Introduction

In 2021, the United States foreign-born population was a record-setting 44.7 million people (or about 13.46% of the total population) [1]. The majority group amongst the undocumented population is Mexican [2]. Many foreign-born people, especially the undocumented Mexican population, contribute significantly to the economy in agriculture but are met with extremely low wages and do not receive any health insurance. A combination of low salaries and constant travel in jobs for these foreign-born workers makes the idea of attaining health insurance unfeasible. In 2019, New Jersey was estimated to have an unauthorized population of 440,000 people and Pennsylvania was estimated to have a population of 153,000, the majority region from both states being from Mexico and Central America. In New Jersey and Pennsylvania, 51% and 46% of family incomes of undocumented immigrants were below 200% of the poverty level respectively [3, 4]. These low familial incomes of undocumented immigrants reflect the inadequate living conditions experienced by many individuals. One of the many problems included in inadequate living conditions is an inability to access healthcare. Undocumented immigrants often face barriers to accessing healthcare information and services due to their legal status, language barriers, and lack of familiarity with the healthcare system in their host country. The Mobile/Rural Health Promoters can bridge this gap by providing essential information about available healthcare services, clinics, hospitals, and programs. The program can also reach undocumented immigrants in various settings, such as community centers, places of worship, or even through virtual platforms. This flexibility enhances accessibility and ensures that health information is disseminated widely. The Health Promoter clinics can also connect undocumented immigrants to appropriate healthcare services and programs, including low-cost or free clinics, community health centers, and government assistance programs. This can help immigrants receive timely medical attention and support, reducing the risk of complications from untreated health issues. Mobile health clinics play a crucial role in promoting preventive care and health education within immigrant communities. They can provide information about vaccinations, screenings, nutrition, hygiene, family planning, and other essential health topics that may otherwise be overlooked due to barriers to accessing healthcare services. To combat the lack of access to healthcare amongst the foreign-born Mexican population in America, the Consulate of Mexico and the Institute of Clinical Bioethics of Saint Joseph’s University is working together to run Health Promoter Programs in local regions where those who lack healthcare are most affected.

Background

 A. National Level
The agricultural industry in the United States is a trillion dollar industry in which migrant farm workers are crucial. Migrant workers have to travel to do work, but cannot return home at the end of the day. Often, migrant workers are from other countries, either on a temporary or seasonal Visa or undocumented. Migrant farm workers are low-paid and largely foreign-born [5]. While migrant labor is predominantly seasonal, changing agricultural patterns over the past 20 years have allowed seasonal migrant workers to travel to other work year-round [5].

In 2021, 23% of the foreign-born population in the United States was unauthorized. In the United States in 2017, there were over 2,000,000 farms spread over 900,000,000 acres of farmland [19]. The National Center for Farmworker Health estimates that there are approximately 2.9 million agricultural workers in the United States and 73% of these workers are immigrants. The majority of workers emigrated from Mexico (63%) and other Central American countries (5%) [20]. Migrant workers harvest over 80% of crops produced in the fruit and vegetable industry. Of these migrant workers, the majority (78%) are Hispanic: 62% reported that they are more comfortable conversing in Spanish rather than English; 29% reported that they could not speak English at all; and 39% reported that they could somewhat speak English. Language barriers prevent migrant workers from obtaining social services, including healthcare[20].

Given that undocumented immigrants are not insured, they often only obtain emergency medical treatment due to a lack of access to healthcare, fear of deportation, and financial hardship. Migrant workers typically do not receive insurance through farm work, regardless of immigration status. Unsafe working conditions, low-income levels, lack of adequate housing, and unusual working hours all contribute to the vulnerability of the migrant population [6]. Health issues that migrant workers face stem from these factors as well; working for long hours in summer heat leads to heat exhaustion and strokes; pesticides used on the farms contaminate the surrounding environment, causing various illnesses; physical labor leads to muscular and skeletal injuries; poor living conditions such as inadequate sanitation results in infection [6].

Migrant workers and undocumented immigrants heavily rely on healthcare through the emergency room. The above factors result in illnesses treated in the emergency room, placing strain on the emergency department at facilities. The Emergency Medical Treatment and Labor Act (EMTALA) states that regardless of immigration status, someone undergoing a medical emergency must have their condition stabilized in the hospital [7]. Following stabilization, patients are either transferred to another facility or are discharged. Patient transfer, however, includes transferring patients to facilities outside of the United States [8]. Undocumented immigrants could be sent to a facility in another country, removing them from work and other opportunities. In the United States’ political landscape, many argue that undocumented immigrants cost the country money in Medicaid and other public spending policies. Spending on undocumented immigrants’ medical emergencies, however, made up 0.2% of Medicaid spending in 2016 [9]. Undocumented immigrants contribute to the nation’s finances through Medicaid expenses, taxes, and other social services [8].

