Social Context of Work Injury Among Undocumented Day Laborers in San Francisco

Authors

  • Nicholas Walter MS,

    1. Received from the School of Medicine (NW), the Department of Anthropology, History and Social Medicine (PB), the Department of Medicine (HML), and the Primary Care Research Center, San Francisco General Hospital Department of Medicine (DS), University of California–San Francisco, San Francisco, Calif.
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  • Philippe Bourgois PhD,

    1. Received from the School of Medicine (NW), the Department of Anthropology, History and Social Medicine (PB), the Department of Medicine (HML), and the Primary Care Research Center, San Francisco General Hospital Department of Medicine (DS), University of California–San Francisco, San Francisco, Calif.
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  • H. Margarita Loinaz MD,

    1. Received from the School of Medicine (NW), the Department of Anthropology, History and Social Medicine (PB), the Department of Medicine (HML), and the Primary Care Research Center, San Francisco General Hospital Department of Medicine (DS), University of California–San Francisco, San Francisco, Calif.
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  • Dean Schillinger MD

    Corresponding authorSearch for more papers by this author

Address correspondence and requests for reprints to Dr. Schillinger: Primary Care Research Center, Ward 95, 995 Potrero Ave., San Francisco, CA 94110 (e-mail: dean@itsa.ucsf.edu).

Abstract

OBJECTIVE: To identify ways in which undocumented day laborers' social context affects their risk for occupational injury, and to characterize the ways in which these workers' social context influences their experience of disability.

DESIGN: Qualitative study employing ethnographic techniques of participant-observation, supplemented by semistructured in-depth interviews.

SETTINGS: Street corners in San Francisco's Mission District, a homeless shelter, and a nonprofit day labor hiring hall.

PARTICIPANTS: Thirty-eight Mexican and Central American male day laborers, 11 of whom had been injured.

PRIMARY THEMES: Anxiety over the potential for work injury is omnipresent for day laborers. They work in dangerous settings, and a variety of factors such as lack of training, inadequate safety equipment, and economic pressures further increase their risk for work injury. The day laborers are isolated from family and community support, living in a local context of homelessness, competition, and violence. Injuries tend to have severe emotional, social, and economic ramifications. Day laborers frequently perceive injury as a personal failure that threatens their masculinity and their status as patriarch of the family. Their shame and disappointment at failing to fulfill culturally defined masculine responsibilities leads to intense personal stress and can break family bonds. Despite the high incidence of work injuries and prevalence of work-related health conditions, day laborers are frequently reluctant to use health services due to anxiety regarding immigration status, communication barriers, and economic pressure.

IMPLICATIONS: On the basis of these ethnographic data, we recommend strategies to improve ambulatory care services to day laborers in 3 areas: structural changes in ambulatory care delivery, clinical interactions with individual day laborers, and policymaking around immigration and health care issues.

Marco [all names are fictitious], a 28-year-old indigenous farmer from Chiapas, Mexico, was working as a roofer in San Francisco when a bucket of hot tar spilled on him.

I thought–now I am dead! I just did this–ay! The foreman Martin was there. Ay papa I said to him. That was the only thing I said and it scared him. They saw my whole shirt black, steam from the tar coming from my shirt, my pants, my shoes. Right away he grabbed me like this because I am burning. He grabbed my pants because they were covered with tar…. But how it burned!! So bad I was crying, my eye was closed, covered with tar. Martin grabbed a soda, a coke, and blew it on my face. Uh, horrible. It was 550 degrees hot that tar. It hurt so much. In the moment I was lost.

Marco's co-workers loaded him in the back of a truck and took him to the local public hospital, where he was found to have partial-thickness burns over 60% of his face, neck, and hands. Homeless, alone, and in excruciating pain, Marco was discharged from the emergency department (ED) to a shelter, where he recuperated without working for 3 weeks. Marco became convinced that he was entitled to compensation for his suffering, his disfiguring scars, and lost income. When he was able to venture out, Marco visited his employer to demand compensation. Through an interpreter his employer retorted: “I know that you are illegal and I have a good lawyer. This has happened to me eleven times before and none of them got a thing…. But I care for my workers and I am willing to take you back on the job.” Furious and insulted, Marco walked off. After looking unsuccessfully for another job, Marco realized that the $70 a day he made as a roofer was the best he could do to support his family in Mexico. Swallowing his pride, Marco returned to his employer, apologized, and resumed work as a roofer.

