 Good evening and welcome to In the Studio. I'm Dr. Mark Schenker, Associate Vice Provost for Outreach and Engagement at the University of California, Davis, and Director of the Center of Expertise on Migration and Health of the University of California Global Health Institute. Our topic tonight is Indigenous population and effect on health among migrants. And it's a great pleasure to have Sandra Nichols with me. Sandra is a research geographer at the University of California at Berkeley and has a lot of experience in this area. So welcome, Sandra, to the program and thank you for coming. Good to be here, Mark. Thanks. So perhaps let's just start with your background and how you got interested in this topic of looking at health among the Indigenous. Well, before I got to the Indigenous, and we could in a minute say really what we mean by Indigenous, but I got really interested in Mexican migrants to California and that came out of that period in the early 90s when there was just that really horrible, really toxic attitude towards Mexican migrants, one of these real backlash times. And my sense was if people knew who they were and had more of a sense of them as human beings, as neighbors, where they came from, what their lives were like, maybe they would kind of tamp down on some of this real hostility and negative reaction. So I went in and I started studying Mexican migration, but in particular an approach of what we call transnational communities. The hometown where people come from, what conditions were like there, why they decided or had to leave, where the whole journey to the states and then where they come, the destination community and what life is like there, the conditions. And so then you start to build up this fascinating story and history of these communities from specific places in Mexico and then clusters here. And that whole work, which I wrote about, I was working in primarily in northern Mexican communities, Spanish speaking, because I'm fluent in Spanish, so that was another reason to work in this field. But that work with Mexican migrants and then farm workers led me to a fantastic collaboration with Rick Mines, a long standing farm labor researcher and other colleagues to look at issues related to people coming from indigenous communities in Mexico, the indigenous farm workers. And we can get into what that, who we mean by that. Well, why don't we do that? So who are the indigenous and how are they similar or different from other Mexicans that we have some idea about? Yes, the first off is we always say as researchers, it's not for us to define the indigenous, they define themselves as such. But for the purposes of our research, the indigenous farm workers study, we chose, worked with people who come from communities, hometowns, where an indigenous language is spoken. And so what we mean by this are these languages that predate the conquest. Some of them go back at least two, three thousand years. These are really ancient, deep languages that are not at all in the Indo-European tradition. And some of these have survived the last 400, 500 years of brutality and discrimination. And those people who these indigenous communities primarily in Mexico are in southern parts of Mexico, the southern states, Oaxaca, in Eastern Guerrero, Puebla, Chiapas and so forth. And folks from these remote villages are the ones who have now started to come to California as farm workers coming in at the very bottom rung of the labor ladder and the very low wage jobs. And it's a pretty new phenomenon. And so very little was known about this and we were asked to try to get a better understanding to provide this to a wider audience and to the health care community. So I assume there are unique factors in this population. You mentioned language and Spanish not being the native language. And are there other factors, influences on health among indigenous that one needs to be aware of when thinking about the health of this population? Yes. And before you even get to health, it's like what are their lives? What kind of, what circumstances are they coming from? What are they encountering here? And as I mentioned, these are people who are coming from pretty often pretty remote areas where the Mexican government has not provided much in the way of services, often very no. Very little in the way of education or what exists only goes up to two or three years, four years. Oftentimes women have very little education and don't even speak Spanish themselves. There are people who've already migrated elsewhere within Mexico to work in agriculture on a contract basis, on a temporary migration basis, very poor, very, very hard workers. But then what happens when they cross the border is that all of the discrimination that they experienced in Mexico, because they are really viewed oftentimes regrettably as second-third-class citizens, that gets perpetuated here on this side of the border so that they really experience discrimination, poor treatment by the mestizo, Spanish-speaking crew bosses, mayor domos, labor contractors, and also by the landlords who are renting them their apartments or the houses. And when they bump into the healthcare system, again, if their Spanish is, you know, as a second language, the interpreters there in the health clinics who may speak Spanish don't necessarily recognize that they're from an indigenous community and speak an indigenous language, and so they just think they're dumb or they can't express themselves. So there are multiple levels in which they're isolated linguistically, culturally, through poverty, and yet their languages are these extraordinarily beautiful ancient languages that are really in risk of being lost. So I imagine you've had a lot of experiences, encounters with people who have received this type of treatment and it's affected them in their lives or their health or their family. Can you think of something that might illustrate what you're talking about? One, in the healthcare setting, I remember a woman who works as an interpreter, actually, who speaks Spanish, not too much English, but some, like Mixteco, the languages we're speaking about here are Mixteco primarily, Zapoteco, Triqui, these are the main language groups we find amongst the indigenous farm workers in California, but they're actually 23 different languages. So in a healthcare setting, even if you have someone who speaks one of these languages, this person might come with a different language and there's a real resistance to following, say a physician prescribes something and they look at this and they're not even sure what is being prescribed to them, what it's for, because they say, you can't understand