B. State Level

In 2017, New Jersey was home to 9,883 farms and over 730,000 acres of farmland [10]. New Jersey is also home to 440,000 unauthorized immigrants [3]. Approximately 42% of this population are from Mexico and Central America [3]. 68% of the unauthorized population are employed, yet 57% are uninsured [3].

Farms typically employ around 20 full-time workers, supplementing with hired workers in seasons of high yield [11]. Some farms have fewer workers because they are able to pick crops using machines. Fruit and vegetable farms are more labor intensive because a delay in harvesting reduces quality of the crop, impacting the ability to sell a crop [12]. Low crop yields or the production of un-marketable crops reduces the amount of money a farm makes, impacting workers’ wages. In 2021, the labor in New Jersey farms produced 5,600 pounds of blueberries 3 per acre, 203 barrels of cranberries per acre, and 3.8 tons of peaches per acre [13]. Cumberland County led the counties in the number of orchards it had in 2017, while Atlantic County led with the number of blueberries and other berries planted.

New Jersey’s Medicaid program, NJ FamilyCare, allows immigrants over the age of 19 who are “lawfully present” to apply for healthcare coverage.[14] NJ FamilyCare covers all immigrants under 19 regardless of immigration status. Undocumented immigrants are able to apply for New Jersey’s Medical Emergency Payment Program, which covers medical costs for undocumented immigrants or immigrants who are not permanent residents. In order to apply for the program, Medicaid qualifications must be met and the application must be filed within 3 months of the medical emergency [15].

In 2017, Pennsylvania was home to 153,000 undocumented immigrants, with 34% of these immigrants from Mexico and Central America [4]. Approximately 44% of unauthorized immigrants in Pennsylvania are uninsured [4]. Pennsylvania is composed of over 7,000,000 acres of farmland, which is made up of over 53,000 farms [16]. Lancaster County is the top county in agricultural sales, followed by Chester County. Lancaster County has over 5,000 farms which primarily produce livestock, poultry, and products of those animals. In Lancaster county, 99% of farms are family-owned, yet 39% of these farms hire supplementary labor [17]. Kennett Square, the mushroom capital of the world, is located within Chester County. Chester County has over 1,600 farms that primarily produce crops such as nursery and floriculture crops as well as grains, beans, and peas. At least 43% of farms in Chester County hire farm labor [18].

Pennsylvania has an Emergency Medical Assistance program that provides limited care for immigrants not eligible for traditional Medicaid, often due to immigration status [7]. Again, all Medicaid qualifications except for immigration status must be met in order to obtain care through this program.

Preventative medicine is more effective in preventing health problems and promoting well-being. Without health insurance, workers are unable to obtain preventative treatment and instead must try to treat illnesses after its onset. Continuing to work when sick worsens the illnesses, and overall lowers quality of life.

On the state and national level, the issue of lack of healthcare access for undocumented immigrants and migrant workers is larger than it appears. Much of this data was collected through the US Census, which occurs every 10 years. Undocumented immigrants often do not participate in the census, thus they are underrepresented in these numbers.

Hispanic Mobile/Rural Health Promoter Model

 A. Background

In 2020, the Consul General at the Consulate of Mexico and the Institute of Clinical Bioethics at Saint Joseph’s University instituted a Hispanic Health Promoter hosted at the Consulate of Mexico. This program was initiated to address the increasing lack of adequate healthcare for the growing undocumented and uninsured Hispanic population. The program proved to be successful and, in 2023, inspired the Consul General at the Consulate of Mexico to approach the Institute of Clinical Bioethics with the opportunity to co-host mobile health promoter clinics in various locations around New Jersey, Pennsylvania, and Delaware. The Consulate of Mexico is responsible for providing services to individuals in these three states, so they often travel to different locations to support large populations of people. After hosting one 4 of the Mobile Health Promoter clinics, the Institute of Clinical Bioethics was approached again by a Resident at Jefferson North East about the idea of hosting a Rural Health Promoter at various blueberry fields in New Jersey. From this, it was clear that the mission of the program was to develop and implement a healthcare program for the Hispanic and migrant farm worker (MFW) populations that would meet two distinct needs: 1) provide healthcare for those most in need, and 2) do so cost-effectively. Much like the Hispanic Health Promoter Program, this new program was based on three different models. Two of the models, Partners in Health (PIH) and Creighton University’s Institute for Latin American Concern (ILAC), were examined in regard to their versions of a Health Promoter Program. The third model examined the work of American based Dominican Sisters in Las Cruces de Arroyo Hondo, the Dominican Republic who have successfully organized a grass-roots effort based on community ownership and responsible stewardship. Each of the three models will be examined to show how they have contributed towards the Institute of Clinical Bioethics’ Mobile Health Program designed to bring a practice from the developing world to a developed nation.

