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Parker, M.D. David L. Hard, Ph.D. Katherine Wilson, M.P.H. Public Law 101-517 April 30 - May 3, 1991 Des Moines, Iowa Convened by U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service Centers for Disease Control National Institute for Occupational Safety and Health September 1992 DISCLAIMER Sponsorship of this Conference and these Papers and Proceedings by the National Institute for Occupational Safety and Health (NIOSH) does not constitute endorsement of the views expressed or recommendations for use of any commercial product, commodity, or service mentioned. The opinions and conclusions expressed in the papers and abstracts are those of the authors and not necessarily those of NIOSH. Recommendations are not to be considered as final statements of NIOSH policy or of any agency or individual who was involved. They are intended to be used in advancing the knowledge needed for improving worker safety and health. This document is in the Public Domain and may be freely copied or reprinted. Copies of this and other NIOSH documents are available from: Publication Dissemination, DSDll National Institute for Occupational Safety and Health 4676 Columbia Parkway Cincinnati, Ohio 45226 FAX (513) 533-8573 U.S. Department of Commerce National Technical Information Services Springfield, VA 22161 NTIS PB 93-114890/$77.00 or A/O6 Superintendent of Documents U.S. Government Printing Office Washington, DC 20402 GPO 017-033-00463-3 DHHS (NIOSH) PUBLICATION NUMBER 92-105 For information on other occupational safety and health problems, call: I-800-35NIOSH ii National Farm Safety Week, 1991 By the President of the United States of America A Fro&math The men and women who work in America's agrIcultura1 aector make a vital contribution to our Nation's well-being. By providing conmunera with a variety of high-quality food and fiber at reasonable costs, they help to keep our work force strong and healthy and, tn so doing. help to maintain the Nation's economic productivity and competitiveness. Because we count on farmem and ranchers for 80 much, both as individuals and aa a Nation, it is fIttIng that we observe National Farm Safety Week-a concerted public awareness campaign aimed at promoting their health and safety. Over the years much hae been done to Improve the safety of agricultural production. Advances in science and technology and increased attention to avoiding safety rilrka have made farms and ranchen safer places to work. Moreover, dedicated profeaeionale and volunteers have been working together to promote health and safety In rural communities. These efforts are reflected by a welcome downturn in farm accident rates. Unfortunately, however, while important strides have been made in reducing the risks of farming and ranching, agricultural production remains one of our most hazardous lnduetrlee, with an accident death rate that is more than four tImea the average of all induetriee. More must be done to reduce the toll of farm-related accidents. Most accidenta on the Nation'8 farme and ranches can be prevented by sensible meaauree that involve little extra time, effort, or expense. For example, farmers and ranchers can reduce their risk of serious injury and illness by following manufacturers' instructions on the use of chemicals and machinery and by utilizing protective apparel and safety equipment when the job calls for it. Children should be kept away from $ardous machinery, and all family members and employees should be trained in safety procedures and first For generations. the men and women who work on our Nation's farme and ranches have endured long hours of tough, physical labor. However, they have continually met the challenges of their vocation with determlna- tion and pride--and with unparalleled success. During National Farm Safety Week, let us resolve to make excellence in health and safety another one of America's great farming traditions. NOW, THEREFORE I. GEORGE BUSH, President of the United States of America, by virtue of the authority vested in me by the Constitution and laws of the United States. do hereby proclaim the week of September 15 through September 21. 19Ql, ae National Farm Safety Week. 1 urge all who live and work on our Nation's farms and ranches to make the presematlon of personal health and safety an Integral part of their daily activities. I also urge them to protect their children, not only by inetructlon In safety habits, but also by setting an example of carefulness and by avoiding needless rmke. I also call upon organizations that serve agricultural producers to strengthen their support for rural health and safety programs, and I encourage all Americans to observe this week with appropriate activities as we express our appreciation for the many contributions that men and women in agriculture make to our Nation. IN WITNESS WHRREOF, I have hereunto set my hand this fifteenth day of April, in the year of our Lord nineteen hundred and ninety-one. and of the Independence of the United States of America the two hundred and fifteenth. . . . 