On a seemingly ordinary day in 2005, a migrant farmworker with a frostbitten hand sought the help of general surgeon Brendan C. Brady, MD, FACS, in Canandaigua, NY. Through an interpreter, the surgeon learned that the worker couldn’t afford to buy gloves to protect his hands and that his employer did not provide them. As the surgeon came face-to-face with the plight of farmworkers in his community, the day became extraordinary and from that point forward, Dr. Brady could not turn away. This experience launched a journey that Dr. Brady has traveled for the last seven years as he has focused on providing migrant workers in upstate New York with access to safe, quality surgical care.
Dr. Brady received the 2012 American College of Surgeons (ACS) Surgical Volunteerism Award for Domestic Outreach, sponsored by Pfizer, Inc., for his efforts to care for migrant workers in his community. The volunteerism award, inaugurated in 2003, recognizes “surgeons and surgical residents committed to giving something of themselves back to society by making significant contributions to surgical care through organized volunteer activities.”1 ACS Operation Giving Back (OGB) works with the Board of Governors in overseeing the volunteer award (see sidebar for more information about OGB).
Yet Dr. Brady is quick to note that he didn’t provide those services alone. He had lots of help. “The award was nice,” he said, “but the real awardees are the people who work at the clinic and, with a very low budget, make it their life’s work to serve an indigent population.”
Dr. Brady is not one to boast about his own accomplishments. But he ultimately agreed that publicizing his work with migrant workers might inspire other surgeons and health care professionals to commit to helping marginalized populations.
A practicing surgeon for 30 years with the Canandaigua Medical Group in New York State’s Finger Lakes region, which lies roughly between the cities of Syracuse and Buffalo, Dr. Brady has provided steady, quality care to patients, and it has all been “fun and interesting,” because the surgical field has always held that fascination for him.
His first inkling that he might want to become a physician occurred to him in the 1960s when, as a teenager on a New York City subway with his brother, he noticed an ailing passenger who looked close to death. The sight of the man affected him profoundly, and he remembers regretting that he lacked the expertise to help him. “That was the first time I felt motivation to become a doctor,” he said.
A few years later, he enrolled at the the State University of New York School of Medicine, Buffalo, graduating in 1975. He completed his surgical residency at Buffalo General Hospital.
“One of the blessings of my life was a Jesuit high school education and growing up in the 1960s,” Dr. Brady said. “It is fair to say the combination made for a heavy emphasis on social responsibility. As the 1960s evolved, and I was in college as a pre-med student, I vividly recall a conversation in chemistry lab with other ‘doctors-to-be’ about spending time in Africa once we were doctors. While others noted they would like to volunteer some time, I bragged that I planned on devoting my life there. Things turned out differently.”
“I had always intended to do some volunteer work, but things got in the way. Medical school was a huge amount of work, and residency even more so. By the time residency was done, we had three kids,” he said. “I had to establish a practice, and before you knew it, there were four college tuitions to pay. I found I was working even harder just to save enough to retire. That is when I knew I was in trouble.”
But Dr. Brady never lost sight of the primary reasons he became a surgeon. For many years, he worked with InterVol, a Rochester, NY-based, not-for-profit organization founded by a physician that provides medical supplies and equipment and connects volunteer physicians with hospitals and medical professionals. Through InterVol, Dr. Brady spent several of his summer vacations at the Rosebud Sioux Reservation in south central South Dakota, providing surgical relief to the indigent populations. Later in his career, he also spent time as a volunteer with Operation Giving Back partner CRUDEM (Center for the Rural Development of Milot) in Haiti. Dr. Brady volunteered in Haiti before and after the 2010 earthquake.
Transient patient population
His work on behalf of migrant workers marks the continued development of Dr. Brady’s social conscience. He took it upon himself to learn as much as he could about migrant workers, who mostly are in the U.S. for a limited time—four to five years, he said. Their goal is to earn money here, send the money home, and eventually return to their native country. Most migrant workers in upstate New York are from Mexico, although some are from other Latin American nations and Haiti and, in more recent years, from Poland and Germany.2
According to Dr. Brady, there is a difference between a migrant worker and a seasonal farmworker. A migrant worker is someone who crosses state lines at least once every two years in search of agricultural employment, he said. A seasonal farm worker, on the other hand, is one who stays in the region. Migrant workers, Dr. Brady learned, “are an integral and neglected part of our communities.”
