From creeks to clouds: The invisible invasion of microplastics
By Will Atwater
Judging by recent developments, microplastics have risen to the status of supervillain. Reports about these new anti-heros read almost like celebrity sightings. The tiny particles are everywhere: in water, on land, on mountaintops, in humans and animals — and even in the clouds.
Microplastic compounds are defined as being less than 5 mm long, which is slightly larger than a sesame seed, but many microplastic particles are much smaller. These substances can last hundreds, even thousands of years in the environment. Globally, more than 430 million tons of plastic is produced annually. Some plastics break down into these microplastic particles, and a significant amount of them end up in the ocean, where marine animals swallow them and they enter the food chain, according to a report by the United Nations Environment Programme.
Chatter about the need for regulations to reduce the proliferation of this problem is growing louder by the day as reports about the adverse health and environmental impacts of microplastics have started piling up.
In November, researchers published studies suggesting more potential risks of microplastic exposure for humans, including a Duke-led study that suggests links between nanoplastic particles and a brain protein that may result in increased risk for Parkinson’s disease and some forms of dementia.
“Our study suggests that the emergence of micro and nanoplastics in the environment might represent a new toxin challenge with respect to Parkinson’s disease risk and progression,” said lead researcher Andrew West, from the Department of Pharmacology and Cancer Biology at Duke’s school of medicine. “This is especially concerning, given the predicted increase in concentrations of these contaminants in our water and food supplies.”
Previous studies have revealed that humans ingest about a credit card-size amount of microplastics weekly and suggested links between microplastic ingestion in people and Inflammatory Bowel Disease. There’s also some suggestion that microplastics alter how hormones function in the body.
Moreover, in October, the Guardian reported that Japanese researchers found microplastic particles in cloud formations around Mount Fuji and Mount Oyama. Researchers said that they found nine types of microplastics in cloud water, such as polyethylene (which composes plastic bags, food and drink containers), polypropylene (which makes up high heat tolerance plastics, cleaning products, pill bottles) and polyethylene terephthalate (PET/disposable drink bottles), among others.
The researchers said their “findings suggest that high-altitude microplastics particles influence cloud formation and, in turn, might modify the climate.”
One step forward, two steps back?
Environmentalists have sounded the alarm about the proliferation of single-use plastics for years and, to be fair, some government agencies and municipalities are making changes. In the United States, 10 states and Puerto Rico have banned single-use plastic bags.
As of June 2023, Surfrider, a nonprofit environmental advocacy organization that works to reduce the impact of plastic debris on beaches and oceans, “identified 491 U.S. local single-use bag ordinances.”
Additionally, the third meeting of the Intergovernmental Negotiating Committee (INC-3) took place in Nairobi, Kenya, earlier this month to continue work toward a treaty to reduce plastic pollution. A fourth round of talks (INC-4) is scheduled to take place in 2024.
“I am encouraged by the forward motion of the negotiations towards a treaty that ends plastic pollution,” said Inger Andersen, executive director of the United Nations Environment Programme, according to a release. He noted the INC’s “determination to get to the finish line and put us on course for a world where plastic pollution is a problem of the past.”
But not all attendees were as encouraged as Andersen.
Neil Tangri is the senior research fellow at the University of California-Berkeley Goldman School of Public Policy and the founder of GAIA, an environmental advocacy group working to promote zero-waste cities. Tangri was disappointed that microplastics “were hardly addressed” at INC-3, he said by email.
“There is a widespread recognition of the need to ban primary microplastics (e.g., beads in personal care products and detergents),” he said in an email to NC Health News. “This is really low-hanging fruit and beyond obvious; many jurisdictions have already done so, but we need a global ban. But some countries are arguing that plastic production is out of scope of the treaty — which would mean that we couldn’t ban particular products such as primary microplastics.”
“Of course, the vast majority of microplastics in the environment are the result of physical breakdown of plastic products — e.g., tire wear or macroplastic waste that breaks down in the marine environment. Again, if we exclude production from the scope of the treaty — meaning we can’t reformulate plastic products to minimize microplastic generation, or ban the items most likely to end up in the environment — we end up with a waste management treaty, and there is no effective waste management solution to microplastics.”
Is it enough to move the needle at home?
While work is underway to reduce plastic pollution, North Carolina has yet to establish any regulations on plastic bags — despite the efforts of environmentalists.
The momentum gained by North Carolina advocates working to curb the use of single-use plastic bags in Durham, Boone and Asheville screeched to a halt in September when a provision in House Bill 259 that prohibits local municipalities from establishing plastic bag ordinances became part of the state budget.
Ways to address the problem
Require stronger regulations around the production and distribution of single-use plastics.
Improve the nation’s recycling system to reduce the amount of plastic going into the waste stream.
Encourage consumers to invest in recyclable/reusable products.
Elect officials who support plastic waste-reduction initiatives.
Efforts to establish a plastic bag ordinance have been a polarizing topic since 2009 when former Democratic state Sen. Marc Basnight of Dare County introduced legislation that called for a ban on single-use plastic bags in retail stores in Outer Banks communities. Basnight’s family runs a restaurant in Nags Head, and the late senator was deeply involved in the coast’s tourism industry.
The legislation passed, and a ban was set in place from 2009 until 2017, when a Republican-led legislature repealed it. Critics argued that the ban unfairly taxed merchants who had to offer $.05 cent refunds or other incentives for customers who shopped with reusable bags. They also argued that paper bags were worse for the environment than plastic.
“The trash traps are important because they physically trap trash before it moves downstream, but when we can also collect data on what the traps are capturing, we are better equipped to keep the trash out of the waterways to begin with,” Lauer said. “The data tells us what plastics are frequently getting into waterways and what the sources of those escaped plastics might be.”
For instance, volunteers removed nearly 40,000 pieces of litter from Durham’s Third Fork Creek from June 2022 to November 2023. Of that amount, 82 percent of the debris was Styrofoam fragments, followed by plastic bottles.
Data collected from Boone’s Winkler Creek from June 2021 to February 2023 shows that volunteers removed 8,000 pieces of debris, and Styrofoam fragments comprised 72 percent of the trash.
The amount of Styrofoam fragments found in the two creeks alone is a concern to West because, in the Parkinson’s disease study, he and colleagues discovered that polystyrene, the source material for Styrofoam, bonded aggressively with a brain protein known as alpha-synuclein.