The Partners in Health (PIH) model was the initial inspiration for the design of this program. Partners in Health strives to achieve two goals by establishing long-term relationships with sister organizations that are based in locations of poverty: provide the benefits of modern medicine to those in need "and to serve as an antidote to despair" [19]. One effective methodology to accomplish such goals is through education and preventative medicine provided by the Health Promoters of Partners in Health through a “community-based model of care.” This model entails access to free health care, education for the poor, community partnerships, and addressing basic social and economic needs [19]. Based on this model, PIH has modified its established and successful programs in Haiti, Peru, Russia, Rwanda, and Lesotho for application in Alabama; Chicago, Illinois; Immokalee, Florida; Newark, New Jersey; New Bedford, Massachusetts; North Carolina; and Pima County, Arizona. One such program launched by the Commonwealth of Massachusetts in collaboration with PIH became one of the biggest statewide Covid-19 initiatives. This program worked to support the efforts of local health departments through the use of prioritized care source coordination [20] . This program had a large impact for the state of Massachusetts: More than 100,000 in-state individuals were connected with community support, resources, and public benefits https://www.mass.gov/info-details/covid-19-community-tracing-collaborative-ctc.

To create a more well-rounded perspective of community health not limited to PIH alone, Creighton University’s Institute for Latin American Concern (ILAC) model was examined. ILAC is based in Santiago, Dominican Republic. One of the aspects of ILAC is the organization, training, and operation of a Health Promoter Program. The program consists of ILAC nurses, doctors, and administrators; regional coordinators; and Health Promoters. The nurses, doctors, and administrators are responsible for training, management and procurement of supplies and medicines, recruitment of specialized medical teams to the Dominican Republic, and all other operational activities and programs. The Health Promoters reach out to and work on a personal level with the people in their individual communities. They carry out education, primary medical care and prevention, and health programs [21].

The third model is sponsored by the Dominican Sisters, which focuses on the value and importance of education and community health. The Dominican Sisters have accomplished and continue to accomplish a great deal for the community of Las Cruces de Arroyo Hondo in the Dominican Republic. In helping the community establish a pre-school, an elementary school and 5 a high school, they have afforded and continue to afford thousands of children a chance to receive an education and the opportunities for improving the community. By building a laboratory, pharmacy, and bakery that are all community-run, the Sisters facilitate improvement in the community’s nutrition, health and economy that otherwise would be unavailable. The methodology by which the Sisters were capable of participating and aiding such crucial developments in that community was believed to be relevant to beginning a community-based program in Philadelphia. This methodology was to unite the community in common goals, empower them to take ownership for their community, train them in areas of leadership, stewardship and finances, and then step-back and allow the community to assume control.[21]

B. Services Offered

The Institute of Clinical Bioethics at Saint Joseph’s University introduced the proactive health assessments to individuals within immigrant communities. This enables them to undergo evaluations of their body mass index, pulse oxygen saturation, blood pressure, blood glucose levels, total blood cholesterol levels, and more. By identifying the initial signs of preventable chronic diseases at an early stage, it gives individuals the chance to embrace healthier habits to delay any chronic illnesses and avert the emergence of expensive medical issues. At the start of the services, each patient receives an individual screening tool that is used to keep track of all of their vitals and critical information throughout the entire program. All of the stations and services offered in the clinic are outlined below.

➔ Body Mass Index The first station that a patient encounters when he or she enters the clinic is the BMI station. Here, the patient removes shoes and any heavy clothing to measure their respective height and weight in the scale. Based on the information, the body mass index of the patient is automatically calculated in the weight balance.

➔ Blood Pressure & Pulse Oximetry The patient then proceeds to sit in a chair with their feet flat on the floor. Once in the proper position, the cuff of the blood pressure monitor is placed an inch above the crest of the elbow and the pulse oximetry device on the index finger of the opposite arm. Readings are calculated and recorded.

➔ Blood Sugar & Cholesterol The patient moves to another chair in which their blood sugar levels and cholesterol levels will be measured. The finger from which blood is drawn is first disinfected with an alcohol wipe. Both the glucose and cholesterol strips are loaded into their respective monitors (glucometer and the CardioChek Cholesterol Analyzer). Using a push-button safety lancet, the finger is pricked for blood. The tip of the glucose strip is dipped into the blood and using a capillary tube, blood is transferred to the cholesterol strip to obtain proper measurements. 

➔ Reading Glasses Patients who are in need of reading glasses have the opportunity to try a range of different prescriptions and choose which one is the best fit for them. Using a reading chart, the patients are able to test each of the reading glasses.