In metropolitan areas throughout the United States, groups of young undocumented Mexican and Central American men congregate on street corners, hoping that an employer will pick them up for a day of manual labor in construction, landscaping, or roofing. 1–3 A study based on a random sample of 481 day laborers in Los Angeles estimated that there are between 15,000 and 20,000 day laborers working in Southern California. These workers are mostly recent immigrants who have undertaken a treacherous border crossing with hopes of supporting their families.

As undocumented people, they are part of a special class, excluded from the formal labor sector, denied access to most health and social services, and considered fugitives from the law. Urban day laborers are restricted to a niche at the margin of society, finding employment only in the informal economy in jobs that are traditionally too dirty, too dangerous, and too poorly paid for domestic workers to accept. 4 They are at exceedingly high risk for work injury. The Bureau of Labor Statistics reports that nationwide, the on-the-job death rate for Latinos is 20% higher than for whites or African Americans; this discrepancy is even higher in the construction trades in which day laborers typically engage. 5,6

This study addresses the occupational risks of this vulnerable population, focusing particularly on how these workers' social context interfaces with their risk for and experience of work injury and health care.

METHODS

Design, Setting and Participants

To explore the relation between social context and work injury, we employed a qualitative ethnographic approach. Ethnography is an anthropological method that uses participant observation as a research tool. The fieldworker participates in an organic role in the research site in order to have fuller access to observe social processes that are normally off-limits to outsiders.

Street level ethnography has been used in health research to document dynamics among hidden populations on the margins of society. 7–10 These groups, which do not appear in official statistics and who often have institutional incentives to distort responses on targeted surveys, are otherwise extremely difficult to access. For obvious reasons, the day laborers are mistrustful of official institutions and would be unlikely to respond candidly to a formal survey. Consequently, participant-observation methods are probably the most effective means of accessing this group.

In San Francisco, hundreds of day laborers crowd the corners of a half-mile stretch of Cesar Chavez Street, a main corridor in the primarily Latino Mission District. A wide, treeless boulevard lined with apartment houses, schools, and businesses, Cesar Chavez is one of the city's main entrances to highway 101, which carries high-tech commuters to Silicon Valley.

For 8 months, the principal investigator (PI), a non-Latino man fluent in Spanish, immersed himself as deeply into the world of day laborers as possible. To gain access to this population and setting, the PI contacted staff members at a nonprofit labor hiring hall and at a homeless shelter frequented by day laborers and received permission from their administrators to initiate the study in these locations. The PI was explicit about his role as health researcher, explaining the purpose of the project to all laborers with whom he became acquainted. While the PI encountered hundreds of day laborers, he included as study participants only the 38 workers with whom he developed relationships over sequential meetings, all of whom verbally consented to our use of observational data. In keeping with ethnographic technique, these participants represented a convenience sample of workers interested in interacting with the PI. The PI developed close ties to several day laborers who served as key informants, contributing particularly deeply to the ethnographic data.

Initially, the PI's agenda was to observe, absorb, and participate in the flow of life for day laborers. Days were spent kicking a soccer ball around a parking lot, tossing bottle caps, and talking about cultural differences, family, migration experiences, sports, politics, and religion as well as work- and health-related topics. Evenings were spent socializing and observing in the homeless shelter. As the PI developed personal relationships with laborers, he was invited to accompany them to the street corners where they waited for work. To avoid posing a competitive threat to the workers, the PI did not accompany workers to work. The PI conducted approximately 700 hours of observational fieldwork over the course of 8 months.

As an extension of ethnographic fieldwork, the PI identified 11 injured day laborers within the larger cohort of 38 participants and obtained their permission to audiotape interviews. The PI conducted in-depth life history interviews in Spanish with these laborers. The interviews were informal, lasting between 1 and 3 hours. Participants discussed the context and implications of their injuries as well as their experiences in obtaining health care. Eight of the 11 men were interviewed on 2 or more separate occasions. In total, approximately 29 hours of interviews were recorded. The interviews took place in a variety of locations workers found convenient, such as restaurants, the homeless shelter, or outdoors. Day laborers were not compensated for their participation except for occasional meals purchased by the PI. Excerpts of these interviews are included in this paper. The study was approved by the Committee for the Protection of Human Subjects at the University of California–Berkeley.