“Charged polystyrene contaminants are among the most toxic in the biological systems we use to study these diseases,” West said.
“Whether it’s lead pipes or different types of toxins that we find out later do more harm than good, I could certainly imagine polystyrene being added to that list as we [discover] what these particles can do,” he said.
Barbara Doll, N.C. State University Agricultural Extension professor and professional engineer, co-authored a study that looked at the distribution and characteristics of microplastics found in the Neuse River Basin.
“When we looked at the microplastics [and] characterized them for type, our main microplastic components were polystyrene, polypropylene, and PET (plastic bottles),” Doll said. “There’s a link [between] the garbage and the microplastic types.”
How it Works
Barbara Doll, N.C. State University Agricultural Extension professor and professional engineer, explains how plastic pollution becomes microplastic compounds over time:
“Trash gets into the water, and it starts to break down and degrade by sunlight, by being banged around in the river, up against the river’s bottom, branches, limbs and rocks. It starts to break apart and become smaller and smaller fragments. It doesn’t go away; it just continues to break down.”
One of Doll’s goals through her research is to raise awareness.
“I wanted to establish that [microplastics] are coming from the garbage that everyone is throwing out of their car window on the ground or is blowing out of trash cans — this incredible prevalence of plastic in our everyday lives,” she said. “[It’s like], ‘Hey, this is what’s getting washed in the streams, floating through small creeks, down the river and getting out into our food resource.”
Rural residents as a group live farther from dialysis treatment facilities than their urban counterparts. Given that rural America generally scores lower on health care access, that’s not a surprise.
But there is some unexpected news in a new study of dialysis access. One of the chronically medically underserved populations in rural America, African American residents, on average live closer to dialysis facilities than white residents do.
Jan Probst, a researcher at the Rural and Minority Health Research Center in South Carolina, has spent a career in medicine. She says she remembers being part of medical boards that decided who got certain treatments like dialysis and who didn’t. Her latest research looked at where dialysis centers are located and who lives in those areas, then compares the findings to similar past studies.
Dialysis is used to clean the blood when kidneys fail, also known as end stage renal disease. Those failures can be caused by diabetes and high blood pressure, among other things. Patients come to dialysis facilities and spend hours hooked up to machines that remove the blood from their body, filters it through an artificial kidney, and returns it to the body.
In her latest study, Probst looked at who lived in the areas around dialysis centers. What she found was that rural residents have to travel farther to get to dialysis treatment facilities.
This isn’t unexpected, she said. In the rural Southeast and Southwest, greater distances between communities mean those residents have to travel farther to get to their treatments. Rural residents, on average, have to travel just over 14 miles to get to the nearest facility. In contrast, urban residents live about 4.5 miles from the nearest dialysis center.
That’s a vast improvement from the last time Probst did the same research in 2013. In that study, rural residents in general had to travel about 40 miles to get to a dialysis facility.
But, the research found, one group, rural African Americans, was closer to dialysis facilities than any other racial group. On average, rural African Americans were only about 10.5 miles from a dialysis facility, while rural white residents were about 16.6 miles away. The study found that nearly three quarters (70%) of rural African American residents live within 15 miles from a facility, while less than half of white residents do. Only 42% of rural Hispanic residents and 39% of rural American Indians or Native Alaskans live within 15 miles of a dialysis facilities.
Funding changes improve access
The increase in access to dialysis centers isn’t solely due to need, Probst said. Since her 2013 study, how dialysis is funded has changed. Now, federal policy requires Medicare and Medicaid to pay for dialysis treatments. And once Medicaid and Medicare guaranteed payment, Probst said, the market responded, shifting most dialysis care to for-profit chains who entered areas knowing they were going to get paid. So, for-profit dialysis treatment facilities started popping up in areas with higher concentrations of patients who need the services.
Dialysis is expensive, Probst said. At current levels, dialysis and treating ESRD takes up about 7% of the Medicare budget, she said. Even for people who are insured, if a patient or their spouse has a sufficient work history, Medicare covers dialysis (or a kidney transplant) starting the fourth month of treatment.
So, providers put dialysis facilities in areas with higher concentrations of patients, she said. But, because these areas also tend to have limited access to other health services, which affects their ability to manage the illnesses that can lead to ESRD like diabetes, they are more likely to need dialysis. Lacking care for diabetes, she said, is a reason many rural African American residents develop end-stage renal disease.
Still, even with dialysis centers closer to rural residents than they were in the past, there are barriers to care that may prevent patients from gaining access to the treatment they need.
“Dialysis is three times a week, and you have to sit there for like three hours,” she said. “That is a big time commitment for the persons or for their family members who are driving them.”
Additionally, dialysis facilities usually don’t have evening and weekend hours, increasing the amount of time taken off work for patients and their care providers. The burden dialysis places on rural patients would make maintaining any kind of job extremely difficult, she said.
“I suspect that for most of these folks that is not feasible, and they probably also have multiple things to deal with,” she said. “They’ve lost their kidneys, but they still have to deal with their dialysis. There’s a lot going on.”
New youth psychiatric hospital will have specialized units for substance use, disabilities
By Taylor Knopf
Later this month, a new 54-bed youth psychiatric hospital in Butner will open its doors to help North Carolina’s children and teens struggling with mental health issues.
The UNC Hospitals Youth Behavioral Health facility will include specialized units for patients with co-occurring mental health and substance use disorders, as well as a unit dedicated to serving children with intellectual and developmental disabilities with mental health needs.
Additionally, hospital leadership say they intend to take a whole-family approach to treatment and will offer family therapy services.
Over the past year, UNC Health and the N.C. Department of Health and Human Services has repurposed and renovated a former state-run substance use treatment facility to serve the growing number of adolescents showing up at emergency rooms across the state in mental distress.
“It was just in December, when we announced this opportunity. And here we are less than a year later about to cut a ribbon. … That is wild fast,” DHHS Secretary Kody Kinsley said. “It is also in recognition of the great need that our state has.”
“Truly, the mental health of our children and adolescents is the most pressing issue for our state and its future health,” said Wesley Burks, CEO of UNC Health and dean of UNC School of Medicine, at a ribbon cutting ceremony for the new facility on Tuesday.