111 Surgeon General's Conference on Agricultural Safety and Health FARM&E 2000 o A National Coalition tbr Local Action Convened by the National institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, lowa PREFACE In 1990, the Congress established a national initiative in agricultural safety and health under Public Law 101-517. The Congress directed that this initiative, when sustained over a period of time, would result in a significant and measurable impact on . . . health effects among rural Americans. As part of that initiative, the Congress appropriated funds for the National Institute for Occupational Safety and Health (NIOSH) to convene a Surgeon General's Conference on Agricultural Safety and Health. This Conference was held in 1991 and was chaired by Assistant Surgeon General J. Donald Millar, the Director of NIOSH. The purpose of this Conference was to raise consciousness, build coalitions, disseminate information, and encourage action to prevent injury and disease in agriculture. The Conference fulfilled this purpose and established a vision for improving the total quality of health and safety for agricultural workers and their families in America: b Raise Consciousness. The Congress found that agricultural workers and their families experienced excessive rates of injuries, many kinds of cancers and lung diseases, and various health effects from exposures to agricultural chemicals. Their findings indicated significant disparities in the quality of health among agricultural workers and their families and a national need to improve the quality of their health. The Surgeon General's Conference reinforced this need, and the evidence was broadened into musculoskeletal problems, noise-induced hearing loss, dermatological conditions, stress, and infectious diseases. Furthermore, participants at the Conference emphasized the need to improve the health of agricultural workers and their families. b Build Coalitions. The Surgeon General's Conference raised the consciousness of many officials in the fields of agriculture, education, labor, and public health at the national, state, and local levels. The need for a concerted effort was recognized by the par- ticipants. Over 500 people participated from 41 states and the Commonwealth of Puerto Rico as well as from other countries. As a result, a growing network of the participants are reaching out among themselves and to others to offer and to receive help. b Disseminate Information, The most visible manifestation of information dissemination is these Proceedings and Papers: Surgeon General's Conference on Agricultural Safety and Health of that Conference, which will be distributed to participants and key prevention leaders at the national, state, and local levels across the nation. b Encourage Action. The action that was overwhelmingly encouraged was to improve 1 health and safety of agricultural workers and their families. Moreover, the word, PREVENTION, came through loud and clear--over and over-at the Conference. This action, the improvement of agricultural safety and health through prevention, was identified with three views: as an action for the 1990's, with national leadership, and through people at the local level. :he Surgeon General's Conference on Agricultural Safety and Health - 1991 V Preface With the recognition of a need for improvement, the Congress, through its national initiative at NIOSH, launched a program for improving the health and safety of agricul- tural workers and their families. This program was comprised of: b A Suwey. The Congress directed NIOSH to undertake a Farm Family Health and Hazard Survey to develop more complete information on the circumstances of agricul- tural injury and disease problems. Based upon this information, informed priority-setting for prevention can be implemented and a baseline for measuring improvement can be established. b Research. To insure that preventive actions are taken based upon scientific findings, including the etiology of the injuries and diseases, the Congress also directed NIOSH to conduct research both intramurally and through university-based Centers for Agricultural Health and Safety. k Intewention. To actively promote and implement the research findings, the Congress directed NIOSH to establish a national Agricultural Health Promotion System in collaboration with county extension agents. The Congress also directed NIOSH to devise an early detection strategy to reduce the number of cancer deaths among farmers through Cancer Control Demonstration Projects for Farmers. In addition, funds were provided for the training of professionals in agricultural safety and health. b SuMZlance. To monitor results, the Congress directed NIOSH to establish an Agricultural Health Nurse Program in which rural hospitals would provide ongoing responsive (focused at intervention) surveillance to identify agriculture-related disease and injury problems through the support of nurses at rural hospitals. In 1991, the Secretary of Health and Human Services issued a report, Healthy People 2000, which included national goals and objectives for improving the health of Americans. Three overarching goals emerged from this effort, each of which apply to agricultural workers and their families. These goals are: increase the span of healthy life for Americans, reduce health disparities among Americans, and achieve access to preventive health services for all Americans. Emerging from the purpose established by the Congress for a national initiative for agricultural safety and health from the goals of Healthy People 2000, and from the Surgeon General's Conference on Agricultural Safety and Health is a national vision for the 1990's for implementing the initiative: To continuously and measurably improve the safety and health of every working man and woman in American agriculture through the prevention of Leading Work-Related Diseases and Injuries consistent with the goals and objectives of `Healthy People 2000.' O (%c?