Study Population

In the absence of demographic data on San Francisco's day laborers, data from a Los Angeles study may be extrapolated to San Francisco's population. 11 The study found that day laborers were largely young (mean age, 33 years) and poorly educated (56% had less than 7 years of education). Seventy-seven percent were Mexican and 20% were Central American. Ninety-five percent were undocumented upon entering the United States. Half of the undocumented people in the United States are women, who generally work in urban areas cleaning houses or caring for children or elders. 12 They were not encountered in the course of this study.

Data Analysis

The PI typed approximately 3 to 7 pages of fieldnotes on a daily basis, recording events and observations. Audiotaped interviews were transcribed verbatim in Spanish by a paid assistant who is a native Spanish speaker. Analysis of these interviews was performed on the original Spanish transcript by the PI. The excerpts cited here were translated to English by the PI; translation was corroborated by the third author (HML), a native Spanish speaker. The original Spanish-language documents were transferred in electronic form into QSR NUD*IST 4 (Scolari, Sage Publications Software, Thousand Oaks, Calif), a qualitative research support program. As ethnographic data were collected, we examined them periodically and used the patterns that emerged to develop constructs and hypotheses that were investigated in greater depth in later phases of participant observation and interviews.

At the conclusion of fieldwork, data were first indexed by broad conceptual category using a grounded theory approach. 13 More extensive codes were assigned by the PI as the data were reviewed and specific themes emerged. This indexing system helped elucidate patterns that generated the conceptual model of the interaction between social circumstances and the experience of injury.

“Credibility” of the analysis, the qualitative equivalent of validity and reliability was established through several forms of triangulation. Triangulation uses multiple sources of information to corroborate and confirm findings. 14 In this case, data were collected in different modalities: notes were taken on direct participant-observation fieldwork and interviews were audiotaped. Repeated contact with the same day laborers in different settings allowed for discussion and confirmation of the same themes sequentially over time. Further triangulation was achieved by comparing these data with participant-observation fieldwork notes taken by the second author (PB) on 300 hours of fieldwork with day laborers 3 years earlier on the same street corners. The data were additionally confirmed by comparison with the experience of the third author (HML), a Latina primary care physician who has worked with undocumented day laborers in San Francisco for 13 years.

RESULTS

Analysis yielded 5 major themes that bear on the immigrants' experience of injury: (1) the border passage; (2) the local dynamics of life on the streets; (3) features of the workplace; (4) emotional stress and family dynamics; and (5) injuries and experiences with health services.

Border Passage

Virtually all of the day laborers contacted entered the United States illegally by walking from Mexico, a journey that has become significantly more arduous and dangerous in the past 8 years due to increases in border security. 15 Undocumented immigrants now cross through remote areas that are less intensively patrolled, walking for days through the mountains or the desert. 16 Pedro, a 42-year-old father of two from Mexico City, remarked,

But now it is hard, it is cruel to enter the way we came in, running all night, hiding during the day. Days without food or water. And how many die? How many die on the border? You know when you start across that you are risking everything, risking your life. Some succeed in making it here, others never arrive.

In 1999, the United States Immigration Service documented the deaths of 369 undocumented immigrants along the U.S.–Mexico border. 17

The ramifications of the border crossing deeply influence workers' lives and health in the United States. As the journey has become more difficult it has become more expensive. Immigrants now pay up to $1,400 to a “coyote” or guide who will lead them to a city in the United States. Day laborers generally borrow this money from friends and family. Thus workers frequently arrive in the United States in arrears and spend their first months repaying debts. Day laborers are functionally in a form of indenture that makes it difficult to leave dangerous or abusive work environments.

The augmented border security increases the opportunity cost of returning home. Day laborers feel compelled to stay to justify the investment that they have made. This deepens the separation between workers and family, leaving day laborers isolated in the event of injury.

Local Dynamics of Life on the Streets

Undocumented laborers' experiences of work injury are shaped by the physical and interpersonal milieu in which they occur. Workers sustain injuries and cope with disability in the local environment of the streets, and this local context shapes their experience of ill health. The following section offers a thumbnail sketch of this street environment by reviewing key dynamics involved. The day laborers seek work in an uncertain and unpredictable environment in which they are subject to street violence and significant economic stressors.