“It was a problem way before the pandemic started. But during the pandemic and now, it really has reached dire levels,” he said. “Today is only a first step in what we need to do to address these issues.”
While health experts and families agree that the E.R. isn’t the safest or best place for kids in need of psychiatric care, it’s where many parents — often as a last resort — bring their children. And sometimes the wait for an inpatient bed can end up being weeks, particularly if a child has more complex needs, such as a disability or co-occurring substance use disorder.
The new youth psychiatric hospital hopes to offer a space designed to treat those patients.
The facility will consist of four units: a general child and adolescent unit; one for patients with more severe mental health issues; a unit for patients with co-occurring substance use and mental illness; and a unit for patients with intellectual and developmental disabilities.
There are also therapists from several disciplines working at the hospital, including music therapy, art therapy, yoga movement therapy, activities therapy, occupational therapy and child-life therapy.
“With novel approaches, integrating cutting-edge research that will have recreational therapy, art therapy, music therapy, family therapy, we will be one of the only units in North Carolina — and very few in the country — that will have a dedicated unit for children and adolescents with neuro-behavioral psychiatric issues,” said Samantha Meltzer-Brody, UNC Department of Psychiatry chair.
Music therapist Ashley Taul said because music can be a huge part of kids’ identities, it is often a great way to connect with them.
“They get their phones taken away and their music taken away, so to be able to offer some sort of normalcy to these kids is really important,” Taul said, a guitar slung over her shoulder. “So I do a lot of music listening interventions. We’ll play some drums. We’ll do songwriting. We’ll do music listening. I love doing a good lyric discussion. All these different kinds of things you can work on through music.”
Occupational therapy is also part of every unit, with one-to-one and group sessions. The units have a “quiet room” filled with tools like fidget devices, rocking chairs, weighted blankets and noise canceling headphones. If a patient is feeling overwhelmed or struggling to regulate their body and emotions, the tools in these rooms are designed to help them cope.
Tyler Harrell, an occupational therapist and therapy supervisor at the hospital, said ideally patients will learn to recognize when they need these interventions and request them. Harrell came to the new facility from the state-run psychiatric hospital across the street, Central Regional. Before that he worked with children with autism in Wake County public schools.
He said he’s looking forward to the opening of the unit for kids with intellectual and developmental disabilities, adding that it will be the last to open due to the increased training those staff will receive and some of the unique sensory equipment the hospital plans to install on the unit. These are the patients who tend to wait in emergency departments the longest for inpatient psychiatric beds because health professionals in many facilities don’t have the skills or training to help them, he added.
“I’m really happy that we’re filling a gap and kind of filling the need,” Harrell said.
The family-integration piece will also be huge for this population, he said. He added that the child-life specialists will be working with parents and siblings to ensure that each child has the best possible transition home after hospitalization.
A promise to families
Over years of reporting on mental health issues, NC Health News reporters have often heard from families of children in crisis who feel as though they’re cut out of the treatment process.
Parents of children in inpatient psychiatric facilities have often said they want to be more involved and know what’s going on with their child’s care. Many have said they don’t feel as though they have a good plan for support and continued recovery when their child comes home from the hospital.
Leaders of the new youth psychiatric hospital promise to instead take a whole-family approach to treatment.
“It’s the individual and the parents that suffer terribly when they can’t get care. And that weighs very heavily on all of us,” Meltzer-Brody said. “We have taken great strides here to ensure family members will play a vital role in the treatment.”
The new facility will also include virtual and in-person family therapy, she said.
“So that every child has the best opportunity to return home safely, that their family is part of the treatment plan and that they can get better as quickly as possible,” Meltzer-Brody added. “To our families — we want you to be able to trust us that we will care deeply and safely for your child so they can learn critical coping skills and recover in a sustained way so they can return home to you and move forward for a bright future.”
UNC child psychiatrist Jim Bedford said family involvement during treatment and during the hospital discharge process is vital for a child’s mental health recovery.
“One of the things that can make an inpatient stay the most meaningful is if the rest of the community-based [mental health] system rallies around the child and says, ‘This child has tremendous support needs and and we need to reach out to the child and family and offer more resources when they come out of the hospital,’” he said.
“That helps to make it the forward path toward a sustained recovery and prevent rehospitalization.”
This is the first in a two-part project about the children’s mental health crisis in Bladen, Columbus, Robeson and Scotland counties. Read the second story, which focuses on the foster care system, story here.
A 9-year-old girl who spent four months last year inside the Columbus County hospital’s emergency department lashed out at nurses and clawed at the drywall. She wasn’t allowed to use a fork over fears she would use it as a weapon.
Each day, staff at the Columbus Regional Healthcare System tried desperately to secure a bed for the child at a pediatric mental health facility. But such placements can be hard to find in North Carolina.
The girl had been in numerous foster homes where she experienced physical and mental abuse, said Dr. Jugta Kahai, the pediatric medical director at Columbus Regional in Whiteville. “Here is a 9-year-old who’s been severely traumatized,” Kahai recalled during a recent interview. “Yet, she’s sitting in a concrete bunker with no window, no therapist and heavily medicated.”
Nationwide, children are dealing with a mental health crisis that experts say is fueled by bullying, the COVID-19 pandemic, discrimination and other stressors. Health care professionals in rural southeastern North Carolina say more and more children are suffering – and struggling to find help in a poor region that needs more mental health specialists.
As a result, children end up staying days, weeks or even months in emergency departments or at local departments of social services, both of which are considered by the state “inappropriate crisis settings.”
Eastpointe, a health management organization that serves Robeson, Scotland and several other counties, saw an average of six Medicaid-enrolled children at any given time in such settings during the first three months of 2023, data shows – an average of five in emergency departments and one in a DSS office. The figure marks a 20% increase from the previous three-month period but doesn’t include children with private insurance who were awaiting treatment.
Trillium Health Resources, which serves much of eastern North Carolina including Bladen and Columbus counties, saw a 55% decrease during the same period, with an average of four Medicaid-enrolled children at any time in emergency departments and one in a DSS office.
The decrease doesn’t paint the whole picture, however. Kahai estimates that more than a quarter of her patients have behavioral and mental health concerns. In her 24 years as a pediatrician, including the past seven in Columbus County, she said she has never seen such intense need.