$wc Antonia C. Novello, M.D. Surgeon General vi Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 . A National Coalition f?~ Local Action Convened by the National institute tir Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa FOREWORD The Surgeon General's Conference on Agricultural Safety and Health was convened by the National Institute for Occupational Safety and Health (NIOSH) in 1991. NIOSH was created in 1970 as a result of the passage of the Occupational Safety and Health Act. NIOSH is the national public health organization responsible for the occupational safety and health of all of the nation's workers. Moreover, NIOSH is a component of the Centers for Disease Control (CDC), The Nation's Prevention Agency. In 1990, the Congress expressed concern that agricultural workers and their families experience a disproportionate share of injuries and diseases associated with numerous chemical, biological, and physical hazards. For example, agricultural workers have the second highest occupational fatality rate. They run a significantly higher risk of dying of certain types of cancer than persons in other occupations. The Congress also observed that inhalation of organic dusts from plant, soil, and animal sources, and from chemical and other substances, results in occupational health risks to agricultural workers. The Congress, recognizing that agricultural workers continue to suffer high levels of injury and illness, directed NIOSH to lead a comprehensive national program and undertake a series of initiatives in surveillance, research, and intervention to prevent occupational injuries and diseases in agriculture. The Congress believed that NIOSH was in a unique position to lead a comprehensive national effort to prevent injury and disease in agriculture. The NIOSH initiative is intended to provide a balanced approach to substantially reduce the incidence of fatal and nonfatal traumatic injury, chronic injury, and occupational diseases among the 3.4 million agricultural workers in the United States. NIOSH expanded its research program to address the safety and health of workers in agriculture and awarded cooperative agreements to enhance the Institute's existing program in the areas of surveillance, research, and intervention. The Congress also directed that NIOSH convene a Surgeon General's Conference on Agricultural Safety and Health. Held in 1991, its purpose was to raise consciousness, build coalitions, disseminate information, and encourage action to prevent injury and disease in rural areas. Several solutions for preventing diseases and injuries were presented and discussed at this Conference. The following is a summary of the Con- ference through the words of its participants, followed by a statement of the problem that emerged from the Conference, and a vision for the future of agricultural safety and health in America as well as a special mention of a particular, fully preventable agricul- tural injury-"an occupational obscenity"-which was repeatedly emphasized at the Conference. CONFERENCE SUMMARY The general design of the Conference was to, first in plenary session, address its purpose, then provide direction through keynote speeches and questions, and pose some as- sumptions about the future of both the agricultural workforce and workplace. The titles Surgeon General's Conference on Agricultural Safety and Health - 1991 vii Foreword of the sessions and titles in this document corresponding to this part of the Conference are: The Potential for a National Coalition, Looking Ahead to the Next Century, Questions to Guide the National Agenda, Medical Intervention Problems and Opportunities, and Issues That Affect the National Agenda. The Conference included five concurrent sessions dealing with the issues of surveillance, research, and intervention. The proceedings from these sessions are addressed in this document in the chapters entitled Surveillance-Agriculture-Related Diseases, Injuries, and Hazards, Research-Chemical and Biological Hazards, Research-Mechanical and Physical Hazards, Intervention-Worker Protection from Environmental Hazards, Intervention-Safe Behaviors among Adults and Children. Within each of these sessions, presentations of factual information were made, and discussions ensued from the perspectives of a range of interested parties. Returning to plenary sessions, the chair of each concurrent session reported the results of deliberations in their session. In addition, a report was made on the issues raised at another conference held concurrently on migrant and seasonal labor. These reports are presented in the chapter entitled Elements of a National Agenda. The closing plenary session provided an opportunity for concluding remarks from a variety of participants who ranged from governmental to those representing farm organizations to a victim. These remarks are documented herein in the chapter entitled Actions for the Future. The Conference included a poster and video tape session with 102 posters presented. The abstracts of the posters and titles of the video tapes are presented in the chapter entitled Making Connections. Six unifying principles emerged from the Conference as operational concepts for the future. They are found in the words of 72 speakers at the Conference-these themes offer a verbal tour through these Papers and Proceedings: b CONTINUOUS