Across the whole of Italy, agriculture counts the fallen like those on a battlefield. People from different nationalities come to work in Italy in the agricultural sector. They often have similar stories to tell and all face a common fate. They are an exploited working class, often immigrants from poorer countries. Their living conditions are grim. Their deaths are quickly forgotten and often invisible to official statistics.  
It is March: the weather is cold, and things look more desolate. Yet, as on any day of the year, work in the fields goes on relentlessly, and so does the exploitation of migrant workers: unseen, untold, unstopped. And people die. The death of agricultural low wage workers knows no seasons.
Sacko was shot while looking for corrugated plates to build barracks. Becky died in a fire. Paola died from heat and exhaustion, Marcus from the cold.  And many other nameless workers are dead, such as the 12 agricultural workers who died in August in a car accident in Puglia. They were crammed into an old van, not fit for purpose, on their way back from the fields. Over the past six years the number of agricultural workers who have died as a result of their work is more than 1500. This affects immigrants and Italians alike. Some have died in fires in ghettos —one hit by a train while returning from work, others dying from exhaustion or killed by intense manual labour. Others have been killed by “gangmasters”—the so called “Caporali,” who are modern slave masters. 
The workers are paid according to the amount of vegetables they collect rather than the time spent at work, or they are paid €12 for eight hours’ work under the supervision of Caporali, and they live in the “Ghetti.” These are shantytowns, isolated from city centers, without water or proper standards of hygiene, sanitation, or health services. Italy has an estimated 50-70 of these settlements, accounting for around 100 000 low wage migrant workers. This is only an estimate, as no official census exists.
They work to make it possible for people from London to Shanghai to buy and eat Italian tomatoes at a low cost, any day of the year. But how much do these tomatoes really cost? What is the human cost of these products?
Over the years the presence of the state, the church, non-governmental organisations, and volunteers has been felt, but it has not been enough to bring about meaningful change. If we are to deal with the “Agromafia” phenomenon—the structure of exploitation and the criminal system behind this exploitation—and achieve fair, working hours and salaries for low wage workers, then strong cultural change and collective actions are required. Yvan Sagnet, a former agricultural worker, began a legal process to have the system officially defined as “Caporalato.” The aim was to recognise the existence of a criminal sector exploiting agricultural workers with unwritten laws and rules. A specific law was passed, but the exploitation continues.
Meanwhile, the human dignity of workers and citizens must be preserved, and essential services must be ensured. Are we not pursuing universal health coverage? Since 2015, Doctors with Africa CUAMM, in partnership with local institutions, has been providing basic health services to these workers. Every Sunday a mobile outpatient clinic is held in three of the ghettos in Puglia.
Over the past four years many services have been provided, resulting in a total of 4800 outpatient consultations (average 43/day). Of these, 60% were first consultations, so 2880 patients have been seen. Our data show that the main reasons for the consultations were: fatigue and/or musculoskeletal conditions (46%); dental problems (19%); respiratory symptoms (10%); dermatological symptoms (8%); obstetric/gynaecological symptoms (4%); trauma (4%); cardiovascular problems (4%); ophthalmic symptoms (2%); metabolic issues (2%); and psychiatric problems (1%). Almost 80% of the patients required pharmacological treatment, while a complex process was required for the 10% of patients who needed referral to secondary care. However, no clear and definite healthcare pathways are in place to make the health interventions fast and efficient. It is hard to imagine that this situation will improve given current political trends in Italy and “Decreto Sicurezza”—a new law regulating migration—and the fact that sees this as a matter of national security only.
In line with the latest evidence, our experience as part of Doctors with Africa CUAMM and global health activists suggests that the health conditions of this population are mainly linked to specific working activities in the agricultural fields, as well as to the hygiene, living conditions, and lack of social protection in their life and job.  Therefore, the issue is: how can we tackle the root causes of these avoidable deaths and diseases? How can we end the exploitation that these workers face? A response is necessary, and the health sector should voice its concerns and make a stand, although it will not be sufficient without coordinated, intersectoral action. Legal, labour, and health protection of low wage agricultural workers and their families is urgently needed. Health, migration, the economy, sustainable development, and justice are all interlinked facets of our world, and we feel a duty for the science and health community to care and to give a voice to the voiceless.
Each of us is involved not only because we are doctors, citizens, scientists, consumers, or economists. We keep working in the field, guided by the principles of “health for all,” universal health coverage, and “leaving no one behind,” enshrined in the World Development Agenda 2030. Yet our work is the work of volunteers, of a society that wants to remain “civilised” and not just civil. The work of doctors who keep believing that we are meant to fight diseases not people—and that all of us need to stand up and fight exploitation, discrimination, racism, and egotism, however disguised their forms might be.
Claudia Marotta, Doctors with Africa CUAMM, Italy; Department of Sciences for Health Promotion and Mother and Child Care, Palermo, Italy
Francesco Di Gennaro, Doctors with Africa CUAMM, Italy; Department of Infectious Diseases, University of Bari “Aldo Moro,” Bari, Italy
Paolo Parente, Department of Public Health, Università Cattolica del Sacro Cuore di Roma, Italy
Giovanni Putoto, MD, DTM&H, MAHMPP, Doctors with Africa CUAMM, Italy
Davide Mosca, Realizing Health SDGs for Migrants, Displaced, and Communities, Italy.
Competing interests: None declared.
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