|Physician leaves lasting legacy in farmworkers' health care
Tina Castañares, MD, a family physician since 1980, has worked as a primary care clinician at La Clínica del Cariño in Hood River and The Dalles, Oregon. In 2003, she also began working in end-of-life care, and currently serves as Medical Director for Hospice of The Gorge.
Dr. Castañares has consulted with more than 60 federally qualified health centers as a technical assistant. She also has been involved in health care reform and grantmaking.
An original member of the Oregon Health Services Commission, she assisted in the pioneering priority-setting work that helped create the Oregon Health Plan.
For 12 years, Dr. Castañares was the Health Officer for Hood River County. She also served as the National Ombudswoman for Farmworker Health to the U.S. Assistant Surgeon General for 11 years.
She has taught and lectured nationally and internationally about resource allocation, Latino and immigrant health, end-of-life care, bioethics, and health care reform.
In an interview with Colors of Influence, Dr. Castañares shares her insights on the status of farmworker health and access to care.
What is your interest in migrant health? My father was Mexican, and I had a great interest in working with other Latino people. I also had a personal draw to live in a rural area. I grew up in Los Angeles, but I was never cut out for the big city.
I spent about 12 weeks during med school in Fort Yuma, Arizona, an Indian health service unit. I liked the public health model on the reservation. I was exposed to community health workers for the first time. I soon started in migrant health, and still think it’s the best population to work with.
How did La Clinica get its start? La Clínica del Cariño was started by a group called the Migrant and Indian Health Coalition, now known as the Oregon Child Development Coalition. Headquartered in the Hood River Valley, their business was running headstart and day care centers for Native American children and children of migrant farmworkers.
They believed there was a real need for health care among the children and their parents. They got in touch with the government during the Reagan administration when very few new community health clinics were being opened. It was a real rarity, hence, it was really wonderful that they got a grant to start a clinic in Hood River.
The intention was to build a migrant clinic. By federal requirement, La Clínica had to have an autonomous governing board, separate from the coalition , so it became an independent agency almost right away.
La Clinica opened its doors in a rented clinic facility in Hood River in June 1986.
We knew that we would have other community patients in addition to migrant farmworkers, but we had no idea how much unmet need there was among other low-income community residents. Almost right away, more than half of our patients were not migrant farmworkers but rather were low-income, mostly Anglo, year-round residents of the mid-Columbia.
How did you get involved with La Clinica? I had been working in a migrant clinic in California and moved to the area for family reasons. It was clear that there were a lot of farmworkers and not a lot of doctors that spoke Spanish. I started a private practice during my first year. I loved living here, and I saw a lot of Latino patients – lots of women. I believe I was the first primary care woman doctor who had ever lived in Hood River.
I’ve told this story about my epiphany before. The hospital didn’t have ER doctors, so we would get called if a patient visited the ER. I got a call in the middle of the night during the winter. I met with a Mexican family with a little child with a fever. The baby had an ear infection. They were uninsured. I told them that I was worried for them, getting this big hospital bill.
“Doctora, we didn’t have any money for an appointment in your office,” they said.
At that time, office visits cost $10. I told them that I wouldn’t have made them pay, if they couldn’t afford it.
Their response: “Doctora, we didn’t want to take advantage of you.”
In the end, it was a lose-lose for everybody. I didn’t like the private practice of medicine. To me, that’s not the best way to serve low-income people.
I had already given my patients advance notice that I was going to close the practice, when I got a cold call from La Clínica organizers. They wanted to know if I would help get a publicly-funded clinic started. I had been the medical director of a federally funded migrant clinic in California so I had experience in this field. I started out as a consultant in September 1985, and they hired me to be our first doctor. I was so grateful, because it’s exactly what I wanted to do.
I still see patients one day a week in La Clínica, alternating weeks between Hood River and The Dalles. I also am officially the Government Relations Coordinator for La Clínica. I’ve been involved in health care reform work for so long, which helps me to report on federal, state and regional health care and immigration reform issues to the leadership team and other doctors.
What are some of the changes you observed over the years? The farmworker population has changed a lot. We no longer have as many migrants; most farmworkers are settled out year-round residents. That change happened during La Clínica’s lifetime, with the 1986 IRCA legislation (Immigration Reform and Control Act), the last major immigration reform overhaul. That allowed for so many people to be legalized and become permanent residents and bring their families over through family unification provisions.
Most of the farmworkers in this area became settled residents. More than half the children in the schools are Latino. That’s within only one generation.
We still have a very special mission to serve migrant farmworkers. During the cherry harvest in The Dalles, in particular, we have special outreach to migrants. It’s a short harvest, and the people are true migrants – most of them coming from California.
