Fresh Fruit, Broken Bodies: Migrant Farmworkers in the United States

Chapter 5 addresses the problems Triqui people face when interacting with healthcare professionals in Mexico and the US. San Miguel has only one clinic, a government-run facility alternately staffed by a resident or nurse, neither of whom works in the town longer than a year. The resident and nurse during Holmes’s fieldwork were from Oaxaca City and didn’t speak the Triqui languages. Holmes asked a government official for permission to observe and learn from the clinic staff. The official responded, “‘That doctor doesn’t know anything’” (112). This response—a common refrain that Holmes heard in many contexts—prompted him to investigate the problematic relationship between clinicians and Triqui patients. This chapter revisits the cases of Abelino, Crescencio, and Bernardo, focusing on the healthcare professionals with whom they interacted in Washington State, California, and Oaxaca. Their experiences serve as a point of departure for a broader discussion of the structural factors impacting migrant and Indigenous health care.

The Clinical Gaze

Holmes approaches migrant health from the perspective of providers to understand how they perceive and respond to Triqui patients—and to assess the care they offer. He draws on the work of Michel Foucault, who described a paradigm shift in the field of medicine between the 18th and 19th centuries. Doctors began asking patients what part of their body hurt, signaling a shift away from treating a whole person toward the treatment of localized ailments. Doctors no longer listened to patients describe their symptoms. Instead, they objectified patients by expecting them to remain silent and focusing on anatomically isolated parts. This change coincided with the dehumanizing practice of dissecting cadavers. Some physicians have pushed back against this paradigm (known as the “clinical gaze”) and have instead promoted a competing approach called “witnessing,” which treats patients “as whole persons” (116). Doctors who practice witnessing find themselves in conflict with the medical system, which emphasizes specificity and pathology. In this chapter, Holmes addresses the impact of the clinical gaze on migrant healthcare through the examples of Abelino, Crescencio, and Bernardo.

Abelino’s Knee: Structure and Gaze in Migrant Health Care

This section focuses on Abelino’s interactions with medical professionals. Holmes accompanied Abelino to an urgent care clinic in Washington State’s Skagit Valley the day after his accident. The doctor listened to Abelino describe how he was injured, ordered an X-ray, and advised Abelino to rest and stop picking berries. He refused to give Abelino a cortisone injection for the pain, despite Abelino’s request, and instead gave him a referral for physical therapy, prescribed an oral anti-inflammatory, and filled out the forms for a worker’s compensation claim with the Department of Labor and Industries (L&I). When Abelino returned to the urgent care clinic a week later, he was seen by a different doctor who recommended only doing light work. Back at the farm, an administrator denied Abelino’s request for light work—despite his doctor’s note. Abelino’s pain subsided with rest, only to return within days of resuming work. The doctor at the urgent care clinic passed the case to a rehabilitation medicine physician, who informed Abelino that he was bending over and picking incorrectly. She also told him that hard work would help his knee. She didn’t request future appointments but prescribed a strong anti-inflammatory—without asking if Abelino had any contraindications (he did).

Abelino’s interactions with L&I were equally ineffective. He filed a claim to receive worker’s compensation, but the farm undervalued his pay. During a meeting with a ranch administrator and an L&I consultant, Abelino learned that he’d lose all benefits if he moved to California with his family at the end of the picking season. The activities the consultant recommended for Abelino in her report included “hand harvest of berries” (122). This form was sent to the urgent care doctor, even though his doctor was now the rehabilitation medicine physician. L&I closed Abelino’s claim after this doctor determined that his condition had improved based solely on an MRI. After spending the winter and spring in Oregon and California, Abelino returned to the Tanaka Brothers Farm to pick strawberries. However, he had to stop working after two days because of the pain in his knee. A physician at the clinic noted that his knee was more swollen than the year before, but L&I denied his new claim for workers compensation. They also denied his appeal. The clinic doctor later explained to Holmes that Abelino was faking his pain to collect workers compensation. Given Abelino’s experiences, it’s no wonder that migrants think badly of doctors.

Holmes points to several assumptions that doctors made in their interactions with Abelino. They assumed that he didn’t have stomach problems, that he had opportunities to return to light work, and that he was faking his pain to collect workers compensation. Abelino’s case highlights three key facets of the clinical gaze in the field of migrant health: 1) Doctors place more value on their observations and biotechnical tests, such as X-rays and MRIs, than on patients’ words. 2) Doctors inadvertently blame patients for their ailments. 3) Structural violence hurts patients and physicians. Overburdened doctors must examine, assess, and formulate a treatment plan within 15 minutes—in addition to filling out forms. They don’t have time to obtain complete information from their patients. The pressures of the capitalist healthcare system hinder doctors from doing the work of listening to patients.

