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STORY APRIL 28, 2021

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Inequality’s Deadly
Toll

Amy
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COVID-19, Farmworkers and the
Erosion of Public Health

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Image by Brian L. Frank/Nature. United States.

n a hazy day in November, Hardeep Singh received a text message from the COVID-19 testing system at

Foster Farms poultry company saying that his mother had tested positive for the coronavirus.

He got the alert because his mother, a 63-year-old line worker at one of the company’s meat-packing

plants in California’s San Joaquin Valley, doesn’t speak English and doesn’t own a smartphone.

Singh couldn’t reach her as she continued to handle chicken parts alongside her co-workers. Her supervisors didn’t tell her,

either. In fact, they assigned her more shifts for the week.

Singh broke the news to her that evening, and convinced her not to return to work, where she might spread the infection to

others. But he couldn’t reach anyone at the company for another five days, to ask whether she qualified for paid time off

while she isolated.

Singh’s mother ended up being among the more than 400 employees at the plant who were diagnosed with COVID-19 last

year, and one of about 90,000 cases linked to food-production facilities and farm work across the United States. Because

the sector feeds Americans and powers part of the US economy, agricultural workers such as Singh’s mother have been

considered essential workers during the COVID-19 pandemic.

That important role comes at a cost. One study  found that food and agricultural workers in California had an almost 40%

increased risk of dying last year, compared with the state’s general population. And within that imbalance lies another

contrast. Latinx food and agriculture workers experienced a nearly 60% increase in deaths compared with previous years;

the increase for white workers was just 16%.

The reasons for such disparities, say public-health researchers, include discrimination, low wages, limited labour

protections and inadequate access to health care, affordable housing and education. These are some of the ‘social

determinants of health’, a concept that has been around for at least 150 years, but which has gained recognition during the

pandemic.

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Workers pick oranges in California’s Central Valley in April. Food and agricultural workers in the state were 40% more likely to die than the general population last year.

Image by Brian L. Frank/Nature. United States.

The phrase was on the lips of Anthony Fauci, the highest-ranking infectious-disease scientist in the US government, as he

explained why Black, Latinx and Indigenous people have been affected by COVID-19 much more than have white people in

the United States. The concept has also attracted infusions of grant money from the Centers for Disease Control and

Prevention (CDC) and the US National Institutes of Health. Yet although scholarship on the social determinants of health

has been growing for decades, real moves to fix the underlying problems are complex, politically fraught and, as a

consequence, rare.

The pace of change looks particularly stagnant when compared with advances in infectious-disease biology, in which

researchers have isolated pathogens and created life-saving therapies and vaccines to stop them.

To understand what makes confronting the social determinants of health so hard, I investigated the tumultuous coronavirus

response in the San Joaquin Valley, where hundreds of thousands of agriculture workers reside. Most of them were born

outside the United States, and many lack legal residency, meaning they have limited access to social services, such as

unemployment benefits or health care, despite paying taxes.

The valley is one of the richest agricultural regions in the world, and simultaneously has one of the highest poverty rates in

the United States. During the pandemic, it has provided a clear example of how inequality renders some groups of people

much more vulnerable to disease.

“We call them essential, but they’re considered expendable,” says Singh, himself a medical student pursuing a dual degree in

public health. He asked for his name to be changed because of concerns that speaking out might cost family members their

jobs.

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Map courtesy of Nature.

As COVID-19 devastated disenfranchised communities in the San Joaquin Valley (see map), grass-roots organizations

joined with local researchers to provide help. They’ve organized testing drives and educated communities about the disease

and vaccines. But much of their work falls outside medical care, such as advocating for labour rights and subsidies for

housing.

These types of social and economic intervention are what’s really needed to address health disparities, but many academics

and health officials are reluctant to push for such measures publicly, says Mary Bassett, an epidemiologist at Harvard

University in Cambridge, Massachusetts, who is a former commissioner of New York City’s Department of Health. That

reticence needs to change, she says. “We need to be more outspoken about things that aren’t in our lane.”

Bassett is one of a growing number of researchers who are getting political, and who hope that COVID-19 will be a catalyst

for change in the field. “The pandemic has turned up the dial, and to me it brings out a sense of urgency,” says Arrianna Marie

Planey, a medical geographer at the University of North Carolina in Chapel Hill. Not content with simply identifying the

social determinants of health, she says public-health researchers should be doing more to address them.