me. How do I know this is going to serve me anything? Be of any use. And so there's a real concern about lack of compliance. People don't follow the doctor does his or her best, but there's not necessarily, it's going to be followed because there was really a lack of communication, even with an interpreter there. So there's a real anxiety really about approaching the western medical setting. And so how does that sort itself out? If you have the indigenous farm worker who has a medical problem is hesitant, even if they have access to medical care, do they go to alternative avenues? That's a really interesting question. One of the things we found in this study is that men in particular, and they are the larger percentage of indigenous farm workers as they are farm workers in general, they avoid it like the plague. They stay away from the, even if they have insurance and very few do, even if they can afford it, which costs is another issue, they really avoid modern medical services. And so the first step is self-medicate or look for an herbalist or various other traditional resources that do exist within the community. They could be these sobadores, massage specialists or curanderos and traditional healers. And if that's not working, well, go down to a local herbalist shop and ask the salesperson for advice or go to a pharmacy and buy something somebody recommended or mentioned or go to a Mexican grocery store or a flea market. And here is the person who's a salesperson actually acting as a pharmacist or this person with a problem, an ailment that isn't yet to be diagnosed. Many of the people that we interviewed will actually go all the way to Mexico across the border to seek treatment, even though this involves a lot of expense, time off of work and a risk getting back if they're undocumented. And then only as a really a last, last resort go to the emergency room. And then it's pretty... So as a physician I can say that for some health problems delay in getting diagnosis and treatment is going to make the outcomes worse. For those problems that would get better by themselves and are self-limited it might not make a difference, but in the other situation this could be a real problem. And with women it's a really very, very serious and troubling situation in particular. Women do access the clinics at a higher rate but much less than mestiza women, mestiza women, farm workers are of course at a much lower rate than the broader population in California in general, women in general. And the real serious problem here though is with not accessing prenatal care. And so part of it is because they're not used to that. There's no prenatal care often in these remote villages. They're used to just going to the midwife and if there's no complications that works out fine. But there's a really high rate of women dying in childbirth in these indigenous communities in Mexico. The United Nations estimates it's among the really high rates of women mortality. It's hard to get data but we know it's a lot higher than for the mestiza women, overall women in Mexico. So they already have problems accessing and getting prenatal care and the same thing applies once they come to this side, to the U.S. and then they wind up when they go to the clinic when it's time to deliver. So immediately they're put as high risk pregnancy and they become terrified because they're surrounded by bright lights, by machines, by tubes, by men touching them. This is really quite frightening that men touching their bodies, they don't know what's going on. So it's a really traumatic experience to give birth in this country and very much in contrast to the traditional way which involves surrounding a very joyful moment surrounded by friends, by other women, by a sense of care, drinking herbal teas, giving ice chips to a woman in labor. This is completely against any of their particular beliefs and then they're used to having sweat baths afterwards and a time of recovery which they become very frightened in the context here. So you raised some many topics but I want to focus on the public health issues and the indigenous because right off it occurs to me that even if we have programs for public health education that are in English and Spanish, you may not be reaching this population. But of course public health involves a lot more in terms of educating the population and is that something where you've seen particular deficiency in the indigenous communities? Certainly there's a whole difference in understanding the body and understanding what is health, what is disease, so there's kind of this gulf in understanding. In our work we were very interested in also talking to providers and what is their level of understanding and appreciation of the indigenous and this sense that they are operating in a different world view, a different context and so yes they're at one level there's a need for outreach and understanding and explaining kind of the introduction to the western medical system but there also is a need for a lot of training of American or western providers to start to build this, bridge this gap I think that exists. It's kind of two worlds that have to start to meet each other in terms of respect. Well let me raise two specific areas of public health and prevention that we know work that are effective but that really require the individual or the community to accept and to buy into. The first one would be pap smears and prevention of cervical cancer. This is a major reason that we have greatly reduced the health burden from cervical cancer. Is that something that would be a particular challenge in the indigenous community and I'll give you the other one and you can cover whichever which would be vaccinations both the standard battery of vaccination as well as the flu vaccine and others for potential epidemic outbreaks. So those are two demonstratively effective public health interventions and I'm wondering from your experience have you seen these in the indigenous community were there particular challenges or how could we do better? Those are both really good areas in this respect to try to talk about, get at. The cervical, the pap smears and cervical exams, well that's a real challenge and just to tell a little story a woman who works in a clinic along the coast in Ventura County was telling me and here she is, Mixteco originally. So she speaks Mixteco English and Spanish and she's been hired by a clinic to serve as a translator and try to put some women at ease and she has an enormous difficulty and challenge in trying to put a woman at ease for a cervical exam for one thing, they never had anything like this and to do anything to do with the reproductive