Nicole Madalon dropped a tiny plastic chip containing a flattened drop of blood into a boxy red machine.

The 34-year-old nursing student bent over her equipment; her patient, 19-year old Eddie Marquez, leaned in curiously behind her. The machine, a blood-glucose meter, beeped and flashed its findings: 246, 2 1/2 times normal.

Madalon gasped. Marquez looked healthy, but the reading showed he was a full-fledged unrecognized diabetic. He needed immediate care, but there was little she could offer him: They were sitting at a rickety cafeteria table at the edge of a rural road.
With one beep, the Farm Worker Family Health Project - a program run by Emory University's Nell Hodgson Woodruff
School of Nursing that brings medical trainees into South Georgia's farm fields - had demonstrated the difficulties of caring for one of the most hidden and unhealthy groups in America.

Farmworkers - and their health, housing and legal standing - sit at the center of bitter national debates over reforming immigration and managing soaring medical costs.

In May, the Pew Hispanic Center estimated that undocumented immigrants who have entered the United States across the Mexican border approach 11 million. Numerous bills to stop, limit or control illegal immigration have been proposed in Congress this year, including a bipartisan measure - introduced in February and killed by filibuster in April - that would have granted residency to 500,000 illegal farmworkers nationwide.

At the same time, concern is growing over the stress that 45 million Americans without health insurance place on the health care system. Most farmworkers lack health insurance, though legal residents and the U.S.-born children of illegal immigrants are eligible for Medicaid.

In 2004, Georgia spent $58.4 million to provide emergency care for undocumented immigrants, according to the state Department of Community Health.

And when farmworkers need emergency care, they are likely to seek it where they live - in agricultural rural America, where the health care system is under particular strain, according to a 2004 Institute of Medicine report.

Georgia sees more than 100,000 seasonal farmworkers each year, according to state and federal estimates. Many, though not all, are believed to be undocumented.

They are part of a migrant stream that picks winter citrus in Florida, spring greens and fruit in Georgia, tobacco up the Eastern Seaboard and apples as far north as Maine before returning to Georgia for the fall vegetable harvest.

‘Anyone who shows up’
In some places up and down the migrant stream, state-funded clinics care for farmworkers and their children. In southwest Georgia, help comes from the Ellenton Clinic, where 11 outreach and health workers offer social services help, medical care, after-school programs and summer day camp for farmworkers' children.

The clinic, which operated for most of a decade in an unused vehicle bay of the Ellenton firehouse before graduating to its own building, is headed by Cynthia Hernandez, whose family on both sides hails from Colquitt County.

"Some of these folks we have known for a long time --- we see them come through three, four years in a row," she said. "Sometimes we are the only medical personnel they will see all year."

In recent years, the Ellenton clinic has had help caring for the roughly 4,000 migrants that the Georgia Department of Community Affairs believes are based in Colquitt County and the additional 15,000 thought to pass through each year.

For two weeks each June, the Farm Worker Family Health Project - a volunteer force of about 100 health care students and faculty from four Georgia colleges and universities - arrives to set up mobile clinics at packing houses, migrant camps and, if necessary, by the side of the road. Every health problem they find and refer to the Ellenton clinic is one less case to stress a local emergency room.

"We treat them for diabetes, for dermatitis, for nicotine poisoning from picking tobacco, for what can be terrible dental problems," said Dr. Judith Wold, a tenured professor at Georgia State University who runs the program from Emory during a summer faculty appointment. "Anyone who shows up, we will see."

One evening last week, the group set up camp on the grass in front of a trailer park in Riverside, a small town west of Moultrie.

They pitched tents for Georgia State's physical therapy students and dental hygienists from Darton College and Clayton State University, and unfolded tables for Emory's undergraduate nursing and graduate nurse practitioner students.

The migrants, who work as long as there is daylight, arrived about 9 p.m., dropped off in pickups by the crew bosses who arrange their work and pay. They came through the trailers by flashlight; the students pulled on tiny hiking headlamps that lit up their patients and left their hands free.

Most who came were men; some looked like boys. "They all say they're 18, but there's no way most of them are 18," said Sue Anne Bell, a nursing professor from Medical College of Georgia.

But there was also a 6-year-old girl, brought by her mother, who had had diarrhea since the morning, and a 65-year-old woman with gray hair down to her hips who needed help with an itchy rash. The students ushered her into the clinic's "Nightingale van" - a trailer with two examining rooms, named after the founder of nursing - for a private exam.

At the nurse practitioners' table, where patients with more complicated cases were sent for evaluation, there was a painfully thin 25-year-old woman who said she had been vomiting for days. She was Mexican, in the United States about four months, and undocumented. She refused to tell the students her name.

She was also pregnant --- about 7 weeks, she said in Spanish. She had been pregnant twice before, but both babies were premature and stillborn. She was worried. She expected to move on to another state in a few days.

The group gave her prenatal vitamins and an anti-nausea drug. "She's very thin, and somewhat dehydrated," said Deena
Yowler, an Emory graduate student. "In the real world I would admit her to a hospital."

Second career for many
The nurses were moved by their patients and troubled by the difficulties they would face getting all the care they need.

Most, though, had too much life experience to be shocked. Few were traditional college students; the majority had come to nursing after starting families or earning other degrees.

Madalon, who diagnosed Marquez, has a psychology degree, two children and a husband who relocated so she could go to Emory. Amy Armstrong, a 26-year-old graduate student who explained diabetes to Marquez, earned two degrees in theology before realizing her heart lay in hands-on care. She enrolled in an Emory program for career changers and will graduate in 2006 as a nurse-midwife.

Marquez, who has lived in the United States since he was 5, insisted he was fine. He was not feeling sick at all; he had come by the encampment "because I saw it, riding by," he said, "and I thought anytime you have a chance to take care of yourself, you should."

But the ugly surprise of diabetes is a common discovery among the poorly fed farmworkers, who seldom make enough money to buy the very vegetables and fruit they pick.

"They'll come in just not feeling good, thinking perhaps they have the flu," said Hernandez, the clinic director. "We've learned the hard way: Always test their blood sugar."

Marquez was reluctant to visit the Ellenton clinic. Knowing the severity of his disease, Armstrong urged him to go.

"Over time, you'll lose feeling in your feet, your hands; you won't be able to see," she said. "It's really important that you go soon."

But the clinic's care has limits, Hernandez acknowledged. It has outreach workers to coach new diabetics patients and their families on changing their diet away from the traditional foods of corn and rice and the new temptations of junk food. It can supply some drugs that regulate blood sugar, which may be an option for Marquez. But diabetics who need insulin require a doctor's ongoing care.

"It can be frustrating for our students," Wold said. "They believe everyone deserves to have health care, and the situations they see can be hard for them to handle. But we've had students change their career paths because of this. It shows them that working with vulnerable groups is what they really want to do."