by Valerie Gregg orning wears on toward noon, yet the farm workers are intent and unceasing in their labor. They squint against the sun and blow the gnats and mosquitoes away from their faces. Their feet slosh and soak in the muddy furrows. There's no time to go to the bathroom. No time to take a drink. There are baskets to fill and mouths to feed. Under a shade tree at lunchtime, a 63-year-old worker with diabetes takes off his shoes for an Emory physician assistant (PA) student. He wears no socks, and his feet are covered with blisters and ulcers. "They were just a mess," says the student, Jennifer Rahn. "I asked him: 'Doesn't that hurt? How can you work?' He looked back at me like it was obvious. He said: 'My family in Mexico, they are counting on me. I have to work.'" So she treated his wounds, gave him socks, and urged him to seek regular care for his diabetes. Rahn was one of 22 PA students who, with three family medicine residents, spent two weeks last summer in Echols, Brooks, and Decatur counties, offering primary care to migrant farm workers. Under the leadership of Tom Himelick, associate PA program director, they worked from dawn to midnight, adapting their schedule to the workers'. "We found so many health problems that would otherwise have gone untreated," said Himelick, who recently won the Humanitarian of the Year Award from the Georgia Association of PAs for his work with the South Georgia Migrant Health Project. "Farm workers have lots of eye and skin problems from the sun, dust, pesticides, and plant irritants. Many of them are chronically dehydrated. They get terrible fungal infections. They often get parasites from unsanitary living conditions. They have lots of back and knee problems, and it's so sad when you see it in even very young workers. The work and lifestyle ages them."

he project began in 1996, when eight PA students gave free medical care to 150 farm workers. This year, more than 1,000 workers received care. Winner of the 1997 Innovations Award from the American Academy of Physician Assistants, the project is a model for those trying to reach underserved populations, says Corinne Lemal Danielson, director of the Georgia Farmworker Health Program. The state program tries to coordinate health care for as many as 100,000 migrant workers that Georgia's farmers employ annually. She is grateful for Emory's help. "Of all these people, we only serve about 7,000 a year," she says. "We have programs serving migrant workers in just six clinics statewide. We are just barely scratching the surface. Primary care is very scarce in these rural counties. Most farm workers have no insurance, and even if they are legal, they don't qualify for Medicaid because they move around so much." And many farm workers won't see a doctor unless they are deathly ill, says Virginia Joslin, director of Emory's Physician Assistant Program. "Farm workers are often paid by the amount they pick, so they're reluctant to take time out from work for routine health care," she says. "They have no transportation. They don't speak English. They're very poor and very fearful. Even if they have all their documentation and are here legally, they feel they are in someone else's country and could be sent away on a whim. The barriers to migrant workers receiving health care are enormous." But for two weeks every year, Emory's program brings down those barriers. Students go to the patient - to the fields, the camps, the packing sheds, or the shade trees where workers gather for lunch. They convince crew leaders and farmers to encourage workers to use their services. The student workload is brutal. "It's an exhausting experience, yet it's revitalizing for me," says Himelick, who works alongside the students every year. "There are only a few times in life when you get a glimpse of what's really important, why we're all here. This is one of those times for me. It gives me purpose."

ost migrant workers are men in their 20s. Most have less than six years of education and send their earnings home. But when the economy at home goes bad, even urban professionals like engineers and accountants turn to migrant farm work to survive. Some families follow the crops up the East Coast with children in tow. They live in temporary housing called "camps," some of which are provided by farmers. Most of the children are enrolled in school but change schools frequently as their families move. "In 1996, we visited an abandoned school where some workers were staying," says Himelick. "It was horrific. The bathroom had water and sewage all over the floor. The kitchen was completely unsanitary. The workers slept in the classrooms on their own bedrolls. And their crew leader was charging them rent even though they were essentially squatting there." The public at large doesn't understand the situation, says Joslin. "They think these people come into the country illegally and are taxing the system," she says. "But the farmers tell us no one else will do this brutal work. Without them, we don't get our vegetables in the market. They contribute to the local and regional economy. Farmers take money for taxes out of their pay, but they really don't have access to the benefits that everyone else does."