Uncertainty, Unpredictability, and Insecurity In San Francisco, most day laborers are homeless. Those who are housed commonly have informal arrangements in which they share a single room with 4 to 6 men. Workers often sleep in the streets when conflicts force them from their shared apartment or when their allotted time in the shelter elapses.

Work arrangements are unpredictable. Day laborers begin arriving at 6 am on Cesar Chavez Street and join hundreds of other work-seekers in clusters on the corners. When an employer pulls to the curb, workers struggle to be chosen, frequently climbing into the employer's vehicle without ascertaining for what work or what pay. The unpredictability of employment in high-turnover temporary jobs is exacerbated by the fact that much of the work depends on the clemency of the weather. Roofing, painting, and construction stop when it rains, and workers may spend weeks standing in doorways without a job.

Due to their immigration status, workers live with a pervasive sense of insecurity. Oscar, a farmer from Hidalgo, described his anxiety.

Because we are not legal we always have to be watching out…. From the point of crossing the border you always have to be watching out for the greens (immigration). It is hard because you don't travel freely and you feel like you have done something wrong…you always have to live with the fear that they are going to nail you.

Competition Workers compete for a scarce pool of jobs. Laborers crush around the vehicle of a potential employer, struggling for attention. Estefan, a 26-year-old indigenous farmer from Chiapas, described,

They'll run you off like you're no use for anything and it makes you ashamed when they don't chose you. The Raza (Latinos) get here, and there is a ton and it is–“one worker!”“Hey! Me! Me!” and sometimes you don't go because you weren't chosen. You feel crushed. It makes you discouraged. I am not going to say that you don't get discouraged….

The street corner competition for jobs is particularly difficult for laborers working while recovering from injuries. Day laborers believe that employers pick the youngest, strongest bodies; the injured feel marked for rejection.

The competition also affects workplace behavior. Pedro, the worker from Mexico City remarked,

At work you are never indispensable. At any moment the boss will get pissed off and tell you to get the hell out. You go and 20 others come asking for the same job even though it is badly paid. They'll go to work there because they need to.

The oversupply of workers appears to limit their ability to protest unsafe or abusive workplaces.

Violence Living and working in the streets, day laborers are subject to the violence that is endemic in low-income neighborhoods in the United States. In addition to this basal level of violence, day laborers seem particularly targeted for robbery and assault because as recent immigrants they lack the urban street skills necessary to avoid dangerous situations, because they have no safe place to store their savings, and because they are frequently reluctant to contact authorities. In the course of 8 months of fieldwork in a shelter with 60 day laborers, we documented 3 instances of robbery at knifepoint and several beatings.

Emotional Milieu The tenor of the street corner where the majority of fieldwork was conducted varied with the particular group of workers present and the job prospects available. Nonetheless, conflicting elements of shame at their social position and pride in their accomplishments was frequently a subtext. While day laborers are living in shelters or overcrowded accommodations with inadequate bathing facilities, they perform hard and dirty physical labor. Workers said that they would be ashamed to be seen in their own communities so filthy. Despite this, they display themselves as conspicuously as possible on a busy thoroughfare. Workers consider how passers-by view them and often conclude that they are despised. Estefan, the 26-year-old indigenous man from Chiapas, reflected:

There is a lot of desperation on Cesar Chavez Street. Sometimes they pass and just to mess with us yell, “Hey! Countryman! Get your ass in gear!” Yeah, it is Latinos like us that pass and–“get your ass in gear!” Or you're just standing there and just to fuck with you there are white guys that come by and stick out their (middle) finger like this. As if they would like to be standing here. It gets you down. Like this kid–this cousin of mine–he got here and during his first days got so discouraged. It made him ashamed when that white guy would pass and give us the finger. It is good, it is good that we are standing here, but it makes you ashamed. Yeah–whatever, no big deal. All you want to do is work.

Despite these stressors, day laborers frequently express pride in their courage at leaving home to support their families and in having endured the danger and hardship of border crossing. When they are working, they feel the money they are making vindicates the sacrifices they have made. They believe that they are advancing the family's prospects. They are pleased by their ability to cope in a foreign land under adverse circumstances and they are proud of their physical prowess and workmanship. Workers like Manuel, a 34-year-old security guard from Vera Cruz, felt that they had maintained moral integrity.