IMPROVEMENT THROUGH PREVENTION. The Congress has directed that a national initiative, of which this Conference was a part, be launched so that when sustained over a period of time, would result in a significant and measurable impact on . . . health effects among rural Americans. Augmenting this direction for continuous improve- ment, the Surgeon General's Conference consistently and in multiple ways demonstrated the need to prevent problems in order to improve the safety and health of agricultural workers and their families. Senator Tom Harkin of Iowa asserted, " . . . we need to make "Prevention First" our motto for health care in the 90's." Dr. Thomas Dean of the National Rural Health Association challenged the Conference, " . . . to go forth in these deliberations with a sense of urgency and with an understanding that every day lives are lost because families are being devastated and futures are being ruined because of our failure in the past to build these coalitions." . . . VIII Papers and Proceedings Foreword Speaking to a paradigm for prevention, Dr. William Popendorf from The University of Iowa said, " . . . we face yet another challenge; how to translate them (parameters of health effects) into "agricultural hygiene," the industrial hygiene paradigm of "anticipa- tion, recognition, evaluation, and control learned in general industry . . . " Jeffrey Human of the Office of Rural Health Policy encouraged the Conference to, ' . . . confront conventional approaches and make new choices with limited funds, choices that help solve rural health problems." Willis Eken of the Minnesota Farmers' Union contended, " . . . that it is something of a sham if the most effective tool for safer environmental protection regarding machinery is a law suit." Joseph Kinney of the National Safe Workplace Institute urged the Con- ference, " . . . to begin to get realistic about how you would like to see these issues ad- dressed." Merlin Plagge of the Iowa Farm Bureau observed about OSHA standards that, (1 . . . knowing they exist has encouraged farmers to work for safer farmsteads." b RECOGNIZETHENEEDS OF THE POPULATIONAT RISK. Fundamentaltoprevention is recognizing the needs of agricultural workers and their families, a population at disproportionately high risk of work-related disease and injury. Dr. Myron Johnsrud of the U.S. Extension Service asserted, "A national strategy could rest on the belief that the most effective preventive efforts will emerge from a process that emphasizes identifying and characterizing problem areas and populations at risk." Relatedly, Dr. James Merchant of the Institute of Agricultural Medicine and Oc- cupational Health at The University of Iowa reported, "Agricultural production is now changing dynamically, resulting in a substantial increase in farmers with non-farm jobs, greater involvement of women and seasonal workers, and involvement of children and recreational farmers in agricultural operations." Dr. Leslie Whitener of the Economic Research Service at the U.S. Department of Agriculture defined this population: `The largest component (46 percent) of the agricultural work force in 1987 was made up of the 3.6 million people who did unpaid farmwork . . . .the hired component of the agricultural work force will continue to grow in importance as hired workers increasingly replace family workers on farms and as the number of large, labor-intensive commercial farms continues to increase." Christopher Atchison of the Iowa Department of Public Health noted, "Because farming has traditionally been a family business, that it is not just the professional farmer, it is the farm family that is at risk for injury." Cheryl Tevis from Succes@Z Faming Magazine observed, " . . . that about half of farm women work outside the home." Todd Frazier from NIOSH expressed his viewpoint, "Because I am from a public health background and have always been interested in the population at risk, these demographics spell out to me a very serious challenge that we are facing when we look at projects that address the problems of farm families in generally rural areas." Surgeon General's Conference on Agricuttural Safety and Health - 1991 ix Foreword Speaking of the migrant labor portion of the population, Roberta Ryder of the National Migrant Resource Program asked, "Is it really acceptable that such a large poriion of our population be relegated to the edge for the duration of their lives?" Dr. Russell Currier from the Iowa Department of Public Health recognized two patterns of disease among agricultural workers, "Migrant farm workers experiencing human-host illnesses, often episodic and exacerbated by substandard living and employment conditions. All other farm workers experiencing sporadic, isolated illness that is most frequently zoonotic, vector-borne, or environmentally acquired in nature." b SURVEILLANCE TO MEASURE IMPROVEMENTS. Part ofpreventionis the study of trends so as to measure progress. Surveillance is the means of doing so. Through surveillance, we can systematically and continually collect, analyze, and interpret data related to health and safety and direct prevention programs so as to control and, when possible, eliminate the occurrence of diseases and injuries. With reference to John Donne's 16th century poem, Dr. William Halperin from NIOSH spoke to the role of surveillance as a guide to preventive action, "Surveillance in modern times is the equivalent of the tolling of the bells with the added