“I see a study saying COVID is higher in farmworkers, and I’m not interested — I want to know what’s next.”

At the turn of the 20th century, sociologist W.E.B. DuBois explored the health and living conditions of Black people in Philadelphia in exquisite detail. Image courtesy of

University Archives Image Collection/University of Pennsylvania. United States.

An unhealthy past

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A Prussian doctor, Rudolf Virchow, described the social determinants of health long before the phrase was coined. In the

mid-1800s, he began a government-commissioned investigation into outbreaks of typhus in Upper Silesia, a coal-rich region

in what is now Poland.

Virchow documented hunger, illiteracy, poverty and depression among Silesians, and concluded that the root of the

problem lay in their exploitation. “The plutocracy, which draw very large amounts from the Upper Silesian mines, did not

recognize Upper Silesians as human beings, but only as tools,” he wrote in his 1848 report on the typhus epidemic.

Virchow’s radical solution was that “the worker must have part in the yield of the whole”.

The US sociologist W. E. B. Du Bois reached similar conclusions at the turn of the twentieth century, in a body of work that

powerfully refuted eugenicist hypotheses suggesting that Black people died earlier in the United States because of their

biological make-up and supposed unsanitary behaviours. Du Bois intensively surveyed people across Philadelphia,

Pennsylvania, and found that mortality rates were similar across races in city wards that ranked well on metrics for housing,

education, occupational status and other variables.

Higher death rates among Black people were linked to wards that were worse off by these metrics. His conclusion: the

conditions of people’s lives mattered, not the colour of their skin.

Despite a steady drumbeat of studies over the next century calling out the social and economic roots of poor health (see

‘Equity boosts life expectancy’ below), policies have rarely changed in response, says epidemiologist Michael Marmot,

director of the Institute of Health Equity at University College London.

Equity boosts life expectancy
Around the world, life expectancy is generally shorter in countries with a high Gini coefficient, a measure of income

inequality. A value of 1 indicates complete inequality, where one person in a population receives all the income and others

receive nothing; a value of 0 shows full equality, where everyone in a population has the same income.

In the United States, higher income correlates strongly with longer life expectancy, even if income percentiles are adjusted

to contain the same proportion of Black, Hispanic and Asian adults.

Sources: World Bank/World Health Organization (left/top); Ref. 3 (right/bottom). Graphs courtesy of Nature.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1698167

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For example, a major investigation in the United Kingdom in 1980 concluded that, to remedy disease disparities, the

government needed to put more money into public education, public health and social services, while raising taxes on the

wealthy. The Black Report, named after Douglas Black — its lead author and an early supporter of the UK national health

system — made waves in health-policy circles, resulting in the World Health Organization leading an assessment of health

disparities in a dozen countries.

But the recommendations gained no traction with leaders at the time . UK prime minister Margaret Thatcher and US

president Ronald Reagan, for example, slashed public expenditure, cut taxes for the rich and deregulated companies to

boost their countries’ faltering economies. The gross domestic product of both countries rose, but so did poverty and

economic inequality (see ‘Economic inequality in the United States’ below).

Economic inequality in the United States
The wage gap in the United States has widened considerably since the 1980s. As wages have increased for high earners,

they have decreased or remained static for those on lower salaries.

In 2019, the highest proportions of people earning less than $15 per hour were Hispanic women and Black women.

Sources: Economic Policy Inst./EPI Current Population Survey (left/top); Bureau of Labour Statistics Current Population Survey/Economic Policy Inst./The Washington

Post (right/bottom). Graphs courtesy of Nature.

Many of the trends set in place during the 1980s continued, even as ruling political parties changed. US president Bill

Clinton’s administration, for example, made welfare harder to receive. And as the gap between the rich and poor grew, so

did health disparities.

By 2014, the wealthiest 1% of men in the United States were living 15 years longer, on average, than the poorest 1% of

men . Those inequalities are poised to grow, predicts a report in The Lancet in February . The report notes that former US

president Donald Trump legislated a trillion-dollar tax cut for corporations and high-income individuals, while weakening

labour protections, health-care coverage and environmental regulations.