➔ Dental Evaluation and Education At this station, patients are screened by a dentist to look for any teeth damage or dental cavities. If any abnormalities are found, patients can be referred to a dental clinic for further evaluation. Patients undergo a fluoride treatment to prevent further cavities. Adults and children are educated on how to properly take care of their teeth and given free kits with mouth care supplies (e.g toothbrush, paste, and dental floss).

➔ Cancer Screening This is a partnership with the University of Pennsylvania Abramson Cancer Center in which patients fill out a questionnaire to predict the likelihood they have undiagnosed colorectal, lung, prostate, cervical, or breast cancer. Based on the information entered, patients are referred to UPenn Oncology for further examination.

➔ Opioid Prevention Station At this station patients receive Narcan, fentanyl strips, and xylazine strips. They are oriented on how to properly use them in order to prevent a self opioid overdose or the overdose of another individual.

➔ Healthy Mothers Station Patients receive daily multivitamins for adults, children, and expecting mothers, available as once-a-day gummies. Additionally, the program provides Pack N’ Play cribs expectant mothers in their third trimester (at least eight months pregnant) as a measure to help prevent and decrease the rates of infant mortality.

➔ Wound Care A major aspect of migrant workers' daily lives is excessive physical labor. This can lead to open wounds that are often not properly taken care of due to lack of resources and can lead to infection or further complications. The wound care station focuses on the proper care of open wounds, including disinfection and proper coverage to avoid complications caused by external pathogens.

➔ Cardiac Screening After patients undergo blood pressure screening and are evaluated by the medical personnel, they can be eligible to receive a blood pressure monitor if their blood pressure was abnormal. These are given so that the patient can continuously monitor and control their blood pressure. After about one month, the patient is intended to return the blood pressure monitor with a record of their vitals to be further evaluated by the medical personnel.

➔ Medical Evaluation Once patients undergo all of the stations mentioned above, they have the opportunity to meet with the medical personnel to discuss past medical concerns or new ones shown in the data collected throughout the screening process. The patient typically presents their now completed screening tool, and the medical professional can then determine if it is prudent to refer the patient to a clinic for further examination.

C. Practical Application:

How it was designed and implemented Taking into consideration the lack of resources of the clinics’ target populations (especially uninsured and underinsured communities), the PIH, ILAC, and Dominican Sisters models were used to shape a clinic that could most importantly provide accessibility to basic, preventive healthcare. It was of utmost importance that the Mobile/Rural Health Promoter clinic could stand out from the Hispanic Promoter Clinic by emphasizing on the accessibility aspect regardless of the fact that both clinics offer similar services. The other clinics of the Institute of Clinical Bioethics at Saint Joseph’s University are held in more metropolitan sectors near the Philadelphia area, where there is a higher cost of living, and thus a lower probability for communities to take advantage of the medical services to the fullest. By bringing the services directly to the farms, the Institute enhances the convenience and overall care for all individuals involved.

To ensure a proper financial assessment of the cost effectiveness of the Health Promoter Promoter, records of the number of patients seen, the most prevalent medical needs and costs are recorded. The financial assessment includes a comparison of the program costs with previously compiled data on the costs of treating undocumented individuals to date at the other Health Promoter clinics (i.e. Chinese, Hispanic, African). These record-keeping techniques can also be utilized for quality assessment of the Mobile/Rural Health Promoter program and individual Health Promoters via community surveys, Health Promoter comments and physician feedback.There is a strong belief that the Health Promoter Program will yield noticeable benefits and cost efficiency in the long run. The program is seeking funding through federal, state, and local grants to provide financial support. Currently, funding is being secured from grants and donations provided by various private organizations.

In our litigious society, concerns arose regarding liability coverage for the Mobile/Rural Health Promoters. (Mercy Health Promoters: A paradigm for implementing third world practices for resource-poor conditions of the developed world.) It was concluded that legal liability for the Mobile/Rural Health Promoters would be of minimal significance as little to no information of the patients is kept in accordance with confidentiality. To fulfill these requirements for record keeping, an approach inspired by current practices in Africa was adopted. Similar to the practice in many African nations, patients themselves will be responsible for holding onto their own medical records. This approach aligns with the objective of maintaining confidential documentation while also being suitable for environments with limited infrastructure. Moreover, this method resonates with the familiarity of many Latin American immigrants. Allowing individuals to retain their own medical records will also prove advantageous for members of this population who frequently relocate due to employment or personal reasons, ensuring continuity of care. This strategy addresses a trust-related concern by eliminating the possibility of adding information to a patient's chart without their awareness. By placing more accountability on the 8 patient, it is hoped that a stronger sense of ownership of the Mobile/Rural Health Promoters program will allow greater trust in the community.