The 9-year-old she treated was one of countless children in the area who have been involuntarily committed to emergency departments for extended periods with nowhere to receive proper psychological care, Kahai said. The girl was eventually placed in an out-of-state psychiatric care facility.
Greg Wood, the outgoing chief executive at the Scotland Health Care System, said a young teenager had to stay so long at the Laurinburg hospital while waiting for a behavioral health placement last year that staff arranged for local first responders to show up in a fire truck to ease the kid’s boredom.
“He always wanted to see a fire engine,” Wood said. “He got to climb on the fire engine.”
Officials say rural southeastern North Carolina needs more of every kind of health care provider, from nurses to specialists. The shortage has been felt acutely in behavioral health.
In Columbus County, home to 50,000 residents, there are about 600 patients per mental health provider, according to the 2023 County Health Rankings from the University of Wisconsin Population Health Institute. The number is even higher in neighboring Bladen County – 1,020 patients per provider.
Meanwhile, suicides per 100,000 children increased from 1.1 in 2018 to 1.7 in 2022 in North Carolina, according to the latest “report card” from NC Child. More than one in five high school students said they have seriously considered attempting suicide, reported the nonprofit organization, which gave the state an “F” grade in April after examining 15 indicators of child health.
Adverse childhood experiences
In one afternoon at Advanced Pediatrics & Family Care in Whiteville, Kahai saw a newborn who tested positive for opiates, a toddler who was cared for by great-grandparents because the child’s mother was using drugs, two children with attention-deficit/hyperactivity disorder and one with clinical anxiety.
The same day, she was scheduled to see two patients under the supervision of the local Department of Social Services, but neither showed up.
Children everywhere and from all backgrounds are experiencing mental health concerns, experts say. Adolescents in rural southeastern North Carolina have challenges that include poverty, drugs, racism and climate uncertainty. Some families are still displaced from their homes following hurricanes in 2016 and 2018.
Poverty is considered among adverse childhood experiences – often called ACEs – that can have lasting negative impacts on children. Others include experiencing or witnessing abuse, growing up in a household with substance use or mental health struggles and being separated from parents who are incarcerated, according to the Centers for Disease Control and Prevention.
The opioid epidemic is contributing to an overburdened foster care system. The number of children in foster care more than doubled between 2018 and 2022, according to the local Department of Social Services.
Columbus County has seen an increase of more than 84% in the number of children under DSS supervision since 2018, according to the local Department of Social Services. As of August, there were 112 children in foster care – and not enough foster families to care for them.
“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”Dr. Jugta Kahai
Meanwhile, North Carolina’s hesitancy to expand Medicaid has compounded the mental health crisis, officials say. More than 23,000 additional people in Bladen, Columbus, Robeson and Scotland counties could qualify for the health care program once Medicaid expansion begins in December, according to the Cone Foundation.
Between 43% and 56% of residents in the four counties currently receive Medicaid, according to the N.C. Department of Health and Human Services.
Some say Medicaid expansion will help lure mental health professionals to rural, low-income areas. But North Carolina has not increased Medicaid rates for psychiatric care since 2012, giving psychiatrists and other mental health professionals little incentive to accept payments from the federal program run by states.
Wood said Scotland Health has tried twice over the years to bring psychiatrists to town. Both times, he said, the hospital system lost money. Unlike counselors or therapists who might see patients once a week, psychiatrists make money by prescribing medication less frequently – and when there aren’t enough patients, there isn’t enough money.
“They’ve got to see an awful lot of patients,” Wood said.
Kahai said trying to manage any clinic on Medicaid patients alone is “a non-viable situation.”
“When you come from a strapped rural county where funding is cut every year,” Kahai said, “you have to manage by compromising. It’s a sad reality. Often those kids need the facilities the most, yet they end up deprived.”
Over the last decade, funding for health care in Columbus County has plummeted. Between 2010 and 2019, the county’s health department saw a 68% decrease in revenues, the BBI previously reported.
David Pope, who will succeed Wood as chief executive of the Scotland Health Care System in December, said changes are needed in pediatric involuntary commitments, or IVCs, which are put in place when patients are deemed dangerous to themselves or others.
Patients who are held under IVCs “lose the right to make their own decisions while being treated under a court order for psychiatric problems or substance abuse,” NC Health News explained in an article in September. They can’t walk out of emergency departments, where the average wait time is 16 days for a placement at a state psychiatric hospital, according to NCDHHS.
“Keeping patients in [emergency department] settings for three, four, five months is a really bad way to care for people,” Pope said. “If I kept you in a small room for an extended period of time, that’s the sort of thing that tends to lead folks to aggravating mental health issues.”
While there are private mental health facilities available — including Holly Hill in Raleigh, Old Vineyard in Winston-Salem and Keep Hope Alive in Greenville — beds are still hard to come by, according to Kahai. It’s also difficult for children on Medicaid, who account for the majority of pediatric IVC cases in the region, to receive treatment at these facilities.
Long stays at emergency departments are largely a result of underfunded and understaffed state psychiatric hospitals. Nearly 3,700 positions were vacant at the state’s three psychiatric hospitals earlier this year, more than triple the vacancies reported in 2020, according to NC Health News. In turn, only 600 of the state’s 894 psychiatric hospital beds are being used, according to DHHS.
North Carolina lawmakers overhauled the mental health care system more than two decades ago, when the state had nearly 1,600 psychiatric beds. The state’s psychiatric facilities saw a 57% decrease in people served, from 5,754 in 2011 to 2,450 in 2020, according to a state report.
State lawmakers and health care providers are trying to combat the crisis. UNC Health announced last year it would build a 54-bed inpatient psychiatric hospital for children and adolescents in Butner in partnership with NCDHHS and a substance abuse treatment provider. The facility is scheduled to open later this year.
The recently passed state budget also invests hundreds of millions of dollars for mental and behavioral health services. That includes $50 million for UNC Health’s construction of a new children’s mental health hospital in the Raleigh-Durham region. The budget also includes $20 million in bonuses for workers in the state’s psychiatric hospitals and increased rates for mental health and substance use service providers. Over the next two years, the state also allocated $80 million for families with children suffering with mental health challenges.
