Demetria Martinez is sitting in a state funded children’s center in Oxnard, wrapping her baby daughter in a shawl, when worry invades her face. Her daughter is sick, she says. Something about her heart. The doctors told her, but she didn’t understand.

Martinez is speaking Mixteco—an indigenous Mexican language full of clicks and tones not used in English or Spanish—but she conveys her emotion without words too. Twisting the ends of her rebozo, frayed from all the baby wearing and worrying, she says what she does understand is that she’s still making payments on a $1,700 hospital bill for the tests doctors did on her 5-month-old daughter.

“I can’t afford it,” she says, speaking through an interpreter. “I’m worried too much about it, and I don’t know what to do. They said her heart isn’t working right. They said her heart is not OK.”

Martinez is among the more than 165,000 indigenous Latino farmworkers who have immigrated to California in the last two decades, driven largely by extreme poverty and drought in their native villages. Indigenous people trace their ancestry to people who lived in what is now Mexico before the arrival of the Spanish in the 1500s.

Their arrival in the United States represents the latest demographic shift among the state’s Latino population. Public health officials and policy-makers often see Latinos as a homogenous group, but they’re far from that. And the indigenous immigrants, with their varying cultures and languages, are already creating new needs for health services in California—needs that providers have yet to fully understand.

Latino Diversity

Bernardina Estrada came to the United States in 2000 from her native village of Paredon, a rural community in the Mexican state of Oaxaca, to look for work. “It was a necessity of our family that we come,” she says. At home, “there was only work when it was time to do the harvest, but because there was no rain, there was no food to harvest.” Estrada has two children she left behind in Mexico after she decided she could not risk their lives in a dangerous and illegal border crossing. She has since had three children born in the States, who are now part of a booming population of young Latinos in California.

More than half of all California children are Latinos, according to U.S. Census data. The number of children statewide grew just 1 percent, or by 45,211 kids, between 2000 and 2010, according to federal data. But the number of Latino children in California increased by 705,395 kids over the same decade, the second-highest increase in the country, behind Texas.

Exactly how many of those children are indigenous is unknown. It’s difficult to make an official count, because they are often lumped into the larger category of “Latino or Hispanic.” But the indigenous population is growing most rapidly among children ages 5 to 12, according to Gaspar Rivera-Salgado, project director for the UCLA Center for Labor Research and Education. About 30 percent of the state’s farmworkers are indigenous, and that number is higher in the agricultural belt that runs between Salinas, Santa Maria and Oxnard. More than 60 percent of the state’s strawberry harvesters are indigenous, and about 60 percent of those don’t speak English or Spanish, instead relying on their native languages to communicate.

Estrada, as well as the other Mixtec women interviewed for this story, said they and their husbands have found work in the strawberry fields in the Oxnard Plain, where some of the nation’s most fertile earth is used to grow acres of strawberries between January and June. Estrada’s husband is at work in the fields right now, she says that morning at the Oxnard children’s center. There’s not enough money to pay rent, and she needs to go back to work too. “I was going to start today, but my son got sick,” she says, holding her 1-year-old, “so I didn’t want to leave him.” She might start again tomorrow, she says.

Indigenous immigrants like Estrada and her young children face a set of issues that are distinct in accessing health care, and different from other Spanish-speaking Latinos in the United States. The first is a steep language barrier. There are 62 indigenous groups in Mexico, each with its own language. “Traditionally, people think you need to just speak Spanish if you’re a physician in this state, but actually it’s more complicated than that, and there are a lot of different languages,” says

Carlos O’Bryan, a family-practice doctor who works at a south Oxnard Las Islas clinic, where about 20 percent of his patients are Mixtec. “Some people assume that if you speak one indigenous language, you’re able to understand others, and it doesn’t work that way.”

Estrada says she understands enough Spanish to feel comfortable taking her children to the local emergency room when they’re sick. But Martinez and another Mixtec woman sitting across from her, Librada Cruz, say they only can make out a handful of words in Spanish. The three women add that they cannot read or write in any language. It is common, health officials say, for Mixtec patients to simply sign all medical and consent forms with an “X.”