He contacted Finger Lakes Migrant Health (since renamed Finger Lakes Community Health), where he established a surgical clinic. He studied the farming industries of upstate New York, where the key crops are apples, grapes, and corn. A number of dairy farms also can be found in the area, and they generally employ seasonal workers. In gathering information about the migrant population in New York State, Dr. Brady learned that anywhere from 3 to 5 million migrant and seasonal workers are in the U.S., and the number is rising.3 Migrant workers in the U.S. earned an estimated $440 billion in 2011, and, according to the World Bank, this population transferred more than $350 billion in earnings to developing countries.4 “Migrant workers are my neighbors,” Dr. Brady said. “They are your neighbors. They are everyone’s neighbors.”
As he pursued his interest in the “invisible population” of migrant workers, Dr. Brady quickly realized the magnitude of their health care needs. Getting involved led him to an epiphany: “The farm worker population is physically and culturally hidden and lives in an almost parallel universe,” Dr. Brady said. “One of the largest on-farm camps in our area is two miles away from an upscale rural restaurant. Those enjoying their meal at the restaurant have little appreciation that those harvesting the crops live just around the corner.”
Harvest of Shame
Dr. Brady’s brother-in-law suggested that he watch a 1960 television documentary, Harvest of Shame, narrated by legendary CBS news anchor Edward R. Murrow. This groundbreaking report, presented the day after Thanksgiving in 1960, brought the stark life of migrant workers and their families into America’s living rooms. “This broadcast is still a powerful messenger of the harsh conditions facing those who harvest our crops, and how poverty has affected their lives and health,” explained Dr. Brady. The TV documentary did have an impact. Two years after the exposé aired, the U.S. Congress passed the Migrant Health Act, which led to the establishment of approximately 400 federally funded primary care health facilities for migrant workers.5
Despite these developments, migrant workers continue to lead lives of diminished potential. Today, the average life expectancy of the migrant worker is 49 years, compared with 77.2 years for most Americans.6 The grueling nature of their work, combined with minimum wage or low piece-rate wages, frequent relocation, and substandard and crowded housing, make migrant workers susceptible to a number of communicable diseases. Toiling daily under a hot sun in fields sprayed with toxic pesticides, they become afflicted with dermatitis and lacerations and are exposed to a variety of carcinogens. Musculoskeletal issues also diminish their well-being. The combined effects of repetitive motion, bending, and twisting often lead to tendonitis, joint deterioration, and chronic back pain. In addition, the sun, dust, and wind that migrant workers confront each day often lead to blinding eye conditions.6,7
A number of general health problems pervade the migrant population.6 Among Mexican populations in the U.S., 1.2 million have been diagnosed with diabetes, and cardiovascular disease remains the leading cause of death among Latinos in the U.S. Ultimately, many migrant workers do not receive any type of medical care, and virtually none of them has employer-provided health insurance.8,9
The workers give more than they receive. Undocumented workers generate goods and services worth more than $120 billion a year in the U.S. Furthermore, documented and undocumented Mexican immigrants pay $25 to 30 billion in U.S. taxes each year.10,11 The U.S. food industry depends on the low-wage workers, as the jobs of planting and harvesting remain essential to providing a wide array of fruits, vegetables, meats, grains, and nuts to supermarkets and restaurants, Dr. Brady noted.
Operation Giving Back: A Global Outreach
The mission of OGB is to facilitate surgical humanitarian outreach to underserved patients throughout the world. An integral part of that mission is to better understand unmet surgical needs in the U.S., the barriers that continue to exist in addressing them, and to seek solutions.
For more information on surgical volunteerism in the U.S., refer to the OGB website:
Resources for volunteering in the U.S.
Legislative and liability issues
The surgeon offers his services
“There’s no way that I’ve done anything that many good-hearted doctors and nurses wouldn’t do,” Dr. Brady insists. He initially planned to provide surgical care gratis to the migrant population, but it was the cost of hospital care, not the physician’s fee, that proved prohibitive for the workers. Dr. Brady appealed to the chief executive officer and the board of the F. F. Thompson Health System, where he operates, and asked them to provide a sliding scale of fees to the workers in Canandaigua. The hospital eventually agreed to provide anesthesiology services at Medicaid rates and to institute a roughly 90 percent reduction in other hospital costs to any Finger Lakes migrant worker. These actions, in effect, made the cost of surgical care both predictable and affordable.
Then came the support of the “amazing” Jessica Hoff, PA, who, according to Dr. Brady, has provided vital support to the migrant program for the past five years. Ms. Hoff, a clinic employee, has happily taken on the “crazy hours,” as she said, to meet the health needs of migrant workers.
“If it’s a day I work, the clinic owns me,” Ms. Hoff said. “That’s why it’s so hard for me to know what time I’m leaving on a daily basis. There is a personal toll, but all of medicine is like that. But because I love what I do, it’s not a sacrifice.” She calls this her “dream job.”