Funding is also provided to establish the Psychiatry Access Line, which allows primary care physicians and pediatricians increased access to behavioral health specialists when they see patients with mental health needs.
To fill the need for child psychiatrists in rural communities, the state established funding to pay mental health specialists up to $100,000 to work in economically distressed Tier One and Tier Two counties, including Bladen, Columbus, Robeson and Scotland. New psychiatrists can also have part of their medical school debt relieved if they agree to work in rural communities for five years, under the $50 million expansion to the N.C. Loan Repayment program.
“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.” David Pope
Medicaid expansion could also help people in mental health crises seek help from primary care providers instead of emergency rooms. Pope said IVCs and placement in emergency settings should be a last resort, but due to a lack of community-based mental health services, it’s become the go-to option for many pediatric patients.
Pope said community care should attempt to intervene early so an individual’s mental health doesn’t end up in crisis.
“Community-based mental health care options should be upstream,” Pope said. “But because those options don’t currently exist, we end up far down the river, very close to the waterfall.”
Kahai takes time to build relationships with her young patients and their families. She says the effort brings a clear picture of the state of her community.
“It’s a new crisis every day,” she said. “And somewhere in between I have to find the time to see the other sick kids, too.”
While she may have a strong exterior, Kahai said the burden of patients’ mental health issues, lackluster communication from the Department of Social Services and the need to work longer hours at the hospital is beginning to take its toll.
“I really have not been sleeping well,” she said. “And with all I see every day, it’s hard to turn the work off and de-stress when I do get home. It’s just always something.”
According to a 2022 Addiction Professionals of North Carolina survey, 85% of behavioral health workers reported at least one symptom of burnout in the last few months. The most commonly reported symptoms were emotional or physical exhaustion, feeling overburdened or overwhelmed with the workload, increased strain on the ability to provide consistent resources and energy to work, and procrastination and trouble focusing on tasks.
“The folks that I know that work in hospitals are doing it because they truly care for people, and they want to make things in their communities better,” said Pope, whose academic dissertation focuses on access to mental health care in rural North Carolina. “But when the very person that you’re trying to care for is physically violent toward you, is verbally assaulting you, it’s hard to sustain that level of compassion.”
Pope’s dissertation was published earlier this year for the UNC-Chapel Hill Gillings School of Global Public Health, where he graduated last spring. In his research, which included interviews with more than 20 experts in mental health, he found “compassion fatigue” was a persistent problem leading people to leave the field.
Kahai said she is not planning to leave pediatrics any time soon, but she said there is a need for systemic changes when it comes to treating children’s mental health.
To avoid staff burnout and create more community-based care, Pope says the state needs to invest money toward mental health organizations. The state budget gives Trillium $2.5 million annually for the next two years and Eastpointe $1.6 million, which is similar to the organizations’ allocations for the past three years.
Making the investment Pope would like to see would “ensure that every county has access to robust mobile crisis response, a regional facility-based crisis center, and outpatient involuntary commitment for Medicaid and uninsured patients,” his dissertation reads.
Trillium already provides some of the community-based approaches Pope recommends, including mobile crisis units, which give patients access to doctors and therapists via telehealth and on-site certified medical assistants and peer-support specialists. The three mobile clinics in Bladen and Columbus counties each serve about 50 residents per week, the BBI previously reported. Robeson County also received funding in this year’s state budget to establish its own mobile crisis unit.
In June, Trillium announced an investment of more than $1 million for a family solutions program that will support the recruitment and training of additional foster care families. More than $89,000 of that funding is going toward the Boys & Girls Homes of North Carolina in the Columbus County town of Lake Waccamaw.
Other efforts are underway. UNC Health announced in August that it will partner with Bladen County Schools to bring four in-person therapists to the district. Students struggling with depression, anxiety and other issues will have access to telehealth appointments with specialists and psychiatrists through “virtual care centers” within the schools.
“Youth across our state are experiencing a behavioral health crisis, and a lack of resources in rural areas is compounding the challenges,” Dr. Mike Steiner, pediatrician in chief at UNC Children’s Hospital, said in a news release. “We are optimistic that this project presents a terrific opportunity to turn the tide and improve treatment for behavioral health conditions.”
Another important solution is improving health literacy, said Cindy Ehlers, chief operating officer at Trillium. Making sure adults are aware of the signs of depression, anxiety and other illnesses is an important step in providing children with proper treatment.
According to the UNC-Chapel Hill Health Literacy Map, a majority of neighborhoods in Bladen, Columbus, Robeson and Scotland counties rank in the state’s lowest quartile when it comes to health literacy.
“Health literacy is the first step in educating people so we can collectively work toward a solution,” Ehlers said. “When we don’t do enough to teach our young people about anxiety, depression and trauma, we perpetuate this stigma around mental health.”
The mental health care system in North Carolina is “profoundly broken,” Pope said. But he and Kahai both say they are hopeful that change is possible through a strong community spirit and a desire to help one another.
Hanging in Kahai’s office in Whiteville is a poster of a rainbow jaguar with pink and purple lettering that reads, “Pediatrician: an expert in all things related to booboos, owies and calming down parental nerves.”
Kahai knows that some of the worst booboos and owies are the ones that can’t be seen.
By the time the sun came up over the rolling green hills of Harrells, North Carolina, on June 23, 2021, a charred metal platform was all that remained of the old trailer. An investigation by the local fire department determined that the fire started at the electric stove in the kitchen. From there, it climbed the cabinets, spread to the living room, and tore through the two bedrooms. Within 30 minutes, the entire structure had been consumed by flames. A photo taken of the aftermath showed a pile of blackened debris, the charred coils of a mattress the only thing that suggested people lived there.
Parked beneath a thicket of tall trees and surrounded by miles of farmland, the trailer was where two cousins, Vicente Gomez Hernandez and Humberto Feliciano Gomez, were meant to spend the summer of 2021. They had traveled there from their Mixteco Indigenous community in San Juan Mixtepec, a rural town in the Mexican state of Oaxaca. Now they’d be returning in body bags.
Gomez and Feliciano were two of the hundreds of thousands of temporary agricultural workers who come to the U.S. each year through the H-2A visa program. It’s the federal government’s most important farm-labor pipeline — and it gets bigger every year. Yet for many visa recipients, the promise of steady work and decent pay quickly devolves into a nightmare of labor trafficking, wage theft, and unsafe living conditions that can lead to injury or even death.
