I visit the bottom floor of the Alisal Health Center in East Salinas in February. It’s home to the Comprehensive Perinatal Services Program, where new parents on Medi-Cal can get prenatal or postpartum care.
The small lobby is filled with posters and pamphlets in Spanish. There’s a giveaway table in the corner with childrens clothes and colorful toys. And tucked in the back, is something you don’t normally find at clinics: a small office with an attorney.
“So every Wednesday I come from my legal office over to this health clinic where I have six appointments with farmworkers and families to provide free legal services to address health-harming legal needs that they might have," says Aaron Voit, an attorney with California Rural Legal Assistance, a nonprofit legal services program.
Medical Legal Partnerships
I’ve caught Aaron in the middle of huge depositions, another time it was leading a farmworker COVID-19 task force. Before the pandemic, you could always find him here on Wednesdays. Today, he’s meeting with Sarah — that’s not her real name.
She’s worked in the fields for nine years and is afraid her boss will hear her talking about an accident she had there. She says she was afraid she had to keep working, but she soon realized she didn’t have to, she could get on disability. She’s here to talk to Aaron about another confidential legal matter, but surprises him. She’s three months pregnant.
“I'm around pregnant women or women who have recently given birth all day,” Aaron says.
Pregnant farmworkers to be more specific. This clinic in East Salinas serves mostly farmworkers and their families. And Aaron’s here because back in 2017, he helped start something called a medical-legal partnership at social safety net clinics in Monterey County. It’s this new model of legal services that gets lawyers like him working alongside health care providers.
“There are about 300 or so medical legal partnerships throughout the nation, under the belief that when doctors and lawyers work together there's more that we can do for people living in communities of need,” he says.
Say for example someone comes in to see the doctor, and the doctor concludes they have mold poisoning, that’s exacerbating their asthma. The doctor only has about 15 minutes, sometimes less, to address the problem.
“Traditionally medical providers might prescribe an inhaler or steroids but those substandard housing conditions are driving those patients to return to the clinic time and time again because a provider has difficulty addressing the underlying root cause of that health issue in a clinical setting.”
In a medical legal partnership, the doctor can refer patients to the lawyer, sort of like a prescription. Aaron says he gets to meet with these patients for an hour, which is way longer than a doctor or nurse usually gets. He can direct them to fair housing resources, or if it's needed, he could help them sue their landlord. And he doesn’t just address housing, it's all these other social determinants of health, like education or economic stability. And with his pregnant patients, the issue is often workplace safety.
“The majority of the women that we work with are farmworkers, which is a line of work that's very physically demanding.”
Hazardous Work Environments
Some lettuce workers are expected to bend over to harvest a head of lettuce every three seconds.
“We're talking about bending over thousands of times over the course of one single day, in the heat, working in fields with uneven ground, where there are high risks of injuries and falls, and being exposed to toxic chemicals,” Aaron says.
But it’s a risk many choose to take, sometimes because they can’t afford not to, especially if they are only a seasonal worker. When Aaron first arrived at the clinic, he kept hearing stories like these. One of the family doctors at the clinic, Dr. Pedro Moreno, was hearing them too.
“My heart breaks every time a pregnant mother tells me, ‘Doctor, will my children have autism? Will my children have learning disabilities? I know that some of my friends have had children with those problems. What can I do about it?’”
Two decades ago, he helped out with the CHAMACOS study, a longitudinal study following farmworker children until they turned 18. Researchers have found links between early pesticide exposure and ADHD, autism, asthma, and low IQs. And as the study educated more community members of the risks, pregnant patients were telling Aaron pesticides were being sprayed less than 100, 50 yards from where they were picking, and asking what their options were. Did they have to keep working? They were worried.
“They're concerned because they might have already had a pregnancy where they worked into their second trimester, their third trimester, and they experienced negative health outcomes for themselves and for their pregnancy. Sadly we have many women at the clinic who have had miscarriages that they believe are due to the workplace conditions that they were working in. We have many women that have children with developmental delays that are scientifically linked to pesticide exposure,” Aaron says.
So the two of them teamed up to see if they could find a solution to a problem they were asked about over and over again — how to help keep these pregnant farmworkers and their children healthy without years of expensive court cases against pesticide companies. They started with the state’s disability insurance program.
In the California employment insurance world, pregnancy is considered a disability. So, workers can stay home and get a percentage of their income through disability insurance. But that doesn’t usually kick in until a month or so before their due date. For farmworkers this could mean months of pesticide exposure.
“I think if you were to ask many providers if they would be comfortable with their wife or their daughter or their family member working well into their second or third trimester doing farm work during their pregnancy, the providers would say absolutely not,” Aaron says.
The workaround? So, doctors have the power to tell the Employment Development Department ( EDD ) — the state agency that provides disability insurance — that someone is unable to work because of a medical condition like say, a fractured tailbone. But most doctors aren’t trained to offer this choice to a pregnant farmworker, potentially facing an invisible harm. One time, I watched Aaron speak to a room full of nurses in the farmworker community. He asked the group when they allow their pregnant patients to go on disability, and the responses were all over the place.
“Some might tell you 20 weeks, some might tell you 36 weeks, some may tell you something in between there.”
So, after lots of discussion with researchers, lawyers, OB-GYNS, most importantly with women themselves who’d been denied coverage, they came to the conclusion that a doctor should be legally able offer disability to a farmworker as early as medically advisable — that could be as soon as a pregnancy test comes back positive. And EDD agreed. It’s simple. If a pregnant farmworker wants to stop working, doctors can use disability codes that already exist.
Testing It Out
Last winter when I visit Aaron, he’s helping a patient fill out a form for disability because she just had a baby. She was one of his first farmworker patients who tried to get disability very early in her pregnancy.
She was actually denied by EDD the first time, so they’re trying again to see if they can get her back-pay. Despite the setback, she says it feels good knowing she’s helping to work out the kinks in the system. She says she tells other women in the field they can apply early. But they’re getting conflicting information from their doctors. So, she tells them about what she’s learned. Women in the field are educating themselves, so Aaron says the biggest challenge now is actually educating the health providers.
Putting Yourself In Their Shoes
Dr. Pedro Moreno says outside of Monterey County, he doesn’t know of many physicians offering disability this early. Part of it, he says, has to do with just understanding where your patients are coming from.
“I think the main reason is because we don’t work in the fields ourselves. If we were brave enough to go to work in the fields for just one day, just one day, I think we will understand what those patients have to go through,” he says.
Before the pandemic, this doctor lawyer team toured different counties, giving presentations to providers about disability insurance alongside researchers from the CHAMACOS study. They’ve traveled to Ventura County, Santa Cruz County, I watched Aaron present in Sacramento, and Santa Clara.
“After a talk like that there's not a single provider in that room that would believe that it's okay, that it's medically advisable for their pregnant farmworker patients to continue working in the fields being exposed to pesticides during pregnancy,” Aaron says.
Power During The Pandemic
The pandemic has slowed these outreach efforts down for now. Farmworkers are three times more likely to get COVID-19 than other workers in Monterey County. And now the team is spending their time leading a coalition of scientists, doctors, farmers and farmworker advocates to address coronavirus in the community. They’ve pushed for PPE and more testing sites, created a farmworker COVID-19 helpline, fought for the ruling that COVID-19 care won’t count against your immigration status. Aaron is hopeful that this increased discussion about the healthcare rights of farmworkers will continue, even after the pandemic, to help the women that come into his office every Wednesday.
Thanks to Adriana Morga for translation help.
This story was produced with support from the UC Berekely 11th Hour Food and Farming Fellowship.