番茄社区

This is the third story in a series by 番茄社区 examining the impact of COVID-19 on vulnerable populations. Past stories reported on the homeless and immigrants in detention.

When the fields near Salinas, California, reopened for the season last week, an undocumented farmworker eager to start earning income after a winter without pay didn't hesitate to catch the bus transporting the crew to the fields for work.

She had a cough and back pain, and her infant and toddler were sick at home with intermittent fever. Under normal circumstances, the single mother would have stayed home to care for them, but she feared losing her job if she didn't work, so she left them with a sitter.

Her son, who is morbidly obese, is at greater risk from coronavirus, said Julia Snell, RD, a registered dietitian in the area who treats him and many other undocumented individuals there.

"It makes me worry because if this chance encounter with this patient who is showing symptoms potentially has it, how widespread is it already?" Snell said in an interview with 番茄社区.

Undocumented individuals, who account for a large proportion of the agricultural frontline workforce, are at a higher risk of contracting the virus. Fears that their status in the U.S. will be compromised if they use Medicaid or other public benefits may be discouraging patients in these communities from seeking COVID-19 testing or care.

A Population at Risk

Preliminary data show non-white individuals to be particularly black and Hispanic people.

In rural areas like Salinas, many agricultural workers live in close quarters, sometimes with multiple families in a single dwelling. Although they are staying home, wearing masks, washing hands, and adhering to social distancing recommendations as best they can, the nature of these dwellings means that once the virus enters, it is likely to spread quickly, Snell said.

"It's not that they're putting themselves at unnecessary risk," Snell said. "They are doing the best they can just like all of us, but they're just not being protected in the same way."

Francisco Fernandez, MD, a psychiatrist practicing in the Rio Grande Valley of Texas, said the community there, which is already marginalized, fears being seen as a "reservoir for infection" and alienated further.

Moreover, health literacy is a major problem in the region, even for common diseases like diabetes. As such, many Hispanic and Latino individuals without access to specific COVID-19 educational materials and outreach programs may not participate in the social distancing recommendations necessary to mitigate the spread of disease.

"It's the perfect storm," Fernandez told 番茄社区. "It came at a time when the people to be most impacted are least likely to respond to it."

Immigrants, of which the undocumented are a subset, comprise the majority of the nation's and .

In these positions, they are often required to be in close quarters or interact with the public, which puts them at higher risk, said Madison Allen, of the Center for Law and Social Policy.

"I think what we're seeing is that the need for increased access by immigrant families to programs that serve basic needs is more acute now than ever," Allen told 番茄社区.

Chilling Effects of Public Charge

Living here illegally, Snell's patient was hesitant to visit the emergency room, unsure if administrators there would ask for her papers or if she would face a greater risk of developing the virus.

"If they do seek care, it may not be until the end of [the infection's] course," Snell said. "Then how many people have they come into contact with already?"

Under the Trump administration's "public charge" rule, which the U.S. Citizenship and Immigration Services (USCIS) finalized on Feb. 24, the agency may for individuals accepting substantial amounts of public assistance, including Medicaid, food stamps, or Temporary Assistance to Needy Families.

The USCIS stated that testing, treatment, or future vaccines for COVID-19 covered by Medicaid will be excluded from public charge considerations.

"If the alien is prevented from working or attending school, and must rely on public benefits for the duration of the COVID-19 outbreak and recovery phase, the alien can provide an explanation and relevant supporting documentation," the USCIS stated. "To the extent relevant and credible, USCIS will take all such evidence into consideration in the totality of the alien's circumstances."

However, with the rule coming just as the outbreak began in the U.S., this information may have been overshadowed by the all-consuming nature of the pandemic.

Amy Tang, MD, of North East Medical Services in San Francisco, said her patient volume has been reduced by about half, though it is impossible to separate how much of that is attributable to isolation and how much is due to the "chilling effects" of public charge.

"It's hard to control the narrative that was out there," Tang told 番茄社区. "There is a real concern that if people are sick during this time, they may be afraid to come in and seek care."

Fear of Deportation

An increase in immigration enforcement and anti-immigrant rhetoric from the Trump administration have contributed to fears of accessing healthcare and other programs, Allen said.

Although Immigration and Customs Enforcement has halted most immigration enforcement to focus on criminal cases, more than 6,000 individuals have been expelled along the U.S. border under a "in the interest of public health."

Ricardo Gonzalez-Fisher, MD, MPH, of the Servicios de de La Raza at the Mexican consulate in Denver, said there have been many deportations in his area since the pandemic began. In fact, he has seen a trend towards reverse migration: individuals who have lost their jobs leaving the country voluntarily.

About 30% of the population he serves is undocumented, and many have disclosed fears that they will be ineligible for using public benefits, Gonzalez-Fisher said.

"A lot of our people have been mistreated before so they don't trust a lot of things even if they're official," Gonzalez-Fisher told 番茄社区. "Because of this, some of our people will not use the resources that are available."

In California, to provide $75 million for nonprofit organizations to distribute to roughly 150,000 undocumented immigrants hurt by the coronavirus.

But undocumented immigrants are ineligible for the federal government payouts announced as part of the $2 trillion stimulus bill, including the 27,000 individuals covered by the Deferred Action for Childhood Arrivals program currently working within the healthcare system. Even U.S. citizens whose the payout.

"They are discouraged," Gonzalez-Fisher said. "People are afraid and a lot of people are thinking [COVID-19] isn't going to affect them and they even got their children out of Medicaid."

Falling Through the Cracks

Undocumented patients who do seek care may face disparities as well.

A healthcare interpreter working at a hospital in New England, who wished to remain anonymous, said she does not enter rooms with critical COVID-19 patients. Instead, they are provided with remote interpreters who deliver information virtually.

At the hospital, which did not wish to be identified either, she communicates with non-critical COVID-19 positive patients from the doorway of their isolation room, sometimes yelling to be understood above the noise. Between appointments, she sprints across the emergency room to minimize exposure.

"Although I'm here and available, because doctors are in a hurry, they'll still pull over the video interpreter," she told 番茄社区. "It's not fair to the patient. They should have the benefit of a live interpreter, which they prefer."

Teaching moments might also be lost in translation in a hurried emergency room setting. Patients, who speak less common languages than Spanish, in particular, may be discharged without understanding the importance of social distancing, or the possibility of reinfection.

"With the speed with which we're working these days, I wonder if people are going to fall through the cracks," she said.

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