Bassett, an author on the Lancet report, says, “We had every reason to prepare ourselves for a bad epidemic when COVID

reached us because this country is full of holes.” She lists several: it lacks universal health coverage and mandatory paid sick

leave; it has a minimum wage that is below a living wage; and it relies on an immigrant workforce, many of whom lack legal

status.

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Community organizations have been at the forefront of efforts to address the root causes of health disparities in the United States. Image by Brian L. Frank/Nature.

United States.

Ground truth
In the bone-dry grape fields of the San Joaquin Valley, farmworkers clip and bag bunches of grapes at a furious speed —

they’re paid by the package. A farmworker whose eyes peek out above a dirt-caked bandana doesn’t stop moving as I ask,

through a translator, whether she would get tested for the coronavirus if the owner of the farm provided tests.

No, she whispers, because if it were positive, she couldn’t afford to miss work. Another farmworker, a broad-shouldered

man with calloused hands, echoes the sentiment. “Farmworkers don’t stop for a pandemic,” he says. “We keep working.”

Both requested anonymity because they are undocumented immigrants from Mexico.

I drive past tidy rows of nectarine, pomegranate and almond trees, on the way to a melon-packing plant in the city of

Mendota, where hundreds of farmworkers queue in their cars alongside a road. They’re waiting for boxes filled with

vegetables and starches.

Food drives such as this occur regularly in California, to assist the estimated 800,000 farmworkers in the state who live far

below the poverty line. On this sweltering afternoon, free COVID-19 tests are available in the car park across from the food

distribution site. But that area remains vacant.

About a dozen farmworkers waiting for food echo what those in the grape fields had told me: a positive test threatens their

survival. In a beaten-up minivan, a woman with blonde hair grips her steering wheel and confesses, “I’m very frustrated.” She

had COVID-19 a few months earlier, but returned to pick lettuces as soon as she felt well enough to stand. Her “bones hurt”,

she says, but she hid the pain from her supervisor out of fear that she might be fired. “Essential workers are forgotten,” she

says, before inching forwards in line.

Similar fears and frustrations had flooded the Facebook inbox of Tania Pacheco-Werner, a medical sociologist and co-

director of the Central Valley Health Policy Institute at California State University in Fresno. Many farmworkers know of

Pacheco because she immigrated to the valley from Mexico City as a child with her parents, who worked in the fields.

Pacheco observed the contrast between what public-health officials were recommending, and what agriculture workers can

realistically do. For example, the CDC said people should physically distance, but that is often impossible in food-processing

plants or in the cars that people share to get to work.

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Such realities meant that deaths mounted for Black and Hispanic people in the United States, who are more likely than

white people to hold low-paying jobs that cannot be performed at home,

With people she knew in dire straits, Pacheco wasn’t content to study COVID-19 disparities. She got in touch with grass-

roots organizations in Fresno — the most populous city in the valley — and learnt that they had similar concerns.

By May, around a dozen groups, such as the African American Coalition, the Immigrant Refugee Coalition and the Jakara

Movement (representing immigrants from Punjab state in India), were lobbying Fresno’s leaders for interventions tailored

to the needs of their communities. They warned that the coronavirus response would fail without their help, because

disenfranchised groups trusted them — not the government.

This was particularly true among undocumented immigrants, who had faced increasing discrimination since the election of

Trump in 2016. Trump repeatedly denigrated Mexicans as criminals, and passed policies to increase deportations.

Farmworkers told me they watched videos of raids by US immigration and customs officers in fear. It made them as wary of

public-health officers as they were of the police. “When you realize how screwed people get here,” Pacheco says, “mistrust

begins to make sense.”

For the first few months, Pacheco and her colleagues say that the Fresno county government, led by a predominantly white

board of supervisors, ignored their requests to enforce safer conditions on farms, food-packing plants and warehouses, or

to provide paid sick leave and other financial assistance for essential workers.

The board also resisted some public-health measures aimed at reducing the spread of the virus. In May, for example, it

revised the wording on masking guidance from the Fresno county health department and publicly undermined the

messaging.

In a statement released just after the original guidance, a Fresno county spokesperson wrote, “The updated Health Officer

Order is a recommendation, NOT a mandate.”

After the pandemic began, Fresno residents pleaded with county leadership to provide protection and financial support.

These two comments were shared by a Fresno-based advocacy organization, the Leadership Counsel for Justice and

Accountability.