Patient Data Analysis and Future Progress of the Program

A. Medical Conditions

Through this Health Promoter Program it is possible to diagnose, triage and/or treat a variety of medical conditions. Since the program’s inception thus far, the vast majority of patients encompassed hypertensives and diabetics. A handful of elderly patients were found to have a blood glucose >400s and surprisingly enough none of them appeared to have been diagnosed with diabetes. Further history, however, revealed several classical symptoms of diabetes such as polydipsia, polyuria, and unhealed wounds. Another prominent trend was hypertension, with some patients receiving blood pressure results in the range of 190–210 systolic. The silent nature of this disease was exemplified in these patients who had no symptoms when these pressures were recorded. One specific case that required more acute attention involved a middle aged gentleman, tormented by severe lower back aches, disabling him from standing straight. Upon history taking and examination, the physician’s differential included severe lumbar spinal stenosis and spinal abscess, the latter of which is more sinister. Overall, middle aged men, elderly men and elderly women seemed to make up the majority of those affected by medical conditions. Children, adolescents, and young adults appeared generally healthy. Middle-aged women seemed to have a mix of comorbidities but overall a low prevalence.

B. Access to Healthcare

Of the above patients mentioned, many were provided referral suggestions to primary care centers in and around their area, with most being in Philadelphia. Unfortunately, within the bounds of this program, there are no resources to transport patients to their referrals; hence they are expected to make the journey to the clinic. Due to the fact that almost all of the blueberry farm workers are concentrated within the farm’s one mile radius, they often rely on clinics to obtain care, typically at the point when it is absolutely necessary. Some individuals mentioned that they visit these clinics for annual health checks or screenings, but it is often inconsistent. The population was aware of the scarcity of medical resources. Some mentioned bringing their medication from their native country but were already running scarce.

C. Future Progress

Given the high prevalence of lifestyle diseases, low income and lack of access to healthcare puts this particular patient population at risk of cardiovascular diseases. The goal of the Health Promoter Program is to provide accessible healthcare screening to underserved populations, with a particular focus on blueberry farmers. An Interheart Risk scoring questionnaire will be included to identify those at higher risk of cardiovascular mortality who would then be subject to a spot lipid testing to obtain their lipid levels. These levels would then be used to obtain the ASCVD score, giving a corroboration with Interheart score, as well as guidance for further management of risk factors. To counter hypertension, the ‘BP Buddy’ program will be implemented. This would allow patients to temporarily borrow automatic BP machines for a 9 certain period of time with instructions to log the data and information to present to the ER if medical attention was required. With the continuous growth of the Health Promoter Program comes the continual evolution of services to provide improved care to all of the populations served. 

Ethical Analysis

In the last four decades, this nation has been trying to improve the quality of our health care delivery system. Despite the efforts to increase the quality in health care, disparities continue to be prevalent and have led to unjust consequences for racial and ethnic minorities. Advances in technology and a better understanding of the disease process have greatly improved due to research in the field of medicine. This has contributed to better management of the disease process, which has in turn improved the morbidity and mortality rates of many patients and increased life expectancy nationwide. Unfortunately, this effect is being seen predominantly among white Americans while other ethnic groups are still vulnerable, especially inner-city Hispanic populations. Even though our healthcare system, in principle, is considered to be the best in the world it has its own flaws and has left millions of Americans as well as documented and undocumented individuals with inadequate health care or no access to basic health care Services. 

In 2018, the United States foreign-born population was a record-setting 44.8 million people (or about 13.7% of the total population). Approximately a quarter of that population is undocumented [22]. The majority group amongst the undocumented population is Mexican [23]. Consequently, regional hospitals have seen an increase in undocumented patients, many uninsured or underinsured. This population has special needs which physicians and hospitals are not well-equipped to provide. The majority of this community is suffering from chronic diseases such as hypertension, diabetes, obesity and with some of the new arrivals from Latin America, even HIV. As health care providers, our duty is to improve the health of the community we serve. To achieve this goal, it is important to understand the diseases prevalent in this community and to develop services tailored to meet these needs. This is certainly a medical problem, but it is also an ethical problem for all Americans. To allow race and ethnicity to play any role in providing health care to our fellow brothers and sisters goes against the basic principles of morality. It will be argued that—according to the ethical principles of respect for persons, beneficence/nonmaleficence, and justice—action must be taken immediately to address these concerns. Such action will not only save lives but will also do much to rebuild a sense of trust between the minority community and the medical establishment.