Associate PA program directors Randy Bundschu and Tom Himelick take students into life's classroom every summer in south Georgia. They work with community organizations to bring health care to migrant workers and their families.

ecause the migrant worker population is so transitory and includes so many undocumented people, appraising its health status is difficult, says Danielson, whose office is part of the Georgia Department of Human Resources. "There is no data, so it is hard to know what to attack from a public health perspective," she says. "Even for legal workers, no health exams, records, or immunizations are required for them to enter the country. Containing infectious diseases is always a problem. Tuberculosis, HIV, and other diseases often go untreated and unreported within this population." Although primary care outreach like the south Georgia project is a good way to start confronting these public health issues, such efforts are not without limitations. The major causes of mortality and morbidity for Hispanics - hypertension, diabetes, and heart disease - are difficult to address in a mobile clinic situation without follow-up, says Himelick. Occupational issues also complicate treatment. "We can't prescribe diuretics - the most effective and one of the cheapest treatments for hypertension - to people who are chronically dehydrated," he said. "And monitoring blood sugar consistently is virtually impossible for these people because of their lifestyle. For insulin-using diabetics, it's a disaster. Insulin needs to be refrigerated and given at regular times throughout the day. That's impossible when you're out in 90-degree heat working 12-hour days." The students found one worker with a blood sugar level of 800, on the verge of slipping into a diabetic coma. They took him to a hospital emergency room, which probably saved his life. But Himelick wonders what happened after he was discharged. "The frustrating part is that we never know what happens to these people," he says. "It's not like a typical patient relationship, where you can follow up. It's a one-shot deal." Migrant women and children offer their own health care challenges. Besides treating infants, children, and several pregnant women, the students ran a health check and education program for 200 school-age children of migrant workers at a local school. They offered as much health information as possible through interpreters. "We decided not to offer pregnancy tests in the camps, although there was a demand," Himelick says. "If we did, that may have been all the prenatal care they'd receive." He trusts that somewhere down the road, others will reach out to these people.

Most migrant workers send their salaries -- an average of $7,500 a year -- home to their families in rural Mexico, Guatemala, Honduras, or Haiti.

rchbold Medical Center is doing its part. An Emory affiliate health care system with several clinics and hospitals in south Georgia, Archbold donates the use of its air-conditioned mobile clinic van and a driver to the project every year. Jason Moore is president of John D. Archbold Memorial Hospital, the largest hospital in the Archbold network. "The migrant program has been a great opportunity for our two organizations to work together on a program that benefits this area," says Moore. "We at Archbold have a long history of initiating and participating in innovative programs which meet the unique needs of our rural service area, and the migrant program fits into that effort very well." Indeed, a complex web of volunteers and community resources plays an important role in the South Georgia Migrant Health Project's success. Personnel from the Marine supply depot in Albany and Moody Air Force Base have served as volunteer interpreters. Nursing students from Thomas College and volunteers from local health departments, churches, the Salvation Army, and local restaurants also chip in. In 1999, two first-year Emory PA students wrote and received a grant to establish a program called "La Cosecha" (Spanish for harvest), which organizes and pays for storage and transportation of donated clothes, vitamins, and medicines. The Southwest Georgia Area Health Education Center (AHEC) and the Georgia Farmworker Health Program in the state Department of Human Resources helped Emory develop the project and continue to support it. "AHEC's community links helped us attract many volunteers to make this project succeed," Himelick says. "That community connection helped us get going, and we hope it will continue in the future."

he farmers and farm workers aren't the only ones who benefit from the project. PA students gain clinical experience like none other. They learn to think on their feet, be flexible, and solve problems creatively.