Federal law spells out numerous protections for H-2A workers. They are to be reimbursed by their employer for the cost of their travel, for instance, and be provided free and safe housing as well as a competitive hourly wage.
But too often these laws are poorly enforced at both the state and federal levels. That lack of oversight creates opportunities for workers to be exploited, cheated, and abused.
Once workers arrive at their destination in the U.S., they’re at the mercy of a patchwork of enforcement that varies greatly depending on the resources available in a given state. For instance, previous reporting by Investigate Midwest found that in Missouri a lack of funding led to a lax inspection process that was easily abused and led to H-2A workers living in deplorable conditions.
Should workers find themselves at the hands of an abusive employer they have few options. They are not allowed to seek employment elsewhere because their visa is tied to their original employer. If they leave that position, they forfeit their visa and risk deportation. If they report abuse, they can face retaliation and be blackballed by both H-2A recruiters and employers, making it difficult to ever return to work legally in the U.S.
“H-2A workers, by the very nature of the program, don’t have any control over their work environment,” said Joan Flocks, an emeritus law professor at the University of Florida who specializes in agricultural labor.
For these reasons, experts say, most abuse in the H-2A program goes unreported, as too often workers are forced to choose between fair treatment and financial opportunity.
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In September, the Department of Labor announced a set of proposed rules designed to strengthen protections for H-2A workers. These include making the recruitment process more transparent and giving workers options to advocate for better conditions, like working with unions. The rules are open to public comment until November, and while worker’s rights advocates, including United Farm Workers, support them, it remains to be seen how effective they will be.
The H-2A visa is supposed to be a safe alternative to crossing the border illegally — a win for both farmworkers and farmers. With the visa, Gomez and Feliciano expected to earn $13.15 an hour picking sweet potatoes and blueberries — a fruit they’d never tasted before coming to the United States.
Instead, the men were exploited from the start. When they began working they were in debt, living in a squalid trailer, and were never paid the full wages they’d come all that way for. Then they died in a fire, the exact cause of which remains unclear.
According to the U.S. Department of Labor, the number of H-2A workers has grown steadily over the past decade. In 2022, some 300,000 came to the U.S., up 15 percent from the year before and more than triple the number of workers in 2012.
H-2A workers spend several months clearing fields, planting crops, and harvesting fruits and vegetables, often in exchange for wages that would be inconceivable in their home country. More than 90 percent come from Mexico, and without them much of the United States’ home-grown produce would not make it to the grocery store.
Cases of abuse and exploitation are well documented across the country. Examples from just this year include a 28-year-old man in Florida who died of heat exposure after employers failed to provide him with adequate water and rest. In Utah, the president of the local Farm Bureau was caught physically assaulting one of his H-2A workers and is now under investigation for human trafficking. And in California, workers had their visas recalled after speaking out about unsafe conditions. While these stories rarely make headlines, in 2021 a federal investigation, Operation Blooming Onion, brought the issue to the nation’s attention. The multiyear probe uncovered a transnational human trafficking operation, headquartered in Georgia, that forced more than 100 H-2A workers to endure deplorable living conditions and what investigators called “modern day slavery.”
From 2018 to 2020, a hotline run by the Polaris Project, a nonprofit that fights human trafficking, identified 2,841 H-2A workers who had been subjected to labor trafficking. Over half of these workers reported being threatened with deportation after demanding decent living conditions or the wages they were owed. Others alleged that their employers withheld or destroyed their immigration documents as a means of control. In addition, nearly a quarter of the workers said the debt they incurred in order to get their H-2A visa, including invalid recruitment fees, was used to coerce them into working against their will.
Yet experts say that these cases don’t capture the full scope of the problems with H-2A, in part because workers are reluctant to report abuse but also because the agencies responsible for preventing abuse are underfunded and understaffed.
According to research by the Economic Policy Institute, a nonprofit think tank, the Department of Labor’s Wage and Hour Division, which is supposed to investigate reports of abuse in H-2A, has seen little increase in funding since 2006. In the ensuing years the number of H-2A workers has increased more than 500 percent.
As a result, the odds that an H-2A farm will be inspected are less than 1 percent, which can lead to a low level of compliance with labor laws, said Daniel Costa, director of immigration law and policy research at the Economic Policy Institute and the author of the report. “Farms can pretty much do whatever they want and there’s a very low likelihood they’ll ever be investigated,” he said.
In a written response, a spokesperson from the Department of Labor said the agency makes “strategic use of the funds appropriated by Congress,” and that it “regularly carr[ies] out thorough investigations of employers and farm labor contractors.”
When it comes to housing, the H-2A program also has strict regulations in place, but the reality is that those rules are often poorly enforced by the state agencies that oversee them.
In North Carolina, for instance, there were just eight compliance officers in 2022 responsible for the pre-occupancy inspections of 2,061 farmworker housing sites, according to the North Carolina Department of Labor (NCDOL). Each officer was responsible for 257 sites. That’s in addition to their other duties, which include enforcing a host of federal farming regulations and running training sessions across the state.
In an email, NCDOL acknowledged the rapid expansion of the H-2A program in the state and said it had received funding this year for two additional inspectors: “As more agricultural employers rely on the H-2A program to meet their workforce needs, NCDOL ASH [Agriculture Safety and Health Bureau] expects the number of registered migrant housing sites to increase as well. We are grateful for the additional two positions given to us by the N.C. General Assembly in the last budget and of course, we would always welcome more inspectors to help the department meet its obligations.”
At the trailer where Gomez and Feliciano lived, the NCDOL inspector found no deficiencies in a pre-occupancy inspection. Investigate Midwest reviewed a copy of the report, which was completed on Feb. 24, 2021, just months before the fire. It included no details about the condition of the trailer; a single box was checked stating that it met all federal standards. (According to its annual report that year, 51.9 percent of housing inspected by the NCDOL were found to have no violations.)
But a worker interviewed by Investigate Midwest, who spent the previous summer in the trailer where Gomez and Feliciano died, described it as barely livable.