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I ask that you have the compassion

to ensure families can stay in their

homes during this pandemic. We do

not need more people in Fresno

County without housing … I lead the

food distribution and we have

doubled the number of families we

serve and desperately need PPE.

We have reached out to various

agencies and have been turned

down. I really need help to keep

families in our county fed, we need

to work together as a team during

times like these.

Image by Brian L. Frank/Nature. United States.

Image by Brian L. Frank/Nature. United States.

Our youngest son lost his job due to

COVID-19, and now our whole

family is paying two rents. We are

struggling to ensure our son

completes the school year and our

bills get paid on time. We please ask

that the county consider families

like ours, hardworking families, who

are not asking for a handout, we are

asking for help to get by during this

pandemic.

Meanwhile, Fresno’s public-health department found itself serving as a mediator between community organizations and

agriculture companies. The tension between the two groups comes through in e-mails obtained through a national COVID-

19 documentation project run by Columbia University in New York City.

ISABEL SOLORIO, LANARE RESIDENT

LUCIA SALMERON MARROQUIN, FRESNO RESIDENT

https://documentingcovid19.io/

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In a message from July, for example, Tom Fuller at the health department wrote to his colleagues about his conversations

with farm and food-plant owners: “I have detected an undercurrent of suspicion and perhaps resistance towards some of

the groups that have identified themselves as wanting to be part of the County response to the pandemic.”

Fresno’s health department had little ability to fight the board’s decisions, because its jurisdiction is limited to a handful of

measures, such as immunizations and disease surveillance. Plus, says Miguel Arias, a member of Fresno’s city council, the

board dictates the health department’s leadership and budget.

“The department of health is as strong as the board of supervisors allows it to be,” Arias explains. Similar power dynamics

played out across the United States, and were exacerbated by protests against coronavirus measures. At least 181 public-

health officials resigned, retired or were fired last year, and many of them had faced harassment from the public for doing

their jobs, according to an investigation by Kaiser Health News and the Associated Press.

Arias, too, was threatened. He and other city-council members pushed the board to expand testing on farms, and couple it

with paid sick leave. But his confrontational approach got him into trouble.

“One of the supervisors said to me, ‘Stay in your lane — we aren’t going to disrupt the agriculture industry at the peak of

harvest’,” he recalls. On another occasion, men associated with the Proud Boys, a violent, far-right organization, showed up

at Arias’s home to confront him.

Buddy Mendes, the chair of the board of supervisors last year, refutes claims that they didn’t push for testing on farms

because it would be bad for business. Rather, he says, the board had concerns about the type of rapid diagnostic tests being

proposed. And he says the board wasn’t ignoring community groups. “It took until August to get the scope of works

prepared, and contracts in place.”

Indeed, the community organizations found their footing in August, just as the outbreak in the San Joaquin Valley exploded.

California governor Gavin Newsom approved US$52 million to fund the coronavirus response in the region, and specified

that it should target the disproportionate number of Hispanic people who were testing positive for the coronavirus — they

accounted for nearly 60% of cases.

It was during this surge that the board gave $8.5 million to the community organizations, after they partnered with doctors

and researchers from the Fresno campus of the University of California, San Francisco (UCSF), to form the Fresno COVID-

19 Equity Project. A few weeks later, the team converted an austere church belonging to the Fresno Interdenominational

Refugee Ministries into a coronavirus testing site.

https://apnews.com/hub/underfunded-and-under-threat

Wow. Things are getting a little out of hand in Fresno… Fresno City Council President clashed with conservative activists outside his apartment. pic.twitter.com/DAEwgaeQ1M

— Veronica Miracle (@ABC7Veronica) May 13, 2020

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Jessica Adley registers people for vaccination at an event at Fresno Community College. Image by Brian L. Frank/Nature. United States.

Community action
Two hands grasp a heart on a billboard outside the church for refugees, beside a Bible quotation from Leviticus: “You shall

love the foreigner as yourself.” People drive slowly past it all afternoon as they head to a car park and wait for a test from a

health worker who will slide a swab far into their nostril.

Kenny Banh, an emergency-medicine physician at UCSF Fresno, paces excitedly around the transformed church in medical

scrubs, reinvigorated by a chance to help people who are healthy enough to walk.