It is good to live within the parameters of decency and the parameters of the community. It is the best one could give to one's self. In a certain way it makes me feel good to say–I live like this. How should I say this–it is like a moral code or an internal code.

Features of the Workplace

Day laborers engage in occupations that are among the most dangerous in the United States, and a variety of social factors related to their undocumented temporary laborer status tend to increase their risk for work injury. These include inadequate training and experience, substandard safety equipment, and economic pressures that limit their capacity to avoid hazardous workplaces.

The bulk of employment is physical labor in construction, landscaping, or moving. Construction is considered the single most dangerous trade in the United States, with 1 in 5 workers in high-risk fields like roofing or sheet metal suffering a work related injury or illness each year. 18 The yearly fatality rate for roofers is 6 times higher than for the average of all jobs; for the lowest skilled job classification, “construction laborer,” the position commonly occupied by day laborers, the death rate is 8 times higher than for the average job. 5,6 The major causes of injury and death are falls and burns. 19

The employers recruiting on the street corner typically are subcontractors that rely on day laborers because labor needs are variable. Employers of day laborers range from bonded, insured, and state-licensed contractors to fly-by-night landscaping or demolition operations. 20,21

Day laborers are cognizant of the risks involved in these occupations. Francisco, a taxi driver from Mexico City, reflected:

The people always work with two thoughts–what if something happens to you. Because it is dangerous. Like if you work at the burner, that's the machine with the tar. It's certain that you are going to get burned. The natural thing that will happen to you is that you'll get burned or smash your hands like this…. Or up high there are parts with wood supports like this. And sometimes those supports are really narrow and half-rotten and if you come carrying a bucket of trash, down you'll go. That happened to me twice…. Sometimes we try to tell them “Listen–we need gloves. Listen we need masks.” There are some that are conscientious and they give masks and gloves, but others, no.

The risks of these inherently dangerous fields are exacerbated by a series of factors related to their marginal social status.

Lack of Training and Experience Despite the hazards of the work, day laborers are rarely trained. They appear to be a flexible resource for employers, used on a short-term basis with little to no ongoing commitment. Language barriers also limit training. Day laborers are often physically unprepared. A 35-year-old piano teacher recalled operating a jackhammer 10 hours a day during his first week in the United States. In retrospect, he laughed at his “softness and aching bones.” Such lack of conditioning and training may predispose to work injury.

Inadequate Safety Equipment Federal regulations set strict guidelines for high-risk workplaces such as roofing, requiring gloves, masks, extensive “fall protection systems” such as harnesses, and set stringent standards for ladders and scaffolding. 22 The day laborers report that these regulations are widely ignored. Manuel, the security guard from Vera Cruz, reflected:

I've worked in roofing, and I've been three stories up on top of houses without a single piece of safety equipment, no harness or anything. There are some that won't even give you gloves or something to cover yourself from the dust. … So with what I know of safety–I think that it is incredible but it is OK. It is OK because someone has to do it, no? Someone that they pay little, relative to a native of here, no? But what little he makes will be enough to help his family. So for that reason it is ok but from the point of view of safety it is not good because if that person has an accident there is not going to be insurance, nothing that is going to help that person. … All this to save some money… Sometimes undocumented people work under a lot of risk that an American wouldn't do.

Although undocumented workers are nominally covered by laws protecting them in the event of fraud or injury, exercising these rights is difficult. Day laborers are reluctant to contact authorities and are limited by language barriers, low levels of education and legal sophistication, and the difficulty of mounting a potentially protracted suit while transient and homeless.

Economic Pressures The economic pressures noted above make day laborers reluctant to leave a job, even if it is objectively hazardous. Injured workers feel that they must continue to work despite their injuries. One participant laying carpet was hurrying because he was paid by the yard and sliced his palm with a blade. Finding a nearby rag, he wrapped his hand as tightly as possible to stop the bleeding, hide the injury, and protect the carpet. He resumed working immediately because he believed he would be dismissed if his employer saw the wound.

Emotional Stress and Family Dynamics

With few exceptions, the day laborers participating in this study immigrated to support families in their home country. Despite their distance from home, day laborers remain rooted in the dynamics of their families. Injury can alter the worker's ability to perform as a provider to the family. The emotional distress caused by the resulting transition in family roles affects day laborers experience of injury.

