This paper describes the socioeconomic conditions under which the 3 to 5 million migrant and seasonal farmworkers in the United States live. Health consequences resulting from occupational hazards and from poverty, substandard living conditions, migrancy, language and cultural barriers, and impaired access to health care are described. Specific problems include infectious diseases, chemical- and pesticide-related illnesses, dermatitis, heat stress, respiratory conditions, musculoskeletal disorders and traumatic injuries, reproductive health problems, dental diseases, cancer, poor child health, inadequate preventive care, and social and mental health problems. By increasing awareness among health care professionals of the plight of migrant and seasonal farmworkers, the authors hope to encourage development of a stronger public health infrastructure and to improve the health status of these individuals.
OBJECTIVE:To determine the relative importance of medical and nonmedical factors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals. DESIGN:Prospective survey of all referrals from generalists to subspecialists over a 5-month period. SETTING: University hospital outpatient clinics.PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology. MEASUREMENTS AND MAIN RESULTS:For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals. CONCLUSIONS:Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost. O n average, fewer than 5% of office visits to primary care physicians result in referral. 1-7 However, referrals generate significant economic costs for both physician fees and diagnostic tests. 3,[8][9][10] Moreover, referral rates for individual generalists vary widely, suggesting a high level of uncertainty about appropriate referral practices. [1][2][3]6,[11][12][13][14][15][16][17] Both underreferral and overreferral can affect quality of care. Underreferral can lead to inappropriate, cost-ineffective, or even dangerous treatment, and may result in costly litigation. 18 Overreferral can lead to fragmented care "by committee"; overtesting and repetitive testing; dangerous polypharmacy; patient confusion and isolation; and complacency on the part of generalists who lose their motivation to continually acquire new knowledge. [19][20][21][22][23] When appropriate, referrals from generalists to specialists can lead to improved patient outcomes, as well as decreased costs through optimal use of physician, hospital, and laboratory services. Studies have suggested benefit for certain patients with severe depression, 24 somatization disorder, 25 AIDS, 2...
In 2009 the American Public Health Association approved the policy statement, "The Role of Public Health Practitioners, Academics, and Advocates in Relation to Armed Conflict and War." Despite the known health effects of war, the development of competencies to prevent war has received little attention. Public health's ethical principles of practice prioritize addressing the fundamental causes of disease and adverse health outcomes. A working group grew out of the American Public Health Association's Peace Caucus to build upon the 2009 policy by proposing competencies to understand and prevent the political, economic, social, and cultural determinants of war, particularly militarism. The working group recommends that schools of public health and public health organizations incorporate these competencies into professional preparation programs, research, and advocacy.
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