The Field of Migrant Health

Holmes examines the social and cultural contexts in which the healthcare professionals who treat migrants work. The Migrant Health Act of 1962, which led to the creation of the Migrant Health Program, earmarked government funds for medical and social services for migrant agricultural workers. The Migrant Health Program provides grants for more than 400 migrant clinics across the country, while the Migrant Clinicians Network, founded in 1984, educates clinicians who treat migrants. However, the changing ethnic makeup of farm laborers since the 1980s—from white to Hispanic—has made the programs controversial. Most physicians Holmes encountered in the migrant clinics in Washington State’s Skagit Valley were white; those in California’s Central Valley were largely Latino; and those in San Miguel were from Oaxaca City and only spoke Spanish. The two American clinics had sliding fee scales.

Structural Factors Affecting Migrant Health Clinicians

Migrant health professionals work under demanding conditions. Most rely on unstable nonprofits for funding. Many lack expensive medicines and instruments. Medical staff perform duties they wouldn’t in other settings, such as filling out forms for patient discounts. Many medical workers are frustrated by the deterioration of their patients. Holmes quotes Dr. Samuelson at the migrant clinic in the Skagit Valley, who made this point: “‘I see an awful lot of people just wearing out. They have been used and abused and worked physically harder than anybody should be expected to work […] They’re screwed, in a word, and it’s tragic’” (129). Racism also weighs on clinic staff. White patients often tell doctors and nurses they won’t come to the clinic at certain times because they don’t want to sit in the waiting room with migrants, whom they describe as foul smelling.

Funding is a critical problem in migrant health. Studies show that only 5% of undocumented migrants have health insurance and that few qualify for Medicare or Medicaid. Consequently, clinics often aren’t reimbursed for their services. Clinics are forced to apply for grants from various private and public sources to stay open. The lack of funds forces administrators to cut programs and clinicians to spend time obtaining free samples.

Inflexible farm schedules make it difficult for migrant workers to go to clinics during the day. As a result, many wait until they’re extremely ill before seeing a doctor. Putting off preventative care, combined with a lack of continuity in care, exacerbates the suffering of migrants.

Language barriers further complicate the care that migrants receive in health clinics. Holmes found that most clinicians were bilingual in English and Spanish. Those who weren’t generally didn’t have access to translators. Most Indigenous workers, however, don’t speak English or Spanish, and clinicians don’t speak Triqui or Mixtec. Despite all these challenges, Holmes found that clinicians were committed to providing quality care to migrant workers.

Crescencio’s Headache: Structure and Gaze in Migrant Health Care

Holmes presents Crescencio’s headache as the product of structural and symbolic violence. Economic inequalities forced Crescencio to migrate and become a farmworker. This work exposed him to racialized mistreatment by his supervisors, who regularly yelled racist insults at him. This abuse caused headaches that led Crescencio to embody the stereotype of the violent, alcohol-dependent Mexican.

Holmes’s field notes reveal that Crescencio’s doctor at the clinic in Washington State’s Skagit Valley failed to consider the social factors producing Crescencio’s headaches. Instead, she blamed him for missing appointments and drinking too much. She also viewed Crescencio’s relationship with his family as “‘a classic case of domestic abuse’” (134). Based on this conclusion, she recommended that Crescencio attend therapy to deal with his issues with authority and alcohol addiction, without considering the role of social inequity in his health problems. Holmes points to the circularity of Crescencio’s situation: “The racialized mistreatment that produces his headaches [was] justified through the embodied stereotypes that were produced in part by that mistreatment in the first place” (135). The migrant clinic, then, subtly justified the symbolic violence that Crescencio experienced on the farm.

The Gaze of Migrant Health Clinicians: Washington and California

Holmes addresses the significance of social perception in migrant healthcare, using clinics in Washington and California as exemplars. Holmes emphasizes the importance of perception, arguing that “human beings are defined through perceptions by others” (136). These perceptions not only determine how people act toward individuals but also shape the actions of individuals in response to their treatment by others. Triqui migrants experienced suffering and sickness in particular ways because of their treatment by medical professionals. Holmes’s ethnographic research revealed that medical staff had a range of perceptions about migrants, from positive to racist. Some saw migrants as “‘the stars of Mexico’” (136), while others complained that “‘they don’t really take care of themselves’” (136). Indeed, the perceptions of healthcare workers were varied and often contradictory: Some saw higher rates of alcoholism among migrants compared to other groups, while others saw the opposite. Misunderstandings played a large role in health workers’ perceptions of migrants. For example, doctors who saw large numbers of unwed pregnancies didn’t understand traditional Triqui marriage practices, which involve payments and aren’t officially recognized by churches or the state. Many in the medical community blamed migrants for their health problems, pointing either to their behavior (such as putting off preventive care), or to their physical makeup (such as their large jaws exacerbating dental problems). Finally, some medical professionals, including the director of the Skagit Valley clinic, believed that migrants came to the US to work the system. This perception directly contradicts Holmes’s field research, which identified labor as the primary reason for migration.