The survival of the languages is a testament to the strength of the people themselves, who have been seen as “second-class citizens” in Mexico since the arrival of the Spanish, Rivera-Salgado says. That discriminatory attitude has, to varying degrees, been carried over into the United States. Indigenous children are frequently bullied in school and teased for their short stature and dark skin—and other Latinos are often the culprits, Rivera- Salgado says. Several commonly repeated Spanish-language folk phrases are disparaging toward indigenous people, including “No seas Indio” (“Don’t be an Indian”) and “No casarse con un Indio” (“Don’t marry an Indian”). Both are used to mean, “Don’t be uncivilized, don’t be backward, don’t be ignorant,” he says. “This is a very racist way of interacting with each other.”

The bullying was so widespread in Oxnard schools that the district recently banned the use of the word “Oaxaquita” (“little Oaxacan”), a derogatory word for people who hail from the Mexican state of Oaxaca, as Mixtecs and many other indigenous groups do. Last year, the Oxnard-based Mixteco/Indigena Community Organizing Project launched a “No me llames Oaxaquita” (“Don’t call me little Oaxacan”) campaign.

“At the very minimum, I think that the challenge for local services providers and also advocates is to be more aware of the diversity within the local Latino and Mexican population,” says Rivera-Salgado. “The fact is that these indigenous communities are here, but they have remained largely invisible to local agencies.”

Health Challenges

Librada Cruz came to California from San Martín Peras, a city in Oaxaca, in 2007. “I was living with my mom and there wasn’t enough space,” she says, cradling her 9-month-old daughter, whom she nursed to sleep in her arms. Life is better here, Cruz says, but it’s still not easy. She lives in a garage in Oxnard’s El Rio neighborhood with her husband and four children. Her husband picks strawberries, and she plans to join him again when her youngest is 1.

Following the pattern of previous waves of new U.S. immigrants, both with and without visas, indigenous Mexican adults and teens often work the lowest-paid and least-desirable jobs— jobs that can carry their own health risks. For Mixtecs and Triques, the two most recent groups of indigenous Mexicans to come to California, that largely means working in the strawberry fields that stretch from Salinas to Oxnard.

The workers—and, consequently, their children—are frequently forced to migrate to other jobs elsewhere in the state after they’ve plucked the berries from their vines and placed them in the little plastic baskets sold on supermarket shelves. Along the way, the migrant laborers face limited access to health care, due to language barriers, their transiency and, sometimes, their immigration status.

Estrada and her husband used to migrate between Oxnard and Salinas throughout the year, she says. Every time they showed up in a new town or neighborhood, drawn by the work in the fields, they once again had to find schools, clinics, hospitals and social-service offices. The undertaking would be daunting for any low-income resident without access to the Internet, but add on top of that the fact that they don’t speak English or Spanish and aren’t literate—and you start to see why it can take some indigenous migrants months to enroll their children in local schools or bring them in for routine vaccinations.

“When we came back, school had already started, and the kids had to settle all over again,” Estrada says. The family stopped migrating a few years ago, to give the children a chance to succeed in school. Estrada and her husband have managed to patch together almost year-round employment by working in Oxnard’s newly planted raspberry fields after the strawberry season ends.

Although their U.S.-born children generally have access to Medi-Cal, Mixtec women interviewed for this story said there are still barriers to health care. Oxnard has a few clinics that employ Mixtec translators, for example, but many California communities do not.

At work, the indigenous laborers may be exposed to high levels of pesticides and herbicides, according to preliminary findings from a Cal Lutheran University study that’s testing the urine of Ventura County farmworkers for chemicals. Strawberries, according to the Environmental Working Group, are among the most pesticide-laden crops. Residue from the pesticide may cling to the clothes, hair or skin of farmworkers, exposing their children to the dangerous chemicals. “I worry about that,” Estrada says, “but I have to work.”

At home, wherever home is that season or month, indigenous immigrants often live in cramped quarters—due to poverty and lack of access to farmworker housing if they’re undocumented—sometimes resulting in spikes in contagious illnesses. “We’ve seen a lot of cases of children who have been exposed to tuberculosis,” O’Bryan says.