All year round, we try to have a special focus to address the occupational health and access needs of farm laborers. A lot of our special services have to do with serving minorities and immigrants. They have special health needs and insurance obstacles by virtue of their immigration status, ethnicity and national origin.
For practical purposes, we often talk about our Spanish-speaking patients and our English-speaking patients, because in many respects, that’s how it shakes out …whether they work on the farms or elsewhere.
What are the most pressing issues facing farmworkers today? The unique needs of farmworkers are the bundle of access, low income, discrimination and occupational health issues. The disparities in income are larger than ever. Farm laborers are, I believe, the only occupational group whose real wages have actually declined since the 1970s, that is, when adjusted for inflation. Migrant farmworkers are poorer than ever. Thus, poverty and related issues are paramount.
More than 90% of farm laborers now are immigrants. The overarching issues are immigration policy, what causes immigration, trade issues.
Some p eople who work in migrant health don’t want to talk about the issue of immigration status very much. I like to talk about it because I don’t think we can solve problems without addressing the need for reform of immigration and trade policies.
There are also occupational health issues have to do with pesticides, orchard or farm accidents. There are issues with children who are dislocated from their school. There are issues of access to healthcare , which are largely because of immigration status, because they’re not eligible for Medicaid. And then most farmworkers face the same issues that other Latinos face: a higher prevalence of diabetes and its complications, for example.
Most farmworkers work in at least one other industry: day labor, service, restaurant and hospitality industries. They face different occupational hazards in these other industries, and face the same access barriers, discrimination and poverty issues that they encounter in farm work.
How can these issues be addressed? I’m very interested in policy-level solutions that demand more realism, both about our present state of affairs and forecasting for the future. There would have to be many players involved. When I teach about immigration reform and health, I really try to make a convincing case about having a robust , legal , secure immigrant workforce in our country, to ensure the future of Social Security and Medicare. If you and I want to be taken care of when we’re older, we have to have a very large immigrant workforce that is secure, welcome and has benefits.
In the sense of enlightened self-interest, it’s good to get that point across.
People say: “Let’s deport or limit immigration and give Americans back their jobs.”
There aren’t enough native-born people to do the jobs, and there wouldn’t be for more than 100 years at best. We’ve got to be realistic about the fact that we need an immigrant workforce, and American values ought to dictate that folks be treated fairly.
Clearly, we need universal access to health care, and that needs to include immigrants.
We need to be realistic about what basic health care is for everyone. We have a crazy system that rewards sophisticated, very highly specialized care while not ensuring basic and essential care. We need an emphasis on primary and preventive care, as well as public health.
There are many side issues around farmworkers’ health that involve a living wage, good housing, the right to organize. All these things are very important. In public health, they call these the “social determinants” of health. Especially with the poor, they are very important.
What spurred your decision to focus on end-of-life care? As I first started doing primary care, I was drawn to work with people and provide end-of-life care. I liked obstetrics too. When you help with births and deaths as a doctor your time is a mixture of the intellectually and medically challenging and the emotionally and spiritually intimate.
In hospice, for the most part, patients have accepted that they are dying. The team can begin to work with them to make the dying process and their last months a more beautiful thing, and more physically and psychologically comfortable for them and their families. So many reconciliations happen within families, and so much beauty is expressed by so many patients.
In my role at Hospice of The Gorge, I don’t get to see a lot of patients pe rsonally. I do some home visits, but mostly our nursing staff gets to see our patients. I’m on call to consult with our nurses. It’s been intellectually gratifying because I had to learn a lot about end-of-life care , and have now become board-certified in the specialty.
What do you enjoy most about the work that you do? I like that it’s variable, creative and flexible. I’m never bored. I feel so lucky. I love both the organizations I work for, and no two days are ever the same.
The most grounded work I do – still my life’s blood – is my day-a-week doing primary care with patients. If I didn’t do that, I don’t think I could do the rest, even the hospice work. It’s the work with individual patients that really reminds me of what it’s all about. It’s the hardest part of my workweek, but also the most satisfying.
What are you most proud of? I think that would be my helping to spread the word about the great value of health promoters or community health workers in the United States. I think the lay health promoter or community health worker model is our future, if we’re going to redesign the health care system effectively.
We’ve had health promoters in La Clínica del Cariño since 1987. Their work has been incredible. I got to be involved in our first health promoter program, doing pediatric health promotion in farm labor camps, churches and all over the Latino community for three years.
Community health workers – often called promotoras de salud – is really a model from the developing world . Someone from the community receives special training that they design, then work s to teach others in the community. They’re people who didn’t go through health professional training, and yet they work quite professionally in the public health care world. They tend to reflect the demographic of communities that have the most barriers to achieving or maintaining their own best health.