commitment to inves- tigation of the causation of morbidity and mortality and dissemination of data and analysis with the goal of prevention." Dr. John May from the New York Center for Agricultural Medicine and Health speaking to the use of sentinel events in surveillance relayed that, " . . . intervention should affect other workers by either addressing the hazardous exposure, by screening similarly exposed workers, or by insuring that at least adequate protection is provided to similarly exposed workers." About surveillance and priorities, Dr. Dennis Murphy from Penn State University contended, "If we are going to let data guide us, we have to get to some specific categories to have some guidance." Dr. Henry Anderson from the Wisconsin Department of Health and Social Services reported, "We need to move away from the broad view to some specific, high-priority activities." Regarding the role of the "helping" professions, Rodney Gilmore from the North Dakota State Department of Public Health related, "We learned that in order to keep a good surveillance system going, you must keep direct and frequent contact with the medical facilities and with the providers who are giving you the information." Dr. Eugene Freund from NIOSH suggested, "Inasmuch as the nurses, through their interactions with providers, can do case surveillance, they can help with the recognition of problems that may not be identified in the community." b RESEARCH TO FIND ROOT CAUSES. A principle that emerged at the Conference was to base actions on facts. Research is a way of finding the facts, and through research, we work to understand the causes of work-related diseases, injuries, and hazards; detect their vulnerabilities to prevention; and discover, assess, and improve measures to reduce them. Dr. Lorann Stallones from Colorado State University reported, "National policy guidance is needed in order to provide focus for targeting proper areas of research and to define the scope of research to be performed within priority areas." x Papers and Proceedings Foreword Regarding high technology, Dr. Ronald Eckoff of the Iowa Department of Public Health introduced two speakers saying that they, " . . . will reveal changes in the agricultural work place as it is affected by new and different crops and by biotechnology." Dr. Daniel Kugler from the Office of Agricultural Materials at the U.S. Department of Agriculture noted, " . . . that agriculture, indeed, is a very high-tech business." Dr. Jane Rissler from the National Wildlife Federation challenged the Conference with, "I hope that this presentation will provoke a wide-ranging consideration and evaluation of the potential impacts of biotechnology on farm worker health." Regarding noise-induced hearing loss, Dr. Matthew Marvel from the Oneonta Health Center observed that, "We also might find some high-technology solutions like using sound cancellation." The occupational problems faced by farmers were seen to be numerous, significant, and preventable. Dr. Susanna Von Essen from the University of Nebraska summarized the problems with lung diseases on the farm, `The presence of inflammation is a common theme in these disorders." Other problems were addressed by Dr. Linda Rosenstock from the University of Washington when she maintained that, "On the basis of this study and the accumulating evidence in the medical literature, we feel that even episodes of acute organophosphate poisoning can cause permanent neurologic dysfunction." Dr. Aaron Blair from the National Cancer Institute observed, "A critical role for suppression of immune responsiveness by pesticides has been demonstrated for infectious disease and maybe for other diseases." The injury problem was addressed by Dr. Sverker Hoghind from the Swedish Farmers Safety and Preventive Health Association who explained that, "Machine design may be related to hazards of two kinds. One is accidents causing acute injuries. The other is chronic injuries or illnesses because of long-term, unfavorable effects on the body during work operations." Murray Madsen from Deere and Company observed that, "Sometimes equipment is in mint condition; other times it is not, or modified, or built from scratch in a local shop." Dr. Thomas Bean from Ohio State University reported that, "In either case, the majority of studies indicated that farm equipment was the single factor most associated with on-farm injury." John Crowley from the Equipment Manufacturers Institute urged that, "Behavioral research is needed to guide engineers on how equip- ment can be designed for safer operation and maintenance." Dr. Susan Gerberich from the University of Minnesota maintained that, "A major barrier to progress in the prevention of agricultural injuries has not only been a lack of knowledge about the magnitude of the problem but also a lack of knowledge about specific causes or risk factors due to the lack of analytical studies." Penn Peters of the U.S. Forest Service stated that, "A high-priorityresearch area is in the injuries that result from a felled tree having hit another tree, which includes hangup fell, broken limbs or tops, and butt rebound." Regarding the hazards of overhead electrical lines, Robert McLymore from North Carolina State University remarked, `That moment of carelessness may end up with that piece of equipment getting in contact with that line. We know how electricity kills." Governor Robert Ray, Chairman of the National Advisory Committee on Rural Health Surgeon