There are numerous barriers to recognizing and treating occupational and environmental health (EOH) problems in the primary care setting. Some of the underlying reasons are the limited EOH training front line providers receive as well as institutional challenges that prevent clinicians from adequately addressing EOH problems.  For migrant farmworkers and other vulnerable populations working in hazardous industries such as construction, an occupational injury or exposure is often the reason for first point of contact with the health care system, underscoring the need to begin addressing EOH concerns at the primary care level.

To address these concerns, the Migrant Clinicians Network (MCN), the nation’s oldest clinical network for the under-served, has developed a program to focus on EOH in the primary care setting. MCN’s program, Saving Lives by Changing Practice, is part of a five-year cooperative agreement with the U.S. Environmental Protection Agency, Office of Pesticide Programs, to address pesticides and other EOH issues in primary care practice setting.

MCN will ultimately recruit and work with six to eight federally funded Migrant and Community Health Centers (M/CHC) to develop a flexible, center-based model to integrate EOH in the primary care setting.  This will involve incorporating key practice skills outlined in National Environmental Education Training Foundation’s, National Pesticide Practice Skills Guidelines for Medical and Nursing Practice (2003).  These skills include:

• Taking an environmental history.
• Awareness of community and individual pesticide risk factors.
• Knowledge of key environmental/occupational health principles.
• Clinical management of pesticide exposure.
• Reporting pesticide exposure and supporting surveillance efforts.
• Providing prevention guidance and education to patients.

The first M/CHCs MCN has recruited are the Maine Migrant Health Program and Golden Valley Health Centers, in Merced, Calif.  The Maine Migrant Health Program is a primary and preventative health care delivery system that serves migrant and seasonal farm workers throughout Maine.  Golden Valley provides comprehensive primary medical and dental care to an ethnically diverse population, including migrant and seasonal farm workers, Southeast Asian refugees, and the homeless population throughout Central Valley of California. 

Key to the success of these partnerships is both administrative and clinical “buy in” to the project.  At both of these health centers, MCN works directly with a “clinician champion,” or a clinician who is interested in environmental and occupational health and willing to spearhead the clinic-based program.  Additionally, MCN has contractual agreements signed by the executive directors and provides the health care centers with a $5,000 stipend to offset the costs. In the case of the Maine Migrant Heath Program, the stipend will be used to conduct a pre and post chart evaluation to determine if the intervention improves the recognition of occupationally related injuries and exposures.

Another integral aspect of this program is its expert advisory committee made up of primary care clinicians, occupational and environmental medicine specialists, and representatives from pesticide regulatory agencies and farm worker advocacy groups.  The Association of Occupational and Environmental Clinics (AOEC), the American College of Occupational and Environmental Medicine (ACOEM), the University of Washington and the National Pesticide Medical Monitoring Program are part of the advisory committee.  MCN not only looks to these experts to guide the program, but uses these partnerships to link primary care clinicians in Migrant and Community Health Centers with occupational and environmental specialists and clinics by: 

• Training primary care providers in occupational/environmental medicine.
• Facilitating clinical consults between the primary care clinician and the occupational medicine clinician.
• Developing referral mechanisms for complicated pesticide cases.
• Supporting clinicians and clinics with workers compensation.

The expert advisory panel is currently assisting MCN to develop a prioritized list of occupational/environmental screening questions for primary care.  If a clinic is only able to ask one occupational screening question, then this list will identify the most critical question to ask.  If the clinic is able to include more questions, then the list will offer additional pertinent questions. 

The key issue for any product or resource developed through this project is that it must be reasonable and practical for a primary care setting where time is extremely limited and the number of topics covered quite extensive.  MCN feels that the equal partnership between occupational medicine specialists and primary care providers offers a needed balance and is critical to bringing about real improvement in care for migrants. 

MCN welcomes the participation of occupational health professionals, primary care clinicians and clinics interested in EOH.  If you would like to be involved or would simply like more information about this effort, please contact Amy K. Liebman at (410)860-9850 or aliebman@migrantclinician.org.

submitted by Amy K. Liebman

aliebman@migrantclinician.org