Bernardo’s Stomachache: Structure and Gaze in Migrant Healthcare

Bernardo received subpar care from an English-speaking doctor at the hospital near the Tanaka farm. This doctor noted that Bernardo spoke broken Spanish (his first language is Triqui) and that he was unclear about his pain’s location. Through his Spanish-speaking daughter-in-law, Bernardo explained that he needed pain medication and something to increase his appetite—neither of which he received. He agreed to stay overnight to rule out a heart attack, but he told the doctor that he had to return to work by 3:30 the following afternoon. He refused a third blood test and an ultrasound due to time constraints and left against medical advice. His treatment cost $3,000. Bernardo’s case underscores several key problems in migrant healthcare—notably, the time pressures on migrants to return to work, the limited time doctors can devote to patients, and the lack of trained interpreters.

Bernardo’s treatment at a clinic in Juxtlahuaca highlights problems in Indigenous healthcare in Mexico. A physician diagnosed Bernardo with gastritis or an ulcer and blamed these problems on his patient. According to this doctor, Bernardo ate “‘too much hot chili, too much fat, and many condiments’” (143). The doctor saw poor eating habits as a broad problem in Indigenous communities, claiming that they “don’t eat at the right time but wait a long time in between meals’” (143). He prescribed pills to reduce peptic acid, recommended eating dairy, and gave Bernardo an injection of vitamin B-12 for nerve pain. Like his counterparts in the US, Bernardo’s Mexican doctor didn’t consider the social and occupational context of his patient’s suffering, instead attributing the pain to behaviors and culture. As Holmes observes, biotechnical medicine erases the structural and symbolic aspects of suffering, such as economic hardship and military torture, and thus provides an incomplete picture of ailments and their causes.

The Gaze of Migrant Health Clinicians: San Miguel, Oaxaca

Holmes addresses the social perceptions of migrant suffering at the government-funded clinic in San Miguel. The waiting room displays a poster titled “The Ten Commandments of the Good Patient,” which advises patients to inquire about contraception, be respectful toward medical staff, and keep themselves and their houses clean. Perceptions of Triqui people at the clinic are predominantly negative and fail to consider the social structures fueling their health problems. For example, one nurse asserted that Triqui parents prefer to send their children to work rather than school without recognizing the role that poverty plays in these decisions. This nurse also called Indigenous people “‘lazy, dirty, ignorant, mean gossipers’” (148). She warned Holmes about the violence of Triqui people, claiming that she started her career wanting to help them but now viewed them as undeserving of her aid and friendship. This nurse also blamed Mexico’s debt and lack of investment in public works on Indigenous people.

The perceptions of clinicians in San Miguel are similar to those of medical professionals in the US but more antagonistic. Holmes speculates that the nurse cited above resented being forced to leave her home in Oaxaca City for several days every week to work in the clinic, as mandated by the government. Her complaint that Triqui people were dirty failed to consider the lack of running water in the town. Although a new nurse was more sympathetic than her predecessor, she presented migration as “an adventure,” not a necessity stemming from economic suffering. For his part, the clinic doctor complained to Holmes that Triqui people were careless with their healthcare. Racist metaphors of violence, laziness, and dirtiness led many clinicians to view their Indigenous patients as undeserving of care.

Acontextual Medicine and Apolitical Cultural Competency

Holmes’s aim isn’t to blame clinicians for their perceptions and treatment of Indigenous patients. Like everyone else, medical professionals are affected by societal structures. The inability of clinicians to see how contexts impact Indigenous people’s health is the product of their hectic work environments—and reflects how medical science is conceptualized, taught, and practiced. Most clinicians Holmes spoke with chose to work with migrants out of compassion and a sense of duty. However, the lenses through which they understood their Indigenous patients were narrow and asocial. Because of this lack of context, clinicians discounted their patients’ social history and social realities, which impacted everything—from assessment to diagnosis to treatment. Equally harmful was the tendency of clinicians to blame patients for their own ailments. Addressing these problems demands training medical staff in structural competency and social analysis. The clinical gaze without context promotes victim-blaming and results in misdiagnoses and poor treatment, in addition to depoliticizing suffering and reinforcing the structures that cause illness. Private profit and the emphasis on cutting costs are antithetical to providing quality care.