The worker, whose identity we are protecting because he fears reprisal, said the floor was full of holes and the water and electricity would often go out. Washing clothes and dishes took place out behind the trailer, he said, with a plastic bucket and water spigot. According to the worker there was no air conditioning or fans and the windows were covered with plywood. He said the trailer was infested with cockroaches and at night, as the workers lay on bare mattresses on the floor, the scurry of mice was loud enough to keep them awake.
Once workers are living in H-2A housing, a state inspector may return to make sure the housing is being properly maintained. However, follow-up inspections during the growing season are rare.
According to NCDOL’s 2022 annual report, only 16 of the state’s 2,052 permitted sites – just 0.7 percent – were randomly inspected once workers were living there.
Thomas Arcury is a public health scientist at Wake Forest University who has spent close to 30 years researching issues pertaining to farmworkers in the state. As part of his research, Arcury inspected many housing sites while workers were living there in the 2010s. He found that 41 percent of housing he inspected did not meet state safety standards due to everything from rodent infestations and broken appliances to having more occupants than the permit allows.
“Even if it passes inspection,” he said in an interview, “you wouldn’t want to live there. If you want my impression, farmworker housing is dangerous.”
It was only in the last 15 years that word of the visa program arrived in San Juan Mixtepec. Before that, a chance to work in the U.S. meant paying thousands of dollars to a smuggler and then risking your life to cross the border illegally. It was a path that many, mostly young men, chose as a means to escape the extreme poverty that plagues Oaxaca.
In 2019, Gomez learned about the visa through another cousin, Valentino Lopez Gomez, who worked as an H-2A recruiter and labor contractor. While U.S. farms will often hire H-2A workers directly through recruiters, increasingly they work through labor contractors, like Lopez, who function as the official employer. Worker advocates say this provides farm owners plausible deniability if things go wrong. Lopez, who was certified by the U.S. Department of Labor, hired men and women from San Juan Mixtepec and brought them to North Carolina where he contracted them out to local farms.
Gomez was 39, with a wife and two kids, and he needed to earn more money. Surviving in San Juan Mixtepec was becoming ever harder. Drought was killing the crops that had supported the community for millennia. He told Feliciano, who was in his early 30s and eager to start a family, about the opportunity. Initially, Feliciano didn’t want to go. He was scared to travel so far away. But Gomez reasoned that the visa was safe and that Lopez was family. Surely they could trust him to look out for them in America.
In 2020, the two men joined 38 other workers from their village who had been recruited by Lopez to harvest blueberries on Ronnie Carter Farms and Hannah Forest Blueberry farms in North Carolina. Gomez and Feliciano lived that summer in the same trailer where tragedy struck the following year, along with the worker who described the trailer’s decrepit conditions to Investigate Midwest. Not much is known about the cousins’ experience on that first trip. But family members said that they earned barely enough to cover the debts they incurred to get there.
In October 2022, 13 of the workers Lopez recruited that year filed a civil complaint in federal district court for the Eastern District of North Carolina alleging that Lopez charged workers recruitment fees that were between $1,200 to $5,245. Again, under Labor Department rules, these fees are prohibited. Many of the fees were paid with high-interest loans, meaning the workers started the harvest season in debt.
Once the workers arrived in North Carolina, according to the complaint, Lopez confiscated their passports. This is how he allegedly coerced the workers; if they didn’t do as he said, he’d call immigration enforcement. The workers claim he refused to reimburse them for the cost of travel from Mexico, as is required by DOL rules. He also allegedly pocketed some or all of their wages. In one instance, the complaint claims, Lopez tried to extort a female worker for sexual favors.
The case is pending, but if Lopez is found liable the workers may eventually be eligible to receive special visas that would allow them to remain in the U.S. permanently.
Neither Lopez nor his lawyer responded to multiple requests, via email and phone, for comment.
Caitlin Ryland, who represents the workers in the case, has spent the last 15 years at Legal Aid of North Carolina, a nonprofit that offers pro bono legal services. In that time she’s seen H-2A workers increasingly become targets of criminal behavior, including debt bondage, fraud, and human trafficking.
“Year after year we hear the same gruesome set of facts from farmworkers that are recruited to work on North Carolina farms and our docket of federal trafficking cases reflects that,” Ryland wrote in an email to Investigate Midwest.
Gomez and Feliciano were not plaintiffs in the civil complaint, but according to Ryland they were among the workers from 2020 whom the federal Department of Labor had identified as being owed either wages or travel costs that Lopez never paid or reimbursed.
Nevertheless, the two men decided to return the following year. According to interviews with their families, going to North Carolina was still the best option they had. This time, the families said, the cousins each needed around $2,000 up front for Lopez’s recruitment fee and for travel costs. In a town where most people earn around $12 a day, this was a small fortune. The cousins borrowed money from several community members at 5 percent interest. It was a gamble, but if everything went as planned they could pay off the debt and still bring home around $3,000 each.
The cousins’ experience is fairly common in the H-2A system. In 2019, Centro de los Derechos del Migrante (CDM), an international workers rights organization, interviewed 100 H-2A workers about their experience in the program. More than a quarter said they had paid a recruitment fee. Abigail Kerfoot, an attorney with CDM, said the real number is likely much higher, and that this abuse is so pervasive in part because U.S. authorities are unable to police this activity because it takes place in a foreign country.
“Obviously, there’s a country-to-country relationship with Mexico that the United States has to take into account,” she said.
In a written response, a Department of Labor spokesperson said that while the agency can fine and debar labor recruiters caught charging illegal fees, “the division has no enforcement authority over entities located outside of the U.S. and its territories.”
On a Tuesday afternoon in late June 2021, Gomez and Feliciano got back to their trailer after a long day spent digging sweet potatoes. A third worker, Luis Rojas, was staying with the cousins at the trailer. Rojas slept in the living room, while the cousins each had a bedroom. According to a statement Rojas gave to the county fire marshal, the men marked the end of the day with three beers each. Then, as they often did, they called their families over WhatsApp.
Around 8 p.m., the men made a dinner of fried fish and, according to Rojas, they each had two more beers before going to bed.
At about 1:30 a.m, according to his statement, Rojas awoke feeling an intense heat on his face. The trailer was filling with smoke, and he saw that the kitchen was on fire. He ran to the back door of the trailer, but it wouldn’t open. As Rojas struggled with the handle, he said he heard Feliciano shouting and saw him go to the bedroom where Gomez slept. Then the door swung open and Rojas stumbled into the night air. He ran across the street to a house where other workers lived to get help.