General's Conference on Agricultural Safety and Health - 1991 xi Foreword Policy, observed that, "the suicide rate for farmers is now 30 to 40 percent above the national non-farm rate." Dr. David Co&ran of the Occupational Safety and Health Administration recounted a conversation' "She was telling me that the top occupational category suffering from tendinitis in the state of Washington is farmworkers." Regarding greenhouse workers, Dr. John Coumbis of the Agency for Toxic Substance and Disease Registry related that, I' . you find some of the reports of back pain in roughly a third of the work force, pain id multiple joints in 19 percent, pain of the upper extremities in 11 percent of the workers, lower extremities in 8 percent, and neck pain in 2 percent." b RESPECT PEOPLE WHILE CONTROLLING THE PIROBLEMS. Another principle that emerged overwhelmingly at the conference was respect for people, and also consistent with our Conference theme of A National Coalition for Local Action, our intervention must be based upon such respect. Speaking to this theme through a video message, Secretary Louis Sullivan of Health and Human Services stated, "The key to making those strategies effective--the critical, vital factor that will determine our success in lowering the risks of agricultural work-is local initiatives and efforts," Assistant Surgeon General William Roper declared, "As the theme of this meeting, N&ionaZ Coalition for Local Action, clearly portends, the foun- dation of our public health system' as it functions in agriculture and other sectors, must be the local public health agency." Dr. James Dosman from the University of Saskatchewan recommended, " . . . the estab- lishment of health and safety committees at the local level, organized by target pop- ulations, for the purpose of identifying issues, facilitating programming, and achieving results." Referring to agricultural workers, Ellen Widess' Children's Advocacy Institute contended, `Unless we also deal with those economic realities of their lives and their limited choices, we will fail in our efforts to improve health and safety." Regarding networking and community involvement' Dr. Dean Stueland from the National Farm Medicine Center related, "We need to close the loop between what is happening on the farm and what is happening in medicine so that people understand each other." Wayne Sprick of the National Young Farmer Educational Association said, `The FFA chapters and those younger people are looking for opportunities to conduct community-service types of projects." Robert Graham with the National Vocational Agriculture Teachers' Association commented, "We encourage students to sit down and do a community review by interviewing resource people with organizations, such as the community health organizations, the district representatives of OSHA and NIOSH, the Farm Bureaus, and National Grange Affiliates." Valerie Wilk from the Farmworker Justice Fund reported, "In a number of the workshops there were very concrete examples of groups who had worked in coalition, either within their community or statewide, on particular health and safety issues: workers' compensation or field sanitation." xii Papers and Proceedings Foreword Gene Graham with the W.K Kellogg Foundation challenged the Conference, " . . . (how can we) develop meaningful opportunities for enfranchisement, access to the institutions of society, and the much needed occupational safety and health interventions for migrant and seasonal workers?" Craig Merrilees with the Consumer Pesticide Project contended, "Health and safety improvements come only when people are organized and when they are able to control their own destiny"' Thomas Seymour from the Occupational Safety and Health Administration observed, "In the OSHA history of writing rules, regulations and enforcement, we have found that the people who are interested in trying to correct these problems need to be on board and in support of the process." Regarding the issue of training, Cynthia Douglass from the Occupational Safety and Health Administration conveyed, `The answer lies in education, training, and increasing awareness of those hazards and how they can be reduced." Malanie Zavala from the University of California-Davis pointed out that, " . . . a lot of these people come here without an excellent education' and this is going to make a difference as to what they can understand in terms of reading-not so much in terms of spoken language, I think' but in terms of things that they are going to have to read." On children and women, Marilyn Adams of Farm Safety for "Just Kids" proposed, "My experience with the youth tells me that they are our best bridge to the farm family. If you take this one step further and train farm women in tractor safety, chemical safety, rescue, and the other aspects of farming along with the youth, Dad and Grandpa will not have a chance after we start rocking the boat and making waves." Surgeon General Antonia Novello declared, "As a woman' I totally agree with the philosophy of Marilyn Adams' group, Farm Safety for "Just Rids"' who say that the one person on a farm who can play the most pivotal role in educating farmers and farm children about the dangers of working on a farm is the woman." Nineteen-year-old Mark Timm from the National FFA Organization related, "Not only does America need its young, but young people need your help, support, guidance, and leadership." Dr. Walter Armbruster of the Farm