questions, quick ones. With respect to the Migrant Health Network, if you were able to connect with that broccoli farmer who was injured, just kind of walk me through how you would have been able to assist him. And two, are there efforts to have insurance, health insurance, both occupational, non-occupational for some of these, for all of these migrant workers? Thank you. That was a great question. Lots of questions. So just start on just sort of what we would have done. I mean, essentially, had that broccoli worker perhaps had a medical home where there could have been a little bit of follow-up between the emergency department and maybe the local federally qualified health center, but there's very little incentive, even though it makes so much sense for emergency partners to talk to federally qualified health centers. They just don't. So, and that's really unfortunate because you could have all these wraparound services that could have potentially gotten that guy back to work. And then in terms of health insurance, it's a huge, huge policy issue, but we have a lot of people that we're doing intake in that are looking for continuity of care. And I'm like, can't you just tell them to go to California? Because- Not everybody in California is comfortable. I know, but California. And the reason is that if immigrants are systematically excluded from even the Affordable Care Act, and then there's also been a chilling effect of even those who might be eligible to get insurance, they don't want to get it because they're afraid that it will potentially interfere with their future adjustment of their immigration status. So there's fear, and then there's the reality. But there is some movement, and I'm joking about California, but California is way more open to recognizing that many of their residents are not authorized to work there, but they need insurance because ultimately, at least the state of California might be thinking about what the pressures are on the emergency health system. In Maryland, we're seeing that needle move a little bit. We saw it with kids, but, and we made some advances in COVID, but man, we're going backwards. So, but I think at the end of the day, it comes down to our broken, I like your ostrich thing, our broken immigration policy, but the bottom line is that immigrants are human beings, they come into our country, they work, they have families, they have babies, and they need healthcare like everybody else, and it doesn't help our system, our US workers, that we exploit them the way that we do. Just a couple of things to add onto that. So, the Biden administration actually just announced that DACA grantees will be eligible for the ACA, which is huge, because when DACA was first announced, the Obama administration carved out DACA grantees from being eligible for ACA, so that's a big victory. In Washington state, they actually received a waiver from CMS to use their state exchange and state funding in order to have undocumented immigrants go into the exchange in Washington state. So, there are things moving forward. There was an employer mandate under the ACA, but many agricultural employers are actually exempt from the mandate due to a seasonal worker exception. So, even though some farm workers may work for quote-unquote large employers, those employers, more likely than not, don't fall under the employer mandate. Hi, Rosie Socas, I wanted to thank each one of the panelists. This was a fabulous, fabulous presentation, and I wanted to see if Dr. Diane Wah is still here to give us a little two-minute history of the Field Sanitation Act and her, not act, regulations, and her experience with it. Diane, are you still here? All right, just two-minute history. No, no, no, come on, come on. Important history. Rosie says. I know, Rosie speaks. I know, Rosie speaks. Rosie, you're wrong. Okay, okay, so. All right, so this was quite a while ago. I'm trying to think of how old my daughter was at the time. I go by kid's age, too. You know, that's kind of the way I date things. She was only, and she was born in 1980, so, okay, so she might have been like four, something like that, okay, something like that. So, I was working at OSHA. I had just finished my rotation there. I was a resident, an Achmed resident at Hopkins. So, I had finished my rotation, and I stayed on working at OSHA with a contract, and the field sanitation standard came up, and those of us who were there, who were residents, and like me, a contractor, and career people, were asked to, we were writing the field sanitation standard, so everyone was really, you know, psyched about this. We were all excited about the fact that there was gonna be a field sanitation standard to provide hand washing, water, and toilets in the field for workers. So, everyone was researching that, and giving the background. We were writing this standard, and then this was under the Reagan administration, and so we were suddenly told that we should divide our team in half, and half should write that there would be a standard, and the other half should write why there should not be a standard. Okay, so, we were totally devastated. We were all sitting in this room around the table looking at each other like, how can we possibly do this? This is so horrible, you know. So, we decided that we were going to write a letter. Someone was going to write a letter, and we were going to say this, and about how wrong we felt it was. This was, you know, just a terrible thing to have happen. So, we all wrote this letter, and somehow the letter appeared in the New York Times. Yeah! So, when it appeared in the New York Times, suddenly people realized that they were career, and I wasn't. I was a contractor. And so, one night, at the time I was a single parent with my daughter, and I was living in Baltimore, and commuting there a couple of days a week, and working in the Hopkins Alchemy Clinic the rest of the week. So, I got this telephone call on a Friday night, and I don't even remember the name of the person who called me. He was high up, you know, but I don't remember who it was at the time. He called me up, he said, Dr. Wall, we would like for you to clean out your desk on Monday. I was like, what? Wow! Your contract is terminated. I was like, oh my goodness, okay. So, I went in on Monday, and I cleaned out my desk, and that was it for me and Osha. This was in the Office of Occupational Medicine when Ralph Yordakian, Dr. Yordakian, was in charge. He was so upset. You know, everybody, they were all very upset. And all the people in the committee kept coming to me and saying, oh, we're so sorry if we realized you are a contractor. You know, we're all career. They can't fire us, but they can. I was like, I mean, this is a, I did it out of conscience. So, if I had known, I don't know if I would have done anything different. I don't know. So, I just said, okay, well, I don't work at OSHA anymore, and so now I'm working, I think, two days a week or something in Baltimore. But the head of the clinic at the