system of the body is sort of taboo, you don't discuss it and the other is she doesn't have terminology, there isn't the vocabulary to describe cervix, to describe other conditions whether it's diabetes, asthma and so forth. So there's a language issue, words, language to describe women's, lots of women's reproductive system, so there's huge kinds of barriers there but it's not insurmountable with the right kind of training and context in the clinic, it takes more time but with gentleness and with respect and explaining to them you do start to have women willing to come in and willing to get these kinds of tests and quickly jump over to the immunization. There's some really important work being done with these outreach workers, the promotora programs and also with some of the radio stations, Radio Bilingüe has programs in Mistecco and in Sapoteco and Triqui and they start talking about that and bring physicians on to the radio and people are interested, so there's ways to do it but it requires an appreciation and understanding and real respect, I think, in approaching. The promotoras have been mentioned before, I think that's important. Can you just describe what promotoras are and perhaps how they add to the health system particularly for this population, to the public health effort? Yes, it's a really wonderful approach, it's really the outreach nurse it's the kind of a trained person, doesn't have to have a whole nursing degree but a trained person who's trusted in the community who can approach members of the community, explain to them, encourage them to come to the clinic they're really a bridge, a lay bridge between the western medical system and this rural population, very well-developed systems in Mexico and I'm sure you can tell us more about them too. Well, and I would just highlight that public health is not the same as health care and that increasingly our understanding is that so many of the factors that affect our health are because of our environments, our behavior, our diet, our activities those non-medical things and of course these are all appropriate for promotoras or others to educate a community. Right. And then having, interviewing those promotoras, health outreach workers on these radio programs that are listened to by members of the indigenous community the Miss Tech Hour or the Sapo Tech Hour but even more they've been developing some really fascinating creative approaches to try to reach out to this community and to the women and it involves promotoras, it also involves having a clinic one really good example I think is this little clinic in Oxnard they have hired interpreters and then the women who are coming through the prenatal program they arrange trips to the hospital and they visit the delivery room so they actually see, they get a little sense of what's coming up and it helps relax them and ease them and make them more willing to be accept the kinds of wonderful services because let me just say that I mentioned the very high rate of women dying in childbirth in Mexico well here it's about a tenth of that for the indigenous women so there's obvious enormous benefits to being able to access our health care system I'm still fascinated by your comment that the terminology for many of the parts of the body or other health related outcomes doesn't even exist, what a challenge that is to overcome to educate someone when you have to develop the terminology exactly, exactly and then it's almost these intermediaries I think they're doing extraordinary work in themselves challenging themselves to try to figure out how to bridge this gap and to communicate and do it in a really gentle way that the patient will come back so I sense by your tone that you have a bit of optimism that things are better, that there's still a ways to go but that it may be going in the right direction is that accurate to say or is this into the dangerous area predicting the future well that and also unfortunately the trends I mentioned that the indigenous are becoming more and more present in the farm worker population in the last twenty years they've increased by four times so this is something that I think the health care system the public health system has not yet come to grips with but there are really interesting small scale models I think that could be scaled up and I think that's the challenges for both sides to really scale up and there are indigenous organizations there's a website where we post a lot of the research and the findings and there's some links to really creative approaches to dealing with this well we're running out of time perhaps can you tell us what that website is and for people interested they could go there and learn more about this topic sure it's www.indigenousfarmworkersonestream.org or you can just Google indigenous farm workers and it will pop up and within the state agencies and county agencies your sense is that there are some areas that are coming up with these innovative programs and new approaches to address this issue well some of the most creative work we've seen is the central coast the indigenous farm workers are concentrated almost half of them are on the central coast from say Oxnard up to Watsonville area and in Oxnard in particular there's some very exciting work being done organizing within the community less so in the central valley they have a little further to go I wonder as we wrap up if this isn't just the story that we see repeated over and over with immigrants that we have new populations, new places of origin but that the story repeats itself and that the challenges in a larger sense are really the same it's people with different backgrounds different experience, different culture and how do you adjust that and bring them into the country and address their health needs I'm glad you brought that up especially in California agriculture we have this constant replacement of workers at the bottom the low wage and now it was the Chinese, it was the Japanese it was Portuguese and Mexicans now the new group coming in are the indigenous well I think we're about out of time I want to thank you for a fascinating insight into a group that's not recognized or thought about but which is providing a major resource and service to the state for sure and in which there are real unique health needs that we need to address so thank you Sandra Nichols for your contribution and for coming here tonight well thanks for having me well that wraps up this show of In the Studio my name's Mark Schenker it's been my pleasure to explore another area of migration and health and some of the innovative and interesting programs happening in California to address this topic thank you