Respect for Persons

This principle incorporates two ethical convictions: first, that persons should be treated as autonomous agents; and second, that persons with diminished autonomy are entitled to protection. The principle of respect for persons thus divides into two separate moral requirements: the requirement to acknowledge autonomy and the requirement to protect those with diminished autonomy. [2] Respect for human persons refers to the right of a person to exercise self-determination and to be treated with dignity and respect. All people deserve autonomy and to be treated with dignity and respect. Failure to provide any person with adequate health care, regardless of their race, creed, color, national origin, sexual orientation, etc., violates 10 this basic right of respect for persons. Fear that undocumented individuals will be turned over to the Immigration and Naturalization Service (INS) if they seek medical care violates personal freedom. It subjects all undocumented persons to the most terrible form of slavery, to be constantly afraid, not knowing their condition or fate, and constantly fearing not living. This way of living does not promote human rights, it violates them.

Second, minorities in this country, especially the undocumented, are the most vulnerable people.When Hispanic refugees, asylees and immigrants arrive, they are often traumatized and shocked.They usually have no jobs and no financial support on which to fall back. In addition, they are in poor health, often because they have moved from town to town or from one refugee camp to another. The children may have not been in school for several years, or they may have not been to school at all. As is often the case in refugee-producing situations, women and children become the most vulnerable members of the refugee community. Statistics show that racial and ethnic minorities are generally poorer than whites and more likely to have family incomes below 200 percent of the federal poverty level. In 2002 more than half of African American, Hispanics and American Indians/Alaska Natives were poor or near-poor. Racial and ethnic minorities are more likely to be uninsured as well. In 2002 more than 30 percent of Hispanics were uninsured. Hispanics are the most likely of any racial and ethnic minority to be uninsured. [25] This vulnerability compounded with racial disparities give these individuals diminished autonomy. In 2002, an Institute of Medicine (IOM) report, which was requested by Congress, reviewed more than 100 studies that documented a wide range of disparities in the United States healthcare system. This study found that racial and ethnic minorities in the United States receive lower health care than whites, even when their insurance and income levels are the same. [25] The IOM report made it clear that disparities between whites and minorities exist in many disease areas. [25] These disparities are even greater among the undocumented population. GiselleCorbie-Smith, MD, and her colleagues found that minorities were “more likely to believe that their physicians would not explain research fully or would treat them as part of an experiment without their consent.” [26] Medical abuses have come to light through the oral tradition of minority groups and published reports. Minorities believe that their physicians cannot be trusted, that physicians sometimes use them as guinea pigs in experiments, and that they are sometimes not offered the same medical procedures that whites are offered, even though they have the same clinical symptoms. [26] This fear and mistrust among the minority population in the United States is magnified with documented and undocumented individuals. The result is that many undocumented and even documented Hispanic immigrants in the Philadelphia area are not seeking medical care until they are in the last stages of their disease. The reason for this, according to those who work with this population and have gained their trust, is a mistrust of the medical establishment and a fear that if they present to an Emergency Department and are found to be undocumented that they will be turned over to the INS for deportation. Unfortunately, this has happened in several cases. Even though Catholic hospitals in the Philadelphia area will not contact INS in these situations, there is still a great fear among this population. Because of this fear, these individuals enter the medical system only out of desperation, when they can no longer stand the pain or have collapsed in a public setting. In most cases, the disease has progressed to the extent that treatment is often futile or extremely expensive. This sense of fear among the undocumented population violates the basic principles of respect for persons. Failure of the medical establishment to give this population adequate health care or to withhold treatment that is the “standard of care” because the individual is 11 undocumented or unable to afford said treatment is denying these individuals their basic rights of dignity and respect. The medical profession is based on treating all people with dignity and respect. Until we can show an improvement in the overall quality of care and work to aggressively promote public health interventions on such diseases as hypertension, diabetes, obesity and even HIV for minorities in general and the undocumented specifically, we will never gain the trust of the minority communities and will never close the ever-widening gap in quality of care.

The failure of the medical profession to be proactive in addressing the medical needs of this most vulnerable population is causing needless suffering and even death. This clear form of prejudice clearly violates the ethical principle of respect for persons. Minority patients’ autonomy and the basic respect they deserve as human beings are being violated because they are allowed to endure pain, suffering, and even death when such hardships could be alleviated. All hospitals, and especially Catholic hospitals, governed by the Ethical and Religious Directives for Catholic Health Care Services, have a moral and ethical obligation to address the medical disparities that exist in minority communities. [27] If Catholic hospitals are committed to treating every person with dignity and respect, then the barriers to health care must be lifted to ensure this commitment, and emphasis must be placed on patient dignity and empowerment.