Foundation observed, "We also know that reaching adults through youth is a very effective channel for modifying adult behavior." b UNDERSTAND 'THE SYSTEMYNORDERTO CONTROLTHEPROBLEMS. Ageneral principle that emerged was to develop win-win situations by understanding the system, recognizing people as part of the system' and intervening early in that system in its design. Dr. Rice Leach, Chief of Staff to the Surgeon General' in speaking to a `win-win' strategy conveyed it succinctly, " . . . I submit that the purpose of this endeavor or our mission is to prepare the next generation to live in harmony with nature." Judith Heffeman of the University of Missouri-Columbia remarked, `There is a social movement afoot that looks at environmental and food safety and a whole host of issues that are . . . put together, and so pesticide usage and water quality-and you know the litany-we have heard much of it here." Dr. Robert Pinger from Ball State University reported, "Integrated Pest Management is the use of the safest and most appropriate Surgeon General's Conference on Agricultural Safety and Health - 1991 . . . XIII Foreword combination of methods (physical, chemical, and biological) to control vector popu- lations." Dr. Kelley Donham from the University of Iowa reported, "One of the items that came out of the group was a call for a sustainable human resource in agriculture. This was based on an analogy to the sustainable agriculture movement from a natural resources conservation perspective." Larry Belmont from the Idaho Panhandle Health District 1 stated, "Our next best alternative is to develop new solutions or new systems of service to cover those areas." Recognizing human behavior as an important part of the system, Dr. Robert Aherin from the University of Illinois propounded, `This theory has proven that intention is strongly correlated to one's behavior and behavioral intentions are formed by two basic determinants, one personal in nature and the other reflecting social influence." Assistant Surgeon General Michael McGinnis offered an avenue for prevention by noting that, ,I the prominent role of behavior in health threats is not novel or unique, some of the lessons that can be gleaned from other public health areas may be germane to the kinds of approaches that we seek to establish for agricultural health and safety." In contrast, Dr. Pamela Elkind from Eastern Washington University contended, "This assumption, simply stated, is that to make agriculture safe for the farm families and workers, it is necessary to motivate them to protect themselves from health and safety hazards . . . I shall attempt to demonstrate to you that these assumptions lack validity." Regarding design, Dr. David Pratt of the New York Center for Agricultural Medicine and Health reported, "Intervention strategies are most effective when they are applied early in the process." Dr. Gary Erisman, a private farmer, declared, " . . . design is the most critical stage for the prevention of hazards and hazardous products." Ray Crammond, consulting engineer, said of design, "I think the biggest problem is people who ignore the human input." Rollin Schnieder from the University of Nebraska stated, "You have to realize that a lot of the equipment that we have in agriculture is not totally designed." Professor Stephan Konz from Kansas State University maintained, "Designing out the problem is the best approach because it is a permanent solution." Dr. Richard Fenske from the University of Washington said, " . . . there are many opportunities, if we are creative, to reduce the hazard before we ever have to worry about personal protec- tive equipment." Dale Baker from J.I. Case Company challenged the Conference, "Is anyone going to invest the time and effort to develop new designs unless there is, in fact, a demand?" THE PROBLEM: DISEASE AND INJURY To help establish priorities for the field of occupational safety and health, NIOSH in 1983 developed a list of 10 Leading Work-Related Diseases and Injuries and proposed national strategies to prevent each of them. NIOSH invited leading experts to improve xiv Papers and Proceedings Foreword and elaborate on these strategies at two national symposia held in 1985 and 1986.' The initial list was based upon three criteria: the scope of the problem, the severity of the problem in the individual case, and the vulnerability of the problem to prevention. More recently, infectious diseases have also emerged as a significant problem in occupational safety and health.' The problem is disease and injury, our common enemy. We have seen how this enemy attacks American agricultural workers and their families. Recognized at this Conference were a number of The Leading Work-Related Diseases and Injuries: 1. 2. 3. 4. 5. 6. 7. 8. 9. IO. 11. Occupational Lung Diseases - farmers' lung, asthma, hog lung, silo fillers' disease, etc. Musculoskeletal Injuries - milkers' knee, tractor drivers' syndrome, tendinitis, repetitive motion trauma, etc. Occupational Cancers - skin, bladder, and brain cancer, leukemia, etc. Severe Occupational Traumatic Injuries - machine-related fatalities, electrocutions, suffocations, suicides, amputations, eye injuries, etc. Occupational Cardiovascular Diseases - heat stroke. Disorders of Reproduction - miscarriages, infertility, etc. Neurotoxic Disorders - dementia, neurologic dysfunction, etc. Noise-Induced Hearing Loss Dermatological Conditions - burns, lacerations, dermatitis, etc. Psychological Disorders - depression, stress, etc. Infectious Diseases - zoonosis, tuberculosis, etc. A VISION FOR THE FUTURE In 1990, the Congress directed NIOSH to lead a comprehensive national program to prevent occupational injuries and diseases in agriculture. NIOSH gains its authority for responding to this direction from the Occupational Safety and Health Act of 1970, which 1 Proposed Natiottal Strategies for the Prevention of Leading Work-Related Diseases and Injuries. Part 1 in 1986 and Part 2 in 1988, Published by the Association of Schools of Public Health under a Cooperative Agreement with the National Institute for Occupational Safety and Health. 