Incorporating Structural Racism, Employment Discrimination, and Economic Inequities in the Social Determinants of Health Framework to Understand Agricultural Worker Health Inequities

Abstract

In 2010, the federal government and several state governments began using the social determinants of health (SDOH) framework to highlight contributing factors of health inequities and, in 2022, recognized that structural racism was associated with health inequities. Yet, efforts to eliminate health inequities have disproportionately focused on individualized solutions instead of addressing structural racism.

Many racial/ethnic-minority workers have been segregated to low-wage occupations that lack access to paid sick leave, such as agricultural work, which has been associated with health inequities. Research shows these inequities are attributable to structural racism enforced through laws that structure the employment system to disadvantage agricultural workers, who are disproportionately racial/ethnic-minority individuals, which will not be addressed with individualized solutions.

In this article, we explain why the current SDOH framework and efforts to eliminate health inequities are inadequate, discuss Yearby’s revised SDOH framework that includes structural racism as one of the root causes of health inequities, and illustrate how Yearby’s revised SDOH framework better captures the impact of structural racism, which is associated with health inequities for agricultural workers. (Am J Public Health. 2023;113(S1):S65–S71. https://doi.org/10.2105/AJPH.2022.307166)

Since the formation of the United States to the present day, structural racism has limited agricultural workers’ employment opportunities as well as their economic conditions.^1,2 Specifically, laws enacted at federal and state levels have limited racial/ethnic-minority individuals’ employment opportunities, leaving them relegated to low-wage jobs, such as agricultural work, compared with White workers.^1,2 Compounding this inequality, federal and state laws limit agricultural workers’ union rights, pay, and benefits compared with the rights provided to White workers.^1,2 These differential conditions caused by structural racism and laws that codified economic inequities have been associated with health inequities in physical and mental health for agricultural workers.^3,4

GAPS IN THE CURRENT SOCIAL DETERMINANTS OF HEALTH FRAMEWORK

The current and most widely used social determinants of health (SDOH) framework includes 5 key areas of social and economic conditions—economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community context—that are considered the main factors determining individuals’ ability to achieve their full health potential. However, the current framework fails to show racism as a root cause of inequality as well as differences in social and economic conditions between White individuals and racial/ethnic-minority individuals.

Healthy People 2030 includes this SDOH framework and acknowledges structural racism as a key factor in health inequities. Healthy People 2030 also provides overarching goals to eliminate health inequities associated with employment or economic conditions that are centered around reducing the proportion of people living in poverty and increasing employment in working-age people.⁵

However, neither the SDOH framework nor Healthy People 2030 provide recommendations for eliminating structural racism, which is a root cause of health inequities among Black, Indigenous, Asian, and other people of color.^6–11 Thus, the goal of the present essay is to provide evidence on how structural racism, codified by employment laws and manifested by economic inequities, fuels health inequities among racial/ethnic-minority individuals. By applying Yearby’s revised framework to agricultural workers, we demonstrate how structural racism is illustrated by the limited employment opportunities and poor economic conditions that results in health inequities for this group.⁶

STRUCTURAL RACISM AS A DRIVER OF HEALTH INEQUITIES

Williams et al. define racism as

an organized social system in which the dominant racial group, based on an ideology of inferiority, categorizes and ranks people into social groups called “races” and uses its power to devalue, disempower, and differentially allocate valued societal resources and opportunities to groups defined as inferior.^12(p106)

Jones notes how the social system of racism determines how opportunity is structured, which unfairly disadvantages some racial/ethnic-minority individuals and communities, unfairly advantages White individuals and communities, and saps the strength of the whole society through the waste of human resources.¹³ Freeman notes that “law serves largely to legitimize the existing social structure” of racism by focusing exclusively on trying to neutralize the inappropriate conduct of an individual or institutional perpetrator, which legitimizes the existing social structures built to limit racial/ethnic-minority individuals’ equal access to education, employment, housing, and health care.^14(p1051)

Building on this work, we define structural racism as both the limitation of racial/ethnic-minority individuals’ employment opportunities and the way social and economic conditions are organized to advantage White individuals and disadvantage racial/ethnic-minority individuals.⁶ Law—including political processes, statutes, regulations, policies, guidance, advisory opinions, cases, and budgetary decisions, as well as the process of enforcing or failure to enforce the law—is one of the tools used to limit racial/ethnic-minority individuals’ employment opportunities as well as to organize social and economic conditions in a racially discriminatory way, which has been associated with health inequities.^6,8–11