Beneficence/Nonmaleficence

The principle of beneficence involves the obligation to prevent, remove, or minimize harm and risk to others and to promote and enhance their good. Beneficence includes nonmaleficence, which prohibits the infliction of harm, injury, or death upon others. In medical ethics, this principle has been closely associated with the maxim primum non nocere (“Above all, do no harm”). Allowing a person to endure pain and suffering that could be managed and relieved violates the principle of beneficence, because one is not preventing harm and, therefore, not acting in the best interest of the patient. The duty to act in the patient’s best interest must take preference over a physician’s self-interest.

Physicians have, as moral agents, an ethical responsibility to treat their patients in a way that will maximize benefits and minimize harms. Failure to adequately assess and manage medical conditions, for whatever reason, are not in the best interest of the patient. Literature and research studies have confirmed the disparities in health care among racial and ethnic groups. African Americans, Hispanics and American Indians/Alaska Natives have higher overall mortality rates than any other population group. [28] The Centers for Disease Control and Prevention state that, “1 of 3 people born in the United States in 2000 will develop diabetes during their lifetime. The risk is higher for African Americans and Hispanics (2 of 5) and for Hispanic girls and women (1 of 2). [28] These statistics are based on facts; the statistics on the undocumented Hispanic populations are unknown. One can assume that if the situation is as bad as it is with minority citizens, the situation with the undocumented foreign population must be even worse.

It is clear, after reviewing these statistics and identifying the biases and stereotyping that exist in the medical profession, that disparities in U.S. health care expose minority patients, especially the undocumented Hispanics, to unnecessary risks, including possible injury and even 12 death. Physicians have a moral responsibility to do what is good for their patients. Should a physician be impeded in the exercise of his or her reason and free will because of prejudice or bias on the part of the medical establishment, then that physician has an ethical responsibility to overcome that impediment and do what is demanded by the basic precepts of medicine—seek the patient’s good. Hospitals also have a responsibility to their communities. If hypertension, diabetes, obesity, and HIV are major issues in the undocumented community of people that a particular hospital serves, then it is the ethical responsibility of hospital administrators and health care professionals to formulate programs that address this immediate need. Failure to recognize prejudice and bias is a failure not only of the test of beneficence; it may also be a failure of the test of nonmaleficence.

Justice

This principle recognizes that each person should be treated fairly and equitably, and be given his or her due. The issue of medical disparities among minorities and especially among the undocumented also focuses on distributive justice: the fair, equitable, and appropriate distribution of medical resources in society. At a time when reforming healthcare in this country has become a high priority, failure to initiate preventative measures that would save medical resources in the long-run violates the principle of distributive justice. The justice principle can be applied to the problem under discussion in two ways.

Inequality concerning adequate health care for Americans is a well-documented fact. For years this inequality was attributed to socioeconomic causes resulting in a lack of access to care. With the publication of the 2002 IOM report, however, it is apparent that subtle racial and ethnic prejudice and differences in the quality of health plans are also among the reasons why even insured members of minorities sometimes receive inferior care. Prejudice and negative racial and ethnic stereotypes may be misleading physicians and other healthcare professionals. Whether such bias is explicit or unconscious, it is a violation of the principle of justice. It has been documented that members of minority groups are not receiving the same standard of care that whites are receiving, even when they have the same symptoms. One example is a 2008 study which found that Hispanic and African American women remain more likely to be diagnosed with poor prognostic breast cancers (i.e., late-stage, large size, lymph node-positive, estrogen receptor-negative). Financial barriers, lack of access to facilities that perform mammography and multiple personal and cultural reasons may explain the difference in screening rates of white women compared with black women and other minorities. [29] Other examples mentioned above also confirm the fact that death rates from heart disease are twice as high among minorities as whites with similar gaps existing for obesity, cancer, and infant mortality. [30] All of these statistics can be applied to the undocumented Hispanic population and the rates will probably be even higher. This is a blatant disregard of the principle of justice. The principle of justice also pertains to the fair and equitable allocation of resources. It has been documented that members of minorities are less likely than whites to be given appropriate cardiac medicines or undergo coronary bypass surgery. Minorities are less likely to receive kidney dialysis, kidney transplants, or the best diagnostic tests and treatments for cancer.