What happened that night has been pieced together from the Sampson County Fire Marshal’s Fire Origin and Cause Report, Rojas’ account, and several statements from other workers who witnessed the fire. It isn’t clear whether Feliciano went to bed or stayed up, but at some point he apparently decided to make something else to eat. He turned on the electric stove, which had only two working burners. According to the report, the fire “most likely” originated in the front right burner. The investigator said two possible causes of the fire that he could not rule out were “failure of a component of the stove” and “occupant negligence.” So it’s possible that Feliciano accidentally started a grease fire that quickly spread out of control. Or it could have been the stove that was faulty and sparked the first flame.
We know that Feliciano caught fire, and investigators suggested he might have run to the bathtub to try to extinguish his burning clothes. There is nothing in the report about whether the trailer had running water that night. All the while, Gomez apparently remained asleep in his room. The pre-occupancy inspection, carried out just months before, doesn’t note whether the smoke detectors were tested, but Rojas said he doesn’t remember hearing them. When Investigate Midwest asked to speak with the inspector for clarification, the request was denied.
Both the deputy and chief fire marshals also declined Investigate Midwest’s request to interview them about the case.
At 1:35 a.m. a worker living in a house next to the trailer ran to alert Lucas Carter, who lived nearby. Carter, who owned the trailer and was listed as the farm’s president in its annual report, called the fire department. Carter did not respond to three phone calls seeking comment.
Other workers attempted to rescue Feliciano and Gomez but were repelled by the heat and flames. Mobile homes, especially older ones, are made of lightweight synthetic materials and burn quickly. Their narrow layout can trap people inside. The workers pulled off a section of the trailer’s siding, creating an opening into Gomez’s bedroom. He was unconscious, so the men dragged him out on his mattress. Thirty minutes after the fire began, paramedics and firefighters arrived but were unable to resuscitate Gomez. Feliciano was found dead in the bathroom.
In their report, investigators speculate that Feliciano likely started the fire as a result of being intoxicated. The county medical examiner determined that Feliciano had a blood-alcohol level of 0.3 percent, or nearly three times the legal limit in North Carolina, suggesting he was “acutely intoxicated.” Gomez’s blood-alcohol level was around half that.
The scenario outlined by investigators is certainly plausible, but there are reasons to think that the trailer’s condition could have played a role in what happened that night — not least of which are the well-documented problems with H-2A housing around the country. In this case, investigators were unable to rule out the possibility that the broken stove started the fire. And the condition of the trailer, as described by the worker who lived there with Gomez and Feliciano the previous summer, differs significantly from what is suggested by the pre-occupancy inspection report approved by NCDL which found no violations. Rojas, too, in his witness statement, described the trailer as “disgusting,” said they had gone a week without hot water, and that he had never been told how to use the fire extinguisher or given any instruction on what to do in case of a fire or other emergency. Finally, while the NCDL inspection cited no problem with the trailer’s smoke detectors, Lucas Carter, the owner of the trailer, told the fire marshal’s office that he could not confirm that it had working smoke detectors on the night of the fire.
According to the workers’ families in Oaxaca, neither Lopez nor Lucas Carter called them after the fire. It was another worker, also from San Juan Mixtepec, who called a member of Gomez’s family to tell him the news. The disaster was so far away and so abstract that for weeks many family members didn’t believe it had actually happened. They would anxiously check their phones, hoping for a WhatsApp message from one of the men to clear up what must have been a misunderstanding. But a month later, when their bodies arrived home, everyone was forced to accept the new reality.
In San Juan Mixtepec it’s customary to pray over the body of the deceased for eight days while the family receives mourners. Each day, some 200 people came to pay their respects to Feliciano, and the family poured sodas and served menudo and sweet breads. Similarly, Gomez’s family mourned his passing by hosting loved ones and praying over his remains.
At the end of eight days, Feliciano was buried, and the family could finally find some closure. But now, in addition to the cost of funeral services, they had to contend with Feliciano’s debt, which was around $11,000.
Feliciano’s family borrowed money, interest-free, from relatives in the U.S. to pay back what he had borrowed from neighbors. Now Feliciano’s father is working on other farms to pay back the family, leaving his own crops and animals unattended.
Each year, as many as 250 people are recruited from San Juan Mixtepec for H-2A visas. Like Lopez, the recruiters are locals, and they charge their neighbors anywhere from $1,000 to more than $5,000 for visa applications that are supposed to be free. The town’s leaders agree that the H-2A program provides much needed economic opportunity, but they’ve grown concerned about abuse.
According to Rey Martinez Lopez, who spoke as a representative of the San Juan Mixtepec community, many workers will return from a season in the U.S. without having earned enough money to repay the recruitment fee. “When this happens, the recruiters extort them, and in the worst scenarios they are blackmailed and threatened, even though the companies in the U.S. already pay the recruiters for each person they bring in,” he said.
Martinez says that none of the families of workers who die while working on H-2A visas is compensated by the U.S. government or by the farms that hired them. He believes the workers should receive life insurance so that their families will be taken care of financially. More importantly, Martinez said, he wants the U.S. government to investigate and punish corrupt recruiters.
In December 2022, the U.S. Department of Labor debarred Lopez from working as an H-2A foreign labor contractor for three years after an investigation determined that he “confiscated workers’ passports … failed to pay weeks of wages to more than a dozen workers, did not pay the inbound and outbound transportation expenses for workers, and charged workers fees between $150 and $8,000 to participate in the federal program” during the 2020 and 2021 growing seasons. It also fined him $62,531 in civil penalties. The investigation also led to the recovery of $58,039 in wages owed to 72 workers. His debarment will last until 2025, at which point he could be allowed to resume his work as a labor contractor.
In San Juan Mixtepec, meanwhile, where most homes have dirt floors and no indoor plumbing, Lopez’s house sits prominently on the side of a hill. The two-story structure, built of cement and white stucco, is surrounded by a tall cinder block wall with an imposing iron gate. People in the community said it’s been years since Lopez has visited. In his absence, the house is a reminder for community members and neighbors of dreams that ended in misery.
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