“We see a lot of injuries, fractured arms and hands,” Ms. Hoff said. “Typically, the workers don’t get a day off. They work from sunrise to sundown, six or seven days a week, so we have this very small window of opportunity to see them. And even though they receive Medicaid rates, it’s still an unbelievably high amount of money, so it’s always important to make a good decision about what the patient needs.
“Surgeons have such busy, stressful jobs that don’t give them a lot of time to volunteer,” Ms. Hoff added. “But by contributing a few hours of volunteer work, they can give people like me their expertise. I can describe a patient’s condition over the phone, and they can advise me if the patient should take a day off from work to see a surgeon.” By consulting with a surgeon, the clinic staff can help avoid unnecessary surgical appointments.
Dr. Brady met Ms. Hoff for the first time last spring when he began traveling to the migrant camps for visits. “I was so impressed with her skills and dedication to her job,” Dr. Brady said.
Dr. Brady’s reputation grows
By word of mouth and through Dr. Brady’s growing reputation among the workers, the migrant population began traveling from a radius of 75 to 100 miles to receive Dr. Brady’s care at the clinic. He and the staff quickly recognized the wide-ranging barriers that prevent migrant workers from seeking medical care, including a lack of English language skills, transportation, and time to obtain health care. “We see some of the craziest things,” said Mary Zelazny, chief executive officer (CEO) of Finger Lakes Community Health. “Many patients have not seen a doctor in 15 years. But that’s our gig, to provide access to care, and that’s what we keep working to do.”
Although the clinic provides interpreters and patient navigators, a lack of communication prevents many workers from seeking help. Transportation issues involving the time and means required to travel from the farm to the clinic add additional challenges to health care access. Time is an essential factor to migrant workers. Scheduling an appointment with a physician cuts into their workday and their already low wages.
Living with fear
Fear may be the migrant worker’s most formidable barrier to accessing care. Most migrant workers worry that they will lose their jobs suddenly without explanation. Although migrant workers are covered by workers’ compensation laws, Dr. Brady maintains that many do not report their injuries in trepidation that doing so may cost them their jobs.
In the meantime, the nation’s Immigration and Customs Enforcement officers have stepped up efforts to find undocumented workers, escalating the general distress among migrant workers, “even among those who are documented,” according to Dr. Brady. Some of the workers are fully documented U.S. citizens who have been detained, he said, and have been denied basic rights, such as being allowed to make a phone call.
Because migrant workers pay for their medical services in cash, they need to know the precise cost of treatment. If that sounds like a simple, obvious step, Dr. Brady points out that it is anything but.
“It is one of the major barriers to health care for migrant workers,” he said. “We know of one hospital that would not even discuss discounting fees unless the patient could prove citizenship. If a hospital is willing to discuss discounts, the discounts are based on sliding scales that demand income history that is generally not pertinent to migrant workers or is hard to obtain. These discussions alone can mean more time off from work.” Furthermore, he said, “many hospital executives do not identify the migrant and seasonal workers as their patients.”
Not so for Dr. Brady, who considers the migrant workers not only his patients, but a source of professional joy and fulfillment as well. “The migrant population is very judicious, especially in the way they relate to physicians,” he said. “They appreciate your help, and they want to pay for the services they receive.”
The skillful Ms. Hoff managed to convince another local hospital to provide care to them on a sliding scale. She explained to the hospital the difficulty she was having finding care for migrant workers. Hospital personnel initially denied that there were any migrant workers in the service area, reflective of the “invisible population” of migrant workers. Ms. Hoff convinced the community hospital to recognize the farmworkers as members of the community, and thanks to her efforts, the workers now need only to bring their pay stubs to be eligible for the sliding scale rates.
“This is a really amazing example of how effective she is, and what a great voice she has been for the farmworker population,” Dr. Brady said.
Dr. Brady is grateful that the work has put him in contact with people he otherwise may not have met. “I love working with migrant workers. You can’t work with this population and not feel appreciated,” Dr. Brady said. “It’s like going to another country and caring for a different culture, right in your own backyard. You just want Americans to appreciate the work that migrant workers provide to produce butter and other products at the prices that we demand.” The clinic’s support of migrant workers, Dr. Brady said, “helps level the playing field.”
Like Dr. Brady, Ms. Hoff values the rewards of working with patients who are truly appreciative. “They are totally different from the general population,” she said. “Maybe it’s selfish of me, but I really like caring for people who are thankful for everything you give them.”