time said, well, you know, work one more day. You know, you can work one more day. So, I think then I was working three days at the clinic, and not at OSHA at all. And I went to the gym at three points. Dropped my daughter off at her preschool and went to the gym. I was so fit. I was in the gym twice a day. It was really, you know, that was something. And then I ended up, the Koch group called me up, Mary Koch, and they called me up, and I ended up testifying on the Hill, you know, about what had happened, about having had my contract terminated. And, I mean, you know, the questions I was asked, things like, well, you went to the Occupational Health Conference, you double-billed. You double-billed for the time you were there, and then you billed for the, I was like, no, I didn't do that. That's not, that's not what happened at all. So, anyway, that. Thanks, Rosie. That's a great history that helps us understand why it took OSHA 17 years from the time that it started to get that. And, ultimately, I think a lawsuit was what helped OSHA move along and finally issue that. But, thank you for, I never knew that story. It's so great to hear. Thank you, Rosie, for sharing it, too. Yeah. That is a great story. That's kind of hard to follow. Just a quick question. Niels Konecki, I'm an OCDOC up in Saskatchewan at the Canadian Center for Health and Safety in Agriculture. Very familiar with the NIOSH model and the NIOSH Center, as we've partnered with many of them, and you've come to our symposia in the past. And we're sort of the, I always tell students, we're sort of the lone NIOSH analog up in Canada as a center there. My question is for Dr. Shannon. A lot of our research teams and one group in particular are very interested in Indigenous and First Nations work and housing and health and air quality and sort of the mix in the urban, sort of compared with urban settings and workplace and home settings. How did you, we can talk offline a little bit more, but how did you, Indigenous means different things in different countries and different societies. How did you define that or how did you sort of compare or did you, were you able to sort of make distinctions between how different locations and geographies define Indigenous groups? In terms of how we define Indigenous, first, I'll start with that. We worked with various librarians to get a comprehensive term list of every Indigenous term for those four countries to make sure our review was comprehensive. And that's why we started with 1,300 articles to start with. In terms of comparing different groups, that just wasn't enough data, to be honest with you, to be able to get that far. And the BMJ came back to us and said, you need to put all those rate ratios in for the different areas. And so I did that and tried to show some comparative stuff in the article, happy to send it to you. But I felt almost wrong saying like the quality's poor, take this as it is. In terms of comparing different groups, in Canada, I've had some recent conversations with people at UBC and people in British Columbia around some recent data they've started working with to do some comparisons in BC. I'd love to keep in touch and maybe talk after this session and see if we collaborate somehow. It's the same challenge I think we face, especially the far North, the Inuit population is very understudied in that realm and sometimes very challenging to compare. So it might be nice to share some of that. Thank you. Thank you. I promise I'll be quick. Just quickly plugging the next session because the first question was related to it. It was the NIOSH's occupational data for health model, which we'll be presenting here in this room also. I wanted to ask the panel about this question. How are you capturing, for example, the underserved population or migrant or agricultural worker population in your electronic health record systems? Or how are they represented in your data? Is there a discrete field that you're capturing or is it in a narrative that you have to get? Is there a specific SNOMED code or ICD-10 code they're using to represent those migrant workers? I see your head shaking. It's not really available in that way. So we're trying to capture, I'm speaking for Lee Friedman, who's the PI on that project and Brett works with him as well, looking for extracting information from the narratives. But I have to say that HRSA, there's the UDS system whereby federally qualified health centers report the number of farm workers and farm worker family members that they're serving. And so that means that you should be able to connect that with their electronic medical record because they're very good at doing that because their funding depends on it. So finding those people in the electronic health records and then secondarily looking for injuries, work-related injuries in the narratives is one way to approach it. Yes, and you're referring to the uniform data system, the UDS and UDS-Plus, yes. I wouldn't say that they're very good at collecting that. One of the reasons that we looked at those three questions, how that intake is done, it's kind of a haphazard approach across health centers and some are very good and others are not. And some are very good at sort of moving it from the front desk to the clinical encounter, which is to us the most important piece. And that doesn't always happen either. So there's a lot of very nuanced work that needs to happen. But in general, the idea is that they do collect that because in theory, their funding is dependent on it. Yes, is there a discrete field for occupation or industry, for example, from what you're seeing in your suit? Okay, we'll work on that. We're working on it, so thank you. Oops. David Duran, Occupational Medicine, Lincoln, Nebraska. I'm very interested in the translation issues that you must be dealing with. Do you have to have two level translation, like from English to Spanish and then Spanish to an indigenous language? And are the indigenous languages written at all? Some are, some are, but it's not uniform. And there are also different dialects within the language. We also try to do what we call, I'm forgetting the word right now, but creating the resource in the language that we want it in. So instead of going from English to Spanish, starting off in Spanish. And then with indigenous languages too. So bringing in those people who are going to be the users of it so they're part of that process. And also working in that language, rather than, even though English is my primary language, I can work with a team that Spanish is their primary language and we can create it first in Spanish. Thank you. Co-creation, co-creation. Thank you again, everybody. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you. Thank you.

occupational and environmental challenges

underserved workers

farm workers

indigenous populations

occupational health and safety training

reporting and underreporting

community outreach

indigenous occupational health

health disparities

policy and advocacy