Masculine Responsibilities as Patriarch and Provider Day laborers have frequently internalized gender roles that require them to perform as patriarch and provider. Providing for the family is central to their conception of manhood and fatherhood. Acting as a provider is a responsibility that they cannot meet within the local economy of their home community; emigrating to the United States enables them to meet this masculine responsibility.

The Double Bind of Conflicting Responsibilities The execution of this role as provider conflicts with another important role that day laborers envision for themselves: the protector and guide of the family. Jesus, a farmer from Chiapas, explained:

Well, they have their mother, but it is not the same as a father. No, like if something happens to the children, you're there right away to take care of it or if they get sick I have to think of where to take them. I'm saying that a woman just isn't the same…. Yes they have responsibility too, but the father is always more. A father, well, is the head of the family and because of that I think that I am going to go. They are still young. If they were big that would be a different story because they could take care of themselves. They're so small and tender….

Day laborers are in a double bind of conflicting visions of fatherhood. Economic necessity and their role as providers force them to migrate north for work, but their self-concept as guide and protector of the family demands that they be in their home.

This tension between conflicting family responsibilities is magnified when a worker is injured. When day laborers can no longer work, the delicate emotional balance they had established collapses. They feel that they are failing at both tasks of fatherhood. Serious injury is an economic catastrophe. Injured workers are faced with the prospect that the sacrifices they made to reach the United States—the danger and hardship of crossing the border, the debt incurred to finance the trip, the strain on the family—might have been wasted. If the injury is serious, workers may have to relinquish their dreams of progress in their own country, whether that involved buying land, starting a business, or educating their children. Workers worry about what will happen if they can no longer work and have to return home.

Mistrust and Accusation Injured workers are reluctant to be entirely honest with their families, often minimizing their injuries, at other times denying it entirely. Workers cite a number of issues—concern that the family will worry, uncertainty about how serious the injury is—but the pain and shame of admitting “failure” is an underlying factor. They are aware of their families' expectations of improved finances and quality of life. Faced with the dismal task of breaking the news, many workers simply avoid it.

Obfuscation about the injury has an unfortunate tendency to lead to further deceit. If the worker is not straightforward about his injury, soon he has to justify why he is no longer sending money home. Workers can find themselves trapped in a cycle of dishonesty. The contrasts between the families' perceptions of life in the United States and the reality that workers live exacerbate these communication problems, giving rise to suspicion, jealously, and doubt. Francisco remarked:

I know that when one is there (Mexico) you think that it is all easy. That you work in an easy job and you're just having a relaxing time…. Sometimes when you send the money, there are times when they think that you're not sending all of it, that you're going around spending it here. Like I said to my family. I tell them, “Don't think that I am spending the money here. Everything that I make I send.” I do everything I can to mail it all. It leaves me with very little money.

Workers complained that when they were not able to send money home they were suspected of alcohol abuse and sexual infidelities. Manuel considered his relationship with his wife:

I talk to her every two weeks but it is logical that the distance causes problems, no? So it seems that there might be a breakup. Because of the distance. Well, it is logical, I think, that she has started to doubt, no? You know that if you have supported her economically and then all of the sudden there is nothing, she starts to doubt–what's going on? Maybe there is another woman…. And that might ruin the relationship, no? So it is most likely that I will lose my wife. I think that if I go back it will be mostly to sign the papers. There is no other option, no? Because she isn't a piece of furniture, right?

Injuries and Experiences with Health Services

While the nature of ethnographic research precludes accurate measurement of incidence and prevalence of injuries and utilization of health services, a descriptive summary of patterns of work injury and health care utilization is supported by the fieldwork and confirmed by the third author's 13 years of providing primary care for this population.

The most common injuries are musculoskeletal, with acute and chronic back pain being the most important causes of distress. Workers frequently complain of joint pain, particularly knee pain among those laying carpet or tile. Overuse syndromes, such as carpal tunnel syndrome due to jackhammer use, are common. The most common serious injuries appear to be those related to falls in construction or roofing. Burns, lacerations, and crush injuries are not infrequent and result in injuries of varying severity. Many workers appeared affected by a range of milder chronic work-related conditions. Dermatitis is frequent among laborers working with cement or irritating materials without gloves. Chronic allergic conjunctivitis from dust exposure is also common. Anxiety, depression, or drug and alcohol abuse are not uncommon.