"It gives budding practitioners a new perspective," says Alison Lauber, medical director of the Emory PA program, who has been with the program from the start. Last year she was named 1999 Physician of the Year by the Georgia Association of PAs. "These students usually come from somewhat affluent backgrounds. Exposure to these real-life problems is very useful and spiritually uplifting for them. It opens their eyes and gives them more of a direction in their career, for why they are in the field." It's certainly different from any experience in the classroom or clinical rotations. "They learn firsthand about occupational health, public health and prevention, and about specific diseases. They don't run into things like pesticide poisoning in too many other clinical situations. The training on cross-cultural issues is extremely important. Our society is becoming more global, and they will need to know how to use an interpreter during a medical exam." As an educator, Joslin says the experience has been rewarding. "It's been an unexpected pleasure to work with students under these conditions and see the character that emerges in them," she says. Several graduates who participated in the migrant project have gone on to take jobs in rural areas, working with needy populations. One graduate developed her own "clinic in a suitcase" program for migrant seafood workers on the North Carolina coast. "We're developing leaders who take with them their experiences at Emory and with migrant workers," says Joslin. "There's a ripple effect. As educators, we're serving a larger purpose that goes beyond the Emory campus or two weeks in south Georgia. That's the beauty of our profession." Jennifer Rahn hopes to work for a migrant workers health program in North Carolina after she graduates. But wherever she ends up, her experience last summer left an indelible mark. "I realized that there is so much need - physical, financial, and emotional," she says. "I expected a different world down there with the migrant workers, but I was surprised by how much we had in common. We all want pretty much the same things: a family, a decent place to live, a decent job, work to be proud of. We are all part of the same human family." Valerie Gregg is an Atlanta freelance writer.

Photos by Tom Himelick and Maria Luizzi

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PA student Mary Johnson (left) provides primary care, with the help of Elizabeth Tharpe, a rising pre-med UGA senior who served as an interpreter.

Student Kathryn Jordan gives a tetanus shot to a farm worker after he suffers a deep cut.

Children of migrant workers benefit from the efforts of Emory physician assistant students, such as John Campbell.

Tom Himelick is impressed by students' willingness to roll up their sleeves and get down to business, no matter what the conditions. He calls it "medicine in the dirt. Students learn to be flexible, to adapt. They use packing crates and picnic tables for exam tables and hang charts on a fence post. One created a private exam space in a tobacco barn."

Many farm workers develop eye inflamation caused by dust, pesticides, sun exposure, and plant irritants.

Through an interpreter, student Jennifer Rahn (left) counsels a pregnant woman and refers her to a health department for more comprehensive prenatal care.

PA program medical director Alison Lauber (center) distributes asthma inhalers.

Besides providing health care, Emory and community organizations provide donated items like sunglasses, socks, shoes, clothes, vitamins, and cortisone cream. To donate nonperishable items, contact Tom Himelick at 727-1367 or Sue Steininger at 727-3832.

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hysician assistants help doctors care for their patients, saving them both time and money. PAs help bring quality care to those who may not have access to it otherwise. Since Emory's PA program began in 1971, it has prepared more than 800 graduates to serve in primary health care and preventive medicine. It encourages students to work in medically underserved areas.

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Recently ranked the second-best such program in the country by U.S. News & World Report, Emory's PA program enrolls 50 students each year. They earn a master of science degree after taking three semesters of course work followed by a year of primary care and specialty rotations, such as internal medicine, pediatrics, family practice, surgery, emergency medicine, and ob/gyn. Students complete the program with an advanced semester, covering topics that include health promotion, epidemiology, statistics, ethics, and writing for peer review journals. These experiences equip Emory graduates to provide diagnostic and therapeutic health care under the supervision of a physician. They typically perform medical exams, take histories, order tests, and treat patients as their supervising physician would. Graduates must pass the PA National Certifying Exam before they enter medical practice. On that exam, Emory has achieved the highest class average score in the nation for the past three years and a 100% pass rate for many more years. For more information about Emory's PA program, check out www.emory.edu/MED/AH/ah.pa.html.