“Dr. Brady is a well-respected surgeon in our region,” noted CEO Ms. Zelazny, “and I can’t begin to tell you how much his work has boosted the health of migrant workers in our area.” Ms. Zelazny noted that with hernias being a common occurrence among the workers, she would frequently see workers with duct tape wrapped around their stomachs. Dr. Brady changed much of that, she said, and has helped to change workers’ perceptions about their own health. “I think as a provider, he appreciates the opportunity to save lives. He takes the time to explain things. I have literally seen doctors do things to patients and never explain anything about the procedure to them. The farm workers can tell that Dr. Brady cares about them and takes the time to make sure they understand what he’s doing,” she said.
“Dr. Brady is just a wonderful person,” Ms. Zelazny added, “and when he comes to see patients in our clinics, I think he really feels appreciated. We’re very low-key around here, and Dr. Brady fits right in. We manage to keep it fun.”
Like wartime medical care
Controversies in the U.S. over the work and presence of the migrant population are not a concern to the Finger Lakes Community Health staff. The job of providing quality care is what matters to the physicians, nurses, and administrative staff. “It’s like medical care in time of war,” said Dr. Brady. “It’s not a political statement. If you’re taking care of patients, you’re taking responsibility for their care, and you are not concerned with whether or not they are documented.”
At the end of 2012, when the 63-year-old Dr. Brady left private practice, he pointedly noted that he had no plans to retire from his volunteer work with the migrant workers.
Dr. Brady “gets it”
Once a month, Ms. Hoff said, Dr. Brady visits the clinic. “He is kind and wonderful with the patients. There’s a whole culture that the volunteer surgeon has to understand, and Dr. Brady gets it,” she said. “He really connects with the patients.”
To Dr. Brady, volunteering is simply an extension of a surgeon’s desire to change the world, one patient at a time. What surgeons must bring to the experience is a singular desire to help without any expectation of monetary award. Volunteer surgeons who bring their expertise to these situations must carry medical liability insurance. “No hospital would let you work at the facility without insurance,” Dr. Brady said.
Dr. Brady’s decision to continue as a volunteer is reassuring not just to the migrant populations in his community, but also to members of the clinic staff.
“Dr. Brady is the ideal volunteer. He knows what needs to be done, and he does it,” said Ms. Zelazny. “He is perfectly comfortable with other cultures, and he is motivated by an honest desire to improve life for these folks.”
“I wish we could have given him an award for his work,” she said. “I’m just so glad that he was honored by his peers. It gives us the chance to confirm what a very valuable resource he is.”
- American College of Surgeons Operation Giving Back. Surgical Volunteerism and Humanitarian Awards. Available at: https://www.facs.org/ogb/award-winners. Accessed February 7, 2013.
- Federal Reserve Bank of New York. Current Issues in Economics and Finance: The Foreign Born Population in Upstate New York. 14:9. October 2007. Available at www.newyorkfed.org/research/current_issues/ci13-9.pdf.
- National Center for Farmworker Health, Inc. Enumeration and population estimates. Available at: www.ncfh.org/?pid=23. Accessed January 23, 2013.
- World Bank. Migrant workers worldwide to remit over $530 billion in 2012. Available at: http://web.worldbank.org/WBSITE/EXTERNAL/NEWS/0,,contentMDK:23315792~pagePK:64257043~piPK:437376~theSitePK:4607,00.html. Accessed December 12, 2012.
- National Center for Farmworker Health. Health center legislation. Available at: www.ncfh.org/?pid=186. Accessed February 1, 2013.
- Hansen E, Donohoe M. Health issues of migrant and seasonal farmworkers. J Health Care Poor Underserved. 2003;14(2);153-164. Available at: http://phsj.org/files/Migrant%20and%20Seasonal%20Farm%20Worker%20Health/Migrant%20and%20Seasonal%20Farm%20Workers%20-%20JHCPU.pdf. Accessed December 13, 2012.
- Moreno Alberto. Migrant Health Fact Sheet. Oregon Department of Human Services. July 2010. Available at: http://oregon.gov/DHS/ph/omh/migrant/migranthealthfactsheet.pdf. Accessed December 10, 2012.
- Moyers B. Public Affairs Television. NOW. On the border. Available at: www.pbs.org/now/politics/migrants.html. Accessed December 17, 2012.
- Dever G. Profile of a population with complex health problems. Available at: www.migranthealth.org/index.php?option=com_content&view=article&id=38&Itemid=30. Accessed January 22, 2013.
- American Immigration Council. Immigration Policy Center. Unauthorized immigrants pay taxes too. Available at: www.immigrationpolicy.org/just-facts/unauthorized-immigrants-pay-taxes-too. Accessed December 13, 2012.
- BOCES Geneseo Migrant Center. Migrant farmworkers in the U.S. Available at: www.migrant.net/pdf/farmworkerfacts.pdf. Accessed December 13, 2012.