He explains that people of colour with COVID-19 were often the “sickest of the sickest” patients that he treated at the

university hospital. A key problem contributing to higher death rates in this group is that they delay seeking help because

they don’t have health insurance, can’t afford medical bills or fear doctors in the United States, he says.

“A lot of them don’t trust the medical community, and I don’t blame them in some respects because historically they haven’t

been treated well.”

On the lawn outside the church, leaders of the Fresno COVID-19 Equity Project were training a legion of people with a

knack for grasping the latest coronavirus news and relaying it to their neighbours.

The project hired and trained 110 of these community health workers, who together speak 16 different languages. That

investment of time and money meant turning down researchers who had asked to join the project to study inequities, says

Pacheco. She and her colleagues thought that community workers would have a higher pay-off in the near term, even if it

cost them publications and grants down the road. What’s more, Banh adds, communities in the valley had grown exhausted

with scientists surveying them year after year.

“By asking people questions, you give them a false belief that you’re going to deliver some sort of help,” he says; when

change never arrives, people grow disillusioned.

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Workers from Texas, Oklahoma, Missouri, Arkansas and Mexico harvest carrots in California in 1937. Image courtesy of Dorothea Lange/Farm Security Administration.

United States, 1937.

Still, a century of neglect isn’t easily undone. Sparse neighbourhoods along the rural roads of the San Joaquin Valley can be

traced back to temporary housing tracts built for migrant workers in the 1930s.

Today, some of these towns don’t have safe drinking water or a single clinic. And the city of Fresno itself is sharply divided.

Predominantly Black, Latinx and Asian neighbourhoods are in the south of the city. These sections were shaded red on maps

from the 1930s, indicating areas with large, non-white populations where banks were discouraged from issuing home loans.

This practice, known as redlining, pushed down property values in the areas, and helped to reinforce racial segregation and

inequality. Although lawmakers attempted to mitigate the discriminatory practice in the 1960s, parts of south Fresno still

have limited access to parks, Internet services, healthy food and other benefits.

According to the Central Valley Health Policy Institute, a child born in a wealthy neighbourhood in northern Fresno is

expected to live past the age of 80 — more than 10 years longer than a child born in parts of south Fresno, and 20 years

longer than a child in rural neighbourhoods in the San Joaquin Valley, where average life expectancy is similar to that for

many low-income countries.

Southwest Fresno is where Guadalupe Lopez lives with her husband and three children in a rented mobile home without

drinkable tap water. By the time she connected with a community group serving Indigenous people from Mexico — Centro

Binacional para el Desarrollo Indígena Oaxaqueño — she was facing eviction and eating barely a tortilla a day.

“It’s a nightmare,” she told me as we sat beside a bed and child-sized desk in her tidy living room. Just after garlic-picking

season in late July, her 34-year-old husband developed a severe case of COVID-19. He gasped for air, but refused to go to a

hospital because he was terrified by the possibility of being permanently separated from his family.

How would Lopez — who asked for her name to be changed because she’s an undocumented immigrant — care for their

children without him?

But her husband agreed to see a doctor referred to him by a friend. The doctor sold Lopez injections of unapproved drugs

that he said would help with COVID-19. She says the bill came to $1,500 — all of the family’s savings.

In the ensuing weeks, her husband’s health deteriorated, and Lopez tested positive for the coronavirus, too. Neither of them

could work in the fields, and their cupboard ran empty. She cries as she describes how her children became so thin that she

could see the outlines of their ribs.

Lopez’s family was not eligible for federal funds to cover unemployment, and the state’s funds for sick leave had run dry.

The Centro Binacional granted her money to cover rent. In October, Lopez’s husband returned to the fields, even though he

still has bouts of intense fatigue.

Lopez’s eyes fill up again as she explains what it feels like to be an essential worker in a country that seems to want her dead.

“When I go to the store covered in dust from working in the field, white people will look at me in disdain, even when I’m

wearing a mask and they aren’t,” she says. “I feel awful because they look at us as less than human.”

Community health workers share similar stories of desperation. Although their intended role was to educate communities

about the coronavirus and assist in contact tracing, they find themselves on phone calls at all hours, scrambling to find funds

for parents who cannot feed their children or keep the lights on.

“I see so much sadness when I talk with people,” says Leticia Peréz de Trujillo, a community health worker with Cultiva La

Salud, a …