2 For an example related to agricultural workers see: Centers for Disease Control. "Prevention and Control of Tuberculosis in Migrant Farm Workers: Recommendations of the Advisory Council for the Elimination of Tuberculosis," MLVIXI? 1992;41 (No. RR-lo). Surgeon General's Conference on Agricultural Safety and Health - 1991 xv Foreword established the national goal "to assure so far as possible every working man and woman in the Nation safe and healthful working conditions and to preserve our human resour- ces." NIOSH is charged in the Act to undertake scientific activities that will enable the goal to be won. In response to this charge, NIOSH identifies those populations at highest risk, defines risk factors that guide our efforts to reduce those risks, and provides information to whomever has the ability to act in preventing the problem. The Surgeon General's Conference of 1991 has established a national commitment to the continuous improvement of safety and health among agricultural workers and {heir families. It is a "Total Quality" commitment! As a result of the Conference, the Surgeon General has identified a VISION for a national program for agricultural safety and health in America: To continuously and measurably improve the safety and health of every working man and woman in American agriculture through the prevention of Leading Work-Related Diseases and Injuries consistent with the goals and objectives of `Healthy People 2000. ' In 1991, the U.S. Public Health Service published a report, Healthy People 2000: National Health Promotion and Disease Prevention Objectives. This document is a statement of national opportunities. This report is not intended as a statement of Federal standards and requirements, but as a product of a national effort that involved over 10,000 people. The Surgeon General addressed three overarching goals from this report in the Preface. These goals are buttressed by specific and substantive objectives, which are aimed at guiding decisions about programs, resource allocations, and profes- sional and personal commitments. The objectives enumerated in Healthy People 2000 deal with Health Status, Risk Reduc- tion, Services and Protection, and Surveillance. The Health Status Objectives address the problem of disease and injury, the Risk Reduction Objectives address the control of the causes of the disease and injury problem. The Services and Protection Objectives relate to the processes that require improvement so that risk can be reduced. The Surveillance Objectives address the process of diagnosing and reporting information about health status, risk reduction, and services and protection so as to better guide and focus our intervention to control disease and injury. With the vision of the future in mind, FarmSafe 2000 is a program commitment to Healthy People 2000. Consistent with this commitment, we have listed, as illustrative examples, 11 Health Status Objectives for the year 2000 that correspond with the xvi Papers and Proceedings Foreword problem, the 10 Leading Work-Related Diseases and Injuries plus infectious diseases.3 Each objective represents a significant improvement in health status over an existing baseline by the year 2000. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. Occupational Lung Diseases - Reduce asthma morbidity, as measured by a reduction in asthma hospitalizations to no more than 160 per 100,000 people (11.1). Musculoskeletal Injuries - Reduce cumulative trauma disorders to an incidence of no more than 60 cases per 100,000 full-time workers (10.3). Occupational Cancers - Reverse the rise in cancer deaths to achieve a rate of no more than 130 per 100,000 people (16.1). Severe Occupational Traumatic Injuries - Reduce work-related injuries resulting in- medical treatment, lost time from work, or restricted work activity to no more than 6 cases per 100 full-time agricultural workers (10.2~). Occupational Cardiovascular Diseases - Reduce stroke deaths to no more than 20 per 100,000 people (15.1). Disorders of Reproduction - Reduce the prevalence of infertility to no more than 6.5 percent (5.3). Neurotoxic Disorders - Reduce nonfatal poisoning to no more than 88 emergency department treatments per 100,000 people (9.8). Noise-Induced Hearing Loss - Reduce significant hearing impairment to a prevalence of no more than 82 per 1,000 people (17.6). Dermatological Conditions - Reduce occupational skin disorders or diseases to an incidence of no more than 55 per 100,000 full-time workers (10.4). Psychological Disorders - Reduce suicides to no more than 10.5 per 100,000 people (6.1). Infectious Diseases - Reduce tuberculosis to an incidence of no more than 3.5 cases per 100,000 people (20.4). Another Health Status Objective, which would be classified under Severe Occupational Traumatic Injuries, is to reduce deