Bioethics Forum Essay

Lost in Translation: When Migrant Farm Workers Get Sick

Carlos and seven other migrant farm workers were brought into a western Canadian hospital emergency department following a gas leak at the mushroom farm where they worked. But carbon monoxide exposure wasn’t Carlos’s only problem that day. The emergency department had no language interpretation services to understand or respond when Carlos pointed to his head and complained of a “dolor de cabeza.”

This case is not an isolated communication glitch; it reflects a systemic failure in the way Canada–and many other countries that rely on migrant farm labor–structure care for these workers.

The failure to guarantee professional medical interpretation for migrant farm workers violates basic ethical principles and fundamental human rights. One of us (FR) is a nurse working in an emergency department in British Columbia and has seen this scenario play out many times. The other (JWB) is a psychiatrist and bioethicist who has cared for migrant farm workers in the United States as well as clinicians who treat them, in part because of the moral distress that can arise when they hope to provide optimal care in settings where that is not possible due to, among other reasons, a lack of medical translation services. The ethical issues we describe in Canada resonate with experiences of migrant farm workers—and the clinicians who care for them—in other parts of the world.

Canada prides itself on providing universal health care, but for many migrant farm workers–given their vulnerable position in society and the lack of language interpretation services–getting sick and seeking care can be very dangerous.

The Canada/Mexico Seasonal Agriculture Workers Program (SAWP) employs roughly 20,000 temporary foreign workers annually, accounting for approximately 30% of the entire agricultural workforce. The program was created because too few Canadians are willing to work in agriculture, one of the most dangerous employment sectors in the world.  Unlike many other countries, Canada mandates that SAWP workers have medical insurance.

Despite this requirement, at least two very large barriers often prevent migrant workers from receiving needed care.

First, their employment is extremely precarious. Guidelines for termination are subjective, and workers know that if they are fired–including for being labeled “problematic,” which can result from things like reporting injuries or safety issues–they will be deported and likely barred from future participation in the program. Given that there are tens of thousands of people waiting to replace them, many workers are loath to report symptoms and often delay doing so until their injuries are severe.

For those migrant farm workers who report their injuries and receive medical care, their treatment is often substandard because most of them don’t speak English. Although it is the official policy of the provincial health authority where FR works to provide language interpretation services for all patients with limited English proficiency, in reality such services are scarce.

As a result, workers’ employers often serve as translators. But this arrangement is ethically fraught. It creates a significant conflict of interest: The person translating and conveying how a worker was injured stands to profit from that worker’s continued productivity. As such, the employer might be motivated–consciously or otherwise–to downplay symptoms or omit information that might expose dangers in the workplace. In addition, many employers barely understand Spanish and have low levels of medical literacy. Because of this, employers may not translate medical terminology appropriately or may fail to convey the full meaning of what clinicians are saying.

Patients’ coworkers often serve as translators, as well. But their English skills and medical literacy are also often extremely limited, and they might have their own reasons to omit or downplay certain symptoms or other information.

Numerous studies have shown that professional interpreters improve patient care. Their use is also correlated with fewer medical errors and better health outcomes. Given its salutary effects, not providing professional interpretation for migrant farm workers flies in the face of basic medical ethical principles. Without it, these vulnerable patients cannot exercise their right to autonomy or offer truly informed consent. And medical professionals–operating with a lack of accurate information–are unable to fulfill their professional duties and obligations, increasing the risk of harm to patients. Given these realities, health care cannot be equitable and just for migrant workers if professional interpreters are not available when needed.

Carlos and his coworkers were lucky. The paramedic who brought them to the ER reported that there had been a gas leak at the farm where they worked, so the clinicians knew to do bloodwork to check for carbon monoxide. After this bloodwork came back normal, they were discharged.

To take migrant workers’ right to health care seriously, countries that utilize migrant farm labor need to guarantee access to professional interpreters in medical encounters. First, governments should fund 24/7 remote interpretation services and mandate their use, especially in EDs and rural clinics where in‑person interpreters are often unavailable. Second, governments need to prohibit employers from serving as interpreters for migrant farm workers. And finally, countries ought to provide independent advocates to help coordinate health care for migrant farm workers, so that employers are no longer the gatekeepers determining who gets access to urgent care.

Given the current political climate, new spending on any aspect of health care–especially for migrant farm workers–seems improbable. Yet as bioethicists we have a duty to advocate for fundamental human rights. Rights that give way to political priorities are not rights at all.

Such changes would not eliminate all the injustices that temporary migrant farm laborers face, but they would promote migrant workers’ health and reduce the moral precarity that clinicians in countries with migrant worker programs face every time they care for these patients.

Fraea Renaerts, BSN, is a Master of Science in Bioethics candidate at Harvard Medical School and a critical care and emergency nurse in British Columbia. LinkedIn Fraea Renaerts

J. Wesley Boyd, MD, PhD, is a senior lecturer in the Center for Bioethics at Harvard Medical School. LinkedIn JWesleyBoydMDPhD