Day laborers' experiences of health care were extremely diverse, and varied with the site at which care was accessed (ED vs urgent care vs clinic), workers' length of residence in the United States, and workers' socioeconomic and educational background. Although no unifying theme arose, it was evident that workers encountered a range of literal and perceived barriers to accessing care, many of which have been described in previous studies of health care utilization by the undocumented. 23,24

Those workers who had experienced limited access to care in their own countries were less likely to seek health care here. Several of the indigenous migrants from Chiapas revealed that they had never visited a physician before and felt a great deal of trepidation about doing so here. In addition, anxiety about their immigration status and their fear of incarceration or deportation prevented some workers from registering themselves in formal institutional settings. One evening, the PI waited in the ED of the county hospital with a young Honduran man who had lacerated his foot on a demolition project. Anxious about the ramifications of registering for care, the worker repeatedly stood to leave and would certainly have exited without care but for extensive coaxing by a friend.

Despite the fact that San Francisco maintains a publicly funded health system to provide care to uninsured patients, workers did experience financial barriers to receiving care. Because day laborers work on an hourly basis and most hiring takes place in the morning, attending a clinic visit means sacrificing an entire day of work. Most workers are reluctant to forgo this income unless absolutely necessary. Many workers were poorly informed about what services are available, assuming that they would be turned away because of their inability to pay.

Among those who accessed care, the language barrier was a primary concern. They frequently expressed concern that they would not receive adequate or appropriate treatment because of miscommunication. Many workers felt that their experiences as day laborers went unrecognized in health care settings. These workers perceived a discordance between the advice of providers and the reality of their circumstances, e.g., when a mover was told “no heavy lifting for 6 weeks” or a worker living on the street was instructed to “change the dressing and clean the wound 3 times a day.”

Because of these barriers, the day laborers in this study only sporadically accessed traditional clinic-based health care. In emergencies, they went to the ED of the public hospital. Of note, a number of laborers did receive ongoing ambulatory care through Department of Health outreach programs in which providers see patients in informal settings, such as a trailer at the labor contractor site or in a corner of a homeless shelter. These programs were highly regarded by the day laborers, particularly because they were accessible and workers felt that providers understood day laborers' circumstances.

DISCUSSION

This study yields important insights into the relationship between day laborers' social marginalization and their experiences of injury. Day laborers can be conceptualized at the center of a series of overlapping and interconnected levels of social context. These interconnected levels of social context combine to shape injured workers' experience of injury and interaction with health services ( Figure 1).

Figure 1.

Conceptual framework for the interaction of social context and day laborers' experience of injury.

In the broadest perspective, the lives of day laborers are shaped by large-scale social forces such as the poverty of their native communities that leads them to migrate north. The politically defined state of being undocumented profoundly affects their experience of the injury and the resulting disability. The border crossing and the enforced separation from family place a great deal of economic strain on workers and isolate injured day laborers from those who would be their primary caregivers.

Individual workers are also situated in a local street corner context of unpredictability and uncertainty, violence, economic stress, and intense competition. This milieu is stressful for all day laborers, but particularly affects those who are injured.

Day laborers' work circumstances represent another level of context influencing injury. Lack of legal status places day laborers at disproportionate risk for work injury by restricting them to employment in the informal sector. These jobs—menial, physical, dirty, low-paid, and dangerous —are largely rejected by workers with other options. Day laborers are confined to a labor market in which adherence to health and safety regulations is spotty and training is inadequate. Practical barriers prevent day laborers from exercising their legal rights.

Despite the thousands of miles separating workers from their families, workers remain rooted in the dynamics of their families. When they are injured and can no longer work, they feel that they have failed as men and as fathers. This bind can lead to excruciating personal and family stress. These interpersonal stresses may contribute to depression and substance abuse.

The choice to use qualitative methods presents some disadvantages. Although social factors appear to contribute to heightened risk of work injury, quantitative studies would be needed to show the strength of the association and to adjust for other predictors of injury and its consequences. The qualitative design of this study and the small study population make it difficult to accurately describe the incidence and prevalence of work injuries among this population. Because participants were recruited from the pool of day laborers living and working on the street, those workers who had experienced more severe injuries and were unable to return to the street were necessarily excluded. Thus, this study may underestimate the impact of serious injury.

Despite these limitations, the use of qualitative methods allowed us to access a population that has rarely been studied by health researchers. Participant observation enabled us to gain in-depth understanding of dynamics among day labors that would be unattainable through surveys alone. Rather than rely on worker's reports of conditions on the street, the PI directly witnessed these circumstances. The hundreds of hours of shared experience generated trust that allowed day laborers to reflect openly on their lives and injuries, an element that increases the validity of data.

Implications for Ambulatory Care

Reflection on these findings suggests strategies for improving health and health care services for this vulnerable population. Our recommendations are in the following 3 areas: (1) structural changes in primary care delivery; (2) clinical interactions with individual day laborers; and (3) political advocacy.

Structural Changes to Primary Care Delivery The barriers to access cited above—workers' undocumented status, communication barriers, and time and economic pressures—make some day laborers reluctant to seek primary care. Adequate provision of primary care will probably require multidisciplinary outreach efforts such as those used for other difficult-to-reach populations, such as the homeless, migrant farm workers, and at-risk adolescents. If day laborers cannot access the clinic, providers may need to reach these workers in nontraditional settings. In San Francisco, in addition to traditional clinic settings, publicly funded practitioners care for day laborers at a nonprofit hiring hall, in homeless shelters, and in a mobile health van. These services are utilized to their capacity.

Improving Clinical Interactions with Individual Day Laborers The ethnographic data can be used by practitioners to improve care by assisting them to: (1) identify day laborers, (2) develop therapeutic relationships, and (3) partner with patients to promote health.

Recognizing day laborers Workers rarely self-identify as day laborers in clinical settings, and the stressors discussed above are rarely recognized or acknowledged by providers. The first step in improving their care is to identify day laborers by inquiring about the circumstances of their work. How frequently does the patient find work? How formal is their work arrangement?

Building therapeutic relationships Acknowledgment and validation of their experiences as day laborers can generate trust. Clinicians can inquire about whether the unpredictability, violence, and competition that workers often encounter on the street has led to emotional distress or substance abuse. Where and under what conditions do they live? Does the injured worker feel that he can acknowledge his inability to work to his family? What are the family's resources and circumstances? What implications does the injury have for his relationships? Does he have the support of friends or family who are in the United States? These lines of inquiry frequently prompt day laborers to express previously hidden concerns. As a therapeutic relationship develops, workers may be willing to discuss the inherently delicate topic of immigration status. Providers should reassure patients of the confidentiality of the relationship and might inquire about the experience of crossing the border. Did the worker incur debt from the passage? Providers should ask about workplace conditions and safety. Does the patient feel that he has the capacity to negotiate with his employers over conditions? For undocumented workers, a medical professional's recognition of the worker's circumstances and validation of their right to a safe workplace in and of itself may represent an empowering intervention.

Partnering with patients to promote health and safety Developing a trusting relationship and gaining information enables the clinician to assist over time. The above inquiries may reveal specific workplace hazards that can be ameliorated. For day laborers who have been injured, providers should determine if workers are aware of their workers' compensation rights and should refer them to legal aid. Injuries should be documented in the medical record. The clinician may identify workers at risk for depression and self-destructive behavior who should be referred for psychosocial support. Ideally, practitioners serving this population should become familiar with local resources such as shelters, advocacy, legal aid and social service agencies.

Political Advocacy This study has revealed that many of the determinants of occupational health for undocumented day laborer are ultimately political. The economic realities that force day laborers to migrate, the process of crossing the border, the implications of what it means to be undocumented and their exclusion from the regulated formal workforce are socially determined factors that shape day laborers' risk for and experience of work injury and health care. Providers should recognize the effects of national and international policymaking on the health of their patients. Presidents Fox of Mexico and Bush of the United States both advocated reforming immigration laws to give many of the 7 million undocumented people in the United States some form of legitimate status. 25 The possibility of such reforms coming to fruition in the near term seems particularly unlikely, given the tightening of immigration policies resulting from the recent terrorist attacks. The impact of any plans on occupational health and access to health care will depend on details of the rights extended to workers and the degree to which these protections are implemented and enforced. In order that health concerns be addressed, primary care providers should consider contributing to these policy debates.

This research was partially funded by the U.C. San Francisco–U.C. Berkeley Joint Medical Program.

The views expressed above are those of the authors and do not necessarily reflect those of the Joint Medical Program.

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