In farming communities like Oxnard, rundown houses and apartments often become something like tenements—with entire families occupying a single room, resulting in a dozen or more people sharing a bathroom and kitchen. Sometimes, a family may live in a garage or shed in the backyard, with no access to the indoor toilet or shower, says Sandra Young, a family nurse practitioner at Las Islas clinic who founded the Mixteco/Indigena Community Organizing Project.

“You have more diarrheal illness in living conditions that don’t have hot water or don’t have access to bathrooms,” she says. “I’ve had patients tell me they’re only allowed to use the bathroom during certain times, or literally the only water they’re allowed to use is from the hose on the side of the house. The more people you put into a small space, the more hygiene is sues you’re going to have.”

Estrada considers herself one of the luckier ones, because she doesn’t have to share a house. She rents a one-room studio for $600 per month, shared by her husband and three U.S.-born children, ages 8, 5 and 1.

Health-care workers need increased training about the diversity and diverse needs of the state’s Latino population, O’Bryan says. They need to understand, for example, that many indigenous immigrants are also illiterate, unable to read hospital consent forms or follow written medication guidelines for themselves or their children. Health-care providers also need to create an environment where indigenous patients feel comfortable “walking into an agency, going through the bureaucratic process we have for everything,” says Young, who primarily sees ob-gyn patients, about 40 percent of whom are Mixtec.

“We want to create an atmosphere where we value the strengths of this community, including their tight-knit culture, which has many protective factors, and have a sense that we are so fortunate that we have this community here, as opposed to seeing them as just, ‘Oh, these poor struggling farmworkers,’” she says.

So Much Worry

Martinez, the mother of four whose youngest has a heart condition, came to the United States in 2004 with her husband, be cause in her native village, they “didn’t have money to buy food,” she says. “Here is better because here I have lots of stuff to eat.”

Here, though, she still lives far below the federal poverty line. Her husband works in the strawberry fields to support their family of six, and she joins him when she’s not caring for a newborn. They rent a room for $450 a month in El Rio, and other Mixtec families occupy other rooms in the house. On Mondays, she walks down the block to a parent-child baby class at the Rio Neighborhood for Learning, a center funded by First 5 Ventura County. It was here that interpreters helped her understand her 6-year-old son’s autism diagnosis a few years ago, after doctors and school officials left her confused. It is here that she turns if the family needs extra food or if her children’s schools send home papers written in Spanish. It is here that she finds pieces of the community and support network she once had in her native village.

But there are still so many things, particularly health related, that Martinez worries about. Much of it has to do with being unable to speak Spanish, or read or write in any language. She avoids taking her children to the local emergency room, for example, because Mixteco interpreters may not be available. Instead, she waits until Las Islas clinic opens, relying on folk medicine in the meantime.

“I get worried about what’s going to happen to them, but I don’t want to take them to the hospital emergency room, because I don’t understand Spanish and I don’t know what the doctors will do,” she says.

At one time, doctors told Martinez her youngest daughter’s heart condition should resolve on its own, but she remains concerned and confused by the diagnosis and tests. The doctors used an interpreter to explain the diagnosis, but the finer points didn’t translate, she says. They also told her Medi-Cal would cover the cost of the tests, but she had someone fill out the paperwork twice and never heard back. She’s also desperately searching for another place for her family to live, because her landlord has threatened to evict them. She believes the threats are unlawful, but she has no recourse, because she fears the police due to her immigration status.

Her face clouded over with worry, Martinez gets up to leave. The parent-baby class is over, and her daughter is almost asleep in her shawl. She swings the rebozo behind her and gathers her 3-year-old son—but then turns back. The interview is finished, but she has one question herself. She wants to know if anyone in the room can help.

“She’s worried too much about it,” the interpreter, Obdulia Vasquez, says, shifting from first-person translation because the interview is over. “She doesn’t know what to do. She’s worried about the kids too.”

This article originally appeared in the California Health Report magazine. Subscribe here and never miss another great story.

Hannah Hough wrote this story while participating in The California Endowment Health Journalism Fellowships, a program of USC’s Annenberg School of Journalism.