INCORPORATING STRUCTURAL RACISM INTO THE FRAMEWORK

Numerous scholars have already proposed methodologies and models to include structural racism as a key factor in health inequities. Ford and Airhihenbuwa created the Public Health Critical Race Praxis methodology, which noted that structural determinism and racial categories are the bases for ordering society, which contributes to racial health inequities.¹⁵ Williams et al. created a model, entitled “the house that racism built,” showing how multiple forms of racism can affect health.¹⁶ Yearby’s revised SDOH framework⁶ builds on these models.

In revising the SDOH framework⁶ to incorporate structural racism, Yearby shows how structural racism and employment laws create differential social and economic conditions between White and racial/ethnic-minority individuals, which are associated with health inequities. We used Yearby’s revised framework in this essay to illustrate how structural racism is evident via the limitation on agricultural workers’ employment opportunities, which, in turn, creates poor economic conditions for agricultural workers. The combination of limited opportunities and poor economic conditions interact to create conditions that lead to health inequities. Laws that have been enacted to limit agricultural workers’ employment opportunities and economic conditions are discussed here and listed in Box 1.

BOX 1—

Laws Impacting Equality Rights, Protected Union Activities, Pay, and Paid Sick Leave for Agricultural Workers: United States, 1865–2021

Law	Coverage and Exclusions	Effective Date
Black Code Lawsa	State laws that restricted Black Americans to working in agricultural or domestic service	1865–1950
13th Amendmentb	Allows for slavery as a punishment for a crime Breaking Black Code Laws was a crime punishable by enslavement	1865–present
National Labor Relations Actc	Guarantees the right of employees to organize and bargain collectively with their employers Provides union activities of employees Excludes all agricultural workersd	1935–present
Fair Labor Standards Act (FLSA)e	Establishes 40-hour work week, overtime pay, and minimum wage requirements and prohibited child labor Excludes all agriculture workers until the 1966 amendment to the FLSAf	1938–present
Migrant and Seasonal Agricultural Worker Protection Actg	Provides employment standards related to migrant and seasonal agricultural workers (i.e. wages, housing, transportation, disclosures, and recordkeeping) Does not provide the right to organize or bargain collectively with their employersh	1983–present
Personal Responsibility and Work Opportunity Reconciliation Acti	Establishes comprehensive restrictions on the eligibility of noncitizens for federal public benefits; these restrictions applied to the majority of nonnaturalized (i.e., non-US citizen) foreign-born persons, including lawful permanent residents (also known as green card holders), asylees and refugees, nonimmigrants, and unauthorized immigrantsj	1996–present
Coronavirus Aid, Relief, and Economic Security Actk	Established limitations (an amendment to the Families First Coronavirus Response Act) on emergency paid sick leave employer payment requirements Does not include noncitizens because it requires US work authorizationl	Apr–Dec 2020 (required) Extended to Sep 2021 (voluntary)

^a The Black Codes and Jim Crow Laws, https://education.nationalgeographic.org/resource/black-codes-and-jim-crow-laws. Accessed November 19, 2022.

^b US Constitution Amendment XIII, Sec. 1.

^c 29 USC §§151–169.

^d 29 USC §§151–169, Title 29, Chapter 7, Subchapter II, §152(3).

^e 29 USC §201, et seq.

^f 29 USC §213(a)(6)(A)-(E) and Pub L No. 89–60, Title I, Sec. 103(a)3(e).

^g 29 USC §1801, et seq.

^h 29 USC §1801, Sec. 4(a)(1)-(3).

ⁱ Pub L No. 104–193.

^j Pub L No. 104–193, Title IV.

^k Pub L No. 116–136.

^l Pub L No. 116–136, Title III, Part IV, Subtitle C, Sec. 3602(f)(1)-(2).

AGRICULTURAL WORKERS’ INEQUALITY OF OPPORTUNITY

Agricultural workers are essential because they are human beings who plant, pick, process, and pack food for shipment and consumption, which ensures that Americans have access to food, including fresh produce. Throughout the history of the United States, the government has used law to limit racial/ethnic-minority individuals’ employment opportunities, including limiting their ability to work in jobs beyond certain industries. From 1787 until 1865, some White individuals enslaved Black and Indigenous individuals, forcing slaves to do agriculture and domestic work for free.

After the end of slavery, a majority of agricultural workers in the South were Black Americans because many states passed “Black Code” laws prohibiting Black Americans from working in any occupation other than agricultural or domestic service.¹ Solomon et al. note, “if [Black Americans] broke these laws or abandoned their jobs after signing a labor contract, they could be arrested,” imprisoned, and forced back into unpaid servitude on White plantations because the 13th Amendment allows for slavery as punishment for a crime.¹ In addition, several laws were passed that prevented Black Americans from migrating to northern states. As a consequence, in the 1930s, approximately 65% of all Black workers in the South were employed as domestic or agricultural workers, while a majority of the agricultural workers in the North and West were White Americans, who were free to work in any industry.¹⁷ Between 1950 and 1990, the agricultural system in the South changed as a result of technological advancements, which reduced the need for agricultural workers. These advancements allowed many Black agricultural workers to shift to other occupations and to also leave the South.

Currently, agricultural workers are largely employed in Western states, including California, Arizona, and Washington.^4,18 Today, agricultural workers in the United States include (1) hired workers and (2) self-employed farm operators and their family members. This article focuses on hired agricultural workers, which includes hired farmworkers that are employed in a variety of occupations—from field crop, nursery, and livestock workers to graders and sorters, agricultural inspectors, supervisors, and hired farm managers.¹⁸ Now a large percentage of hired agricultural workers are foreign-born individuals from Mexico and Central America. For the fiscal year 2017–2018, 77% of all agricultural workers were Latino and 64%, 32%, and 3% of all agricultural workers were born in Mexico, the United States (including Puerto Rico), and Central America, respectively.¹⁹ Agricultural work is one industry in which the federal government and several state governments allow non‒US citizens to work legally in the United States under a H-2A visa, but permits employers to pay these workers less than US citizen workers.

The percentage of hired crop farmworkers who are not US citizens has greatly increased—growing from 14% in 1989‒1991 to 55% in 1999–2001 and stabilizing slightly under 50% in recent years. Between 2005 and 2020, the number of H-2A visas requested and approved for agricultural workers increased more than fivefold—from approximately 48 000 to more than 275 000 positions. In 2020, the average hourly rate for nonsupervisory workers was $14.64, but this rate is not what is typically paid to most racial/ethnic-minority agricultural workers.¹⁸ Some agricultural workers, including racial/ethnic-minority workers with H-2A visas, are paid an adverse effect wage rate, which, on average, can be as low as $11.71 per hour.² Because of increased demand and scarcity of agricultural labor in the United States, many of the agricultural positions are held by H-2A workers whose pay is lower than that of US citizen workers who must be paid minimum wage.² As Holmes notes, laws, such as California’s Proposition 187, make it legal for farmers to pay non‒US citizen agricultural workers only enough for daily survival.²⁰ In addition, Title IV of the Personal Responsibility and Work Opportunity Reconciliation Act of 1996 prohibits the majority of non‒US citizens—including lawful permanent residents, asylees and refugees, nonimmigrants, and unauthorized immigrants—from receiving federal public benefits, such as Medicaid and the Supplemental Nutrition Assistance Program.²¹ As a consequence, almost a third of agricultural workers have incomes below the poverty level as defined by the US Department of Labor.⁴

Historical and modern-day structural racism, enforced through laws, limits racial/ethnic-minority individuals’ employment opportunities by restricting their ability to travel, attain jobs outside of low-wage industries like agriculture, and access public benefits. Specifically, historical structural racism limited Black Americans’ equality rights by forcing them to stay in the South and work in agricultural or domestic work, while modern-day structural racism limits non‒US citizen agricultural workers’ pay and access to public benefits. Each of these restrictions interacts to leave many agricultural workers, who are predominately racial/ethnic minority individuals, in poverty and unable to attain high-wage jobs.

AGRICULTURAL WORKERS’ ECONOMIC CONDITIONS

During the Jim Crow era (1875–1964), many of the federal laws passed to protect and support workers did not cover agriculture workers or other occupations that were predominantly filled by racial/ethnic-minority individuals. For example, in 1935, the Social Security Act was passed providing old-age, survivor’s, and disability insurance to workers and their families, yet it excluded agricultural, domestic, and service workers, who were predominantly racial/ethnic-minority individuals.²² In 1950, amendments to the Social Security Act provided coverage to most agricultural workers and domestic workers, yet many Jim Crow‒era laws remain in effect that limit agricultural workers’ access to equal pay and paid sick leave.²²

The National Labor Relations Act of 1935 (NLRA) expanded collective bargaining protections for White workers, allowing them to join unions, which resulted in their higher wages and benefits, such as paid sick leave.²³ The NLRA did not apply to domestic or agricultural workers, who were predominately racial/ethnic-minority individuals, and the government allowed unions to not represent racial/ethnic-minority workers employed in other industries, such as manufacturing.¹ Workers covered by the NLRA who join unions are protected from being fired or punished for collective bargaining activities, such as negotiating for raises or benefits. In 1983, the Migrant Seasonal Agricultural Worker Protection Act was passed, which provided some protections for “migrant and seasonal agricultural workers by establishing employment standards related to wages, housing, transportation, disclosures, and recordkeeping.”²⁴

For instance, it requires that employers must disclose the terms of employment at the time of recruitment and comply with those terms. However, it did not make the NLRA applicable to agricultural workers. Although agricultural workers are not prohibited from creating unions, farmers do not have to negotiate with the union when bargaining for wages and benefits. Farmers can also fire workers who form unions without consequence, which is not allowed in industries covered by the NLRA. Therefore, many of these workers still do not have high wages or paid sick leave.

The Fair Labor Standards Act of 1938 (FLSA) also explicitly exempted agricultural occupations.¹ The FLSA limits the workweek to 40 hours and establishes federal minimum wage and overtime requirements.²⁵ It also requires employers to keep records of the payroll. In 1966, the minimum wage requirements of the FLSA were applied to agricultural workers, but many workers are still not paid minimum wage. If farmers did not utilize more than 500 man days (any day in which an employee performs agricultural work for at least 1 hour) of agricultural labor in any quarter in the previous calendar year, then the FLSA does not apply to any of the hired workers for the entire year.²⁵

Moreover, the FLSA minimum wage requirements do not apply to “local hand harvest laborers who commute daily from their permanent residence, are paid on a piece rate basis in traditionally piece-rated occupations, and were engaged in agricultural less than thirteen weeks during the preceding calendar year.”²⁶ Eighty percent of hired crop workers who hand harvest live in one place, commute daily, and work at a single location within 75 miles of their home. Hence, these workers are not paid minimum wage because the FLSA does not apply to them. In addition, the FLSA requirement for overtime pay does not apply to agricultural workers. Newer laws also limit agricultural workers’ economic conditions.

During COVID-19, the federal government enacted several COVID-19 economic relief bills that provided federal public funds. The Coronavirus Aid, Relief, and Economic Security Act of 2020 (CARES Act) provided unemployment benefits and provided direct payments to individuals through refundable tax credits.²⁷ These benefits provided workers with federal financial assistance; however, they were not available to non‒US citizens, especially undocumented workers. Because roughly 50% of agricultural workers are not US citizens, including H-2A visa workers, the expanded employment benefits provided by the CARES Act did not cover them.²⁸

Historical and modern-day structural racism, enforced through laws, limits the economic conditions of agricultural workers, who are predominately racial/ethnic-minority individuals. Employment laws not only advantage White workers, including farm managers, inspectors, and supervisors, as well as those working in other industries, by giving them union rights that boosted their wages, but they also advantage farmers who are predominantly White by limiting their employee costs.¹ However, racial/ethnic-minority agricultural workers remain in poverty because they do not receive union rights, minimum wage, overtime pay, or paid sick leave. Compounded by the laws that limit agricultural workers’ opportunities, each of these employment restrictions interacts to leave many agricultural workers in poor economic conditions, which has been associated with health inequities.

AGRICULTURAL WORKERS’ HEALTH INEQUITIES

Agricultural workers suffer from a host of health inequities compared with other workers, including diabetes, respiratory disease, and heart disease. In this article, we focus on mental health and pandemic health inequities, because these have been tied to employment conditions in the literature. There is an increasing global concern for the mental health of agricultural workers as national and international studies have linked key risk factors to negative mental health outcomes for agricultural workers, including employment conditions, pesticide exposure, financial difficulties, climate variabilities and drought, poor physical health, and past injuries.²⁹

In the United States, psychosocial stressors such as rigid work demands, poor housing conditions, low family income, and living in poverty have been significantly associated with anxiety and depression for Mexican migrant farmworkers.³ Other significant stressor categories specific to migrant farmworkers that have also been associated with anxiety and depression are social isolation and hazardous, poor, and stressful working conditions.³⁰ As pay concerns for these workers go unaddressed, the mental health and livelihood of these workers continue to be jeopardized.

Several research studies provided evidence that lack of equality and poor economic conditions were associated with higher rates of H1N1 infections, hospitalizations, and deaths for racial/ethnic-minority workers across the United States.^31,32 These studies, which included national surveys, showed that racial/ethnic-minority individuals were unable to practice social distancing or stay at home during the H1N1 pandemic because they did not have the freedom to work at home and lacked paid sick leave.^31,32 In fact, Quinn et al. found that a majority of Spanish-speaking Latino workers (63.1%) did not have paid sick leave, compared with 23.2% of Black workers, 26.1% of White workers, and 33.3% of English-speaking Latino workers.³¹ The study also found that 73.1% of Spanish-speaking Latino workers were only able to do their job in the workplace, compared with 34.3% of Black workers, 45.4% of White workers, and 47.3% of English-speaking Latino workers. As a result, Spanish-speaking Latino workers had an increased exposure to H1N1 within the workplace that was associated with higher rates of infections, hospitalizations, and deaths.³¹

This association between employment factors and H1N1 infections was supported by a study that tracked self-reported influenza-like symptoms during the 2009 H1N1 pandemic. The researchers found that there was a higher incidence of self-reported influenza-like illness for those who lacked paid sick leave or could only do their job in the workplace. Of those surveyed, Latino individuals were more likely to lack paid sick leave (40.5%) or could only do their job in the workplace (56.8%), compared with White workers (22.4% and 40.4%) and Black workers (22.0% and 26.2%).³²

A study conducted by Schoch-Spana et al. showed that Latino farmworkers were also at risk for increased exposure to H1N1 because many of them did not have paid sick leave and could only do their job in the workplace.⁴ Furthermore, even if the workers were sick, they could not afford to lose the wages or jeopardize their jobs by not showing up to work. These inequities in H1N1 infections, hospitalizations, and deaths were particularly notable because Latino individuals traditionally have lower mortality rates than White individuals. In fact, from 2009 to 2013, Latino individuals had a “24% lower all cause death rate and lower death rates for nine of the 15 leading causes of deaths” compared with White individuals.^33(p470) These inequities in infections have persisted during the COVID-19 pandemic.

Although COVID-19 data disaggregated by occupation are limited, the available data and news stories show that there are agricultural worker health inequities in COVID-19 infections. For instance, in May 2020, all 200 workers on 1 farm in Tennessee were infected with COVID-19, while Yakima County, Washington—a key agricultural area—“had the highest rate per capita infection rate of any county on the West Coast.”³⁴ In addition, there was one study that highlighted agricultural workers’ heightened COVID-19 risks. The study estimated that in the first 13 months of the COVID-19 pandemic, cumulative rates (deaths) were 170 137 (2969), 202 902 (3812), and 27 223 (459) among hired agricultural workers, unpaid agricultural workers, and migrant agricultural workers, respectively.³⁵ Counties with more agricultural workers had significantly higher COVID-19 cases and death incidence rates.³⁵ Many employment factors have been associated with these inequities in COVID-19 infections, including lack of paid sick leave and gaps in health and safety protections for workers.

CONCLUSIONS

As illustrated by the conditions of agricultural workers, racial/ethnic-minority workers disproportionately tend to be employed in low-wage jobs that do not provide minimum wage, overtime pay, collective bargaining rights, or paid sick leave. As a result, many racial/ethnic-minority workers remain in poverty, which has been associated with poor physical and mental health outcomes. These problems are not captured in the current SDOH framework and cannot be fixed by using the individualized worker training programs suggested in Healthy People 2030. To eliminate health inequities, the government must aggressively work to end structural racism perpetuated by employment laws and economic inequities as discussed here. Yearby’s revised SDOH framework as applied to agricultural workers provides a clear model for government officials to understand the connection among structural racism, employment law, the SDOH, and health inequities.