Minorities are also less apt to receive the most sophisticated treatments for HIV and diabetes. The estimated national cost of diabetes in 2022 is $412.9 billion, of which $306.6 billion (74%) represents direct health care expenditures attributable to diabetes and $106.3 billion (26%) represents lost productivity from work-related absenteeism, reduced productivity at work and at home, unemployment from chronic disability, and premature mortality. Excess costs associated with medications constitute 44% of the total direct medical burden, including 7% for insulin, 9% for non insulin glucose-lowering agents, and 28% for other prescription medications. In contrast, the costs associated with medications constituted 28.4% of the total direct medical burden, including 3.5% for insulin, 7% for non insulin glucose-lowering agents, and 18% for other prescription medications in 2012. [31] On average people with diabetes incur annual medical expenditures of $19,736, of which approximately $12,022 is attributable to diabetes. People diagnosed with diabetes, on average, have medical expenditures 2.6 times higher than what would be expected without diabetes. Glucose-lowering medications and diabetes supplies account for ∼17% of the total direct medical costs attributable to diabetes. Major contributors to indirect costs are reduced employment due to disability ($28.3 billion), presenteeism ($35.8 billion), and lost productivity due to 338,526 premature deaths ($32.4 billion). [31] If Hispanics are twice as likely to die from diabetes than whites, in many cases because of a lack of adequate medical treatment, then the principle of distributive justice would dictate that programs should be implemented to screen, assess and treat Hispanics and other minorities, especially the undocumented Hispanic population, not only for their benefit but also to benefit society as a whole.

We Americans espouse the belief that all men and women are created equal. Equality has also been a basic principle of the medical profession. If we truly believe in equality, we should insist that all men and women must receive equal medical treatment and resources. Denying certain minorities medical treatment, when whites receive them as a standard of care, is an unjust allocation of resources and violates a basic tenet of justice. Physicians and the medical profession have an ethical obligation to use available resources fairly and to distribute them equitably. Failure to do so is ethically irresponsible and morally objectionable. To compromise the basic ethical foundations upon which medicine stands is destructive not just to minority patients but to society as a whole.

To address these medical and ethical concerns, the Consulate of Mexico in Philadelphia in conjunction with the Institute of Clinical Bioethics at Saint Joseph’s University in Philadelphia have designed a comprehensive education and prevention model that will meet the needs of the Philadelphia area undocumented Hispanic community. The Mobile/Rural Health Promoter Program is an initiative whose foundation is based on an established program in developing nations, which has not only increased medical care in these areas but has also saved countless lives. As the undocumented population continues to increase in the United States, and health care costs continue to skyrocket, this new initiative can become a paradigm for all hospitals in the United States. Racial and ethnic disparities in health care constitute a complex issue that pertains to individuals, institutions, and society as a whole. Unless we Americans address these disparities and begin to eradicate them, we will never attain the goal of equitably providing high-quality health care in the United States. The Mobile/Paper Health Promoter model will not only save valuable medical resources; it will also save precious human lives. If we do not make this a priority now, everyone will pay a price in the future. 

Conclusion

The Mobile/Rural Health Promoter Model is a micro-sized system with the ability to tackle the issues presented in the Triple Aim under the Patient Protection and Affordable Care Act (PPACA). The goal of the PPACA is to reduce medical costs, save health care resources, and most importantly provide patients access to the healthcare system prior to developing chronic or end-stage conditions so that they can live fuller, healthier lives. In the process of doing so, special attention is given to the principles of beneficence and distributive justice by highlighting the human dignity of each person no matter race, ethnicity, creed, socioeconomic status or immigration status. Our work with the Mobile/Rural Health Promoter Model in collaboration with local communities with a large number of undocumented residents has the opportunity to set a precedent and offer a framework for future applications across the country and the globe. Thus, this developing nation community-based model has the ability serve as a paradigm for other hospitals across the nation in treating some of the most vulnerable members of our society – the undocumented, while also empowering their own health and well-being.

Recommendations and Improvements

The Mobile/Rural Health Promoter was first developed in January of 2023 and it is still looking for new innovative ideas to bring the best care possible to the most vulnerable members of the community. In order to improve the quality of care of the clinic, there are five different recommendations that could result in benefits for all patients. Supplies and other purchases can be covered by looking for private grants to cover the costs.

1. The creation of a new station focusing on mental health and wellness for migrant farm workers and the hispanic community of the tri-state area. This could be carried out by partnering with Partners Horizon House Inc. which focuses on assertive community treatment. Also, having clinical psychology students from the Philadelphia College of Osteopathic Medicine (PCOM) so that patients can undergo a brief evaluation.
2. An expansion to the eyeglasses station, this could potentially include a partnership with the Optometry School of Salus University to provide full eye exams to patients. In terms of reading glasses, new reading charts can be created which will ensure that the patients choose eyewear appropriate for their needs.
3. An expansion to the healthy mothers, healthy babies station. This would include the distribution of menstrual pads and tampons, and educational materials on women’s health and wellness.
4.  Drexel Hope already attends most of the other Health Promoter clinics to provide patients with HIV and Hepatitis C testing. This service can be extended to the Mobile/Rural Health Promoter Clinic in order to properly educate migrant farm workers and the hispanic community on these often overlooked topics.
5. Partnership with University of Pennsylvania student-led organization Service-Link. The purpose is to connect the patients to social benefit resources including housing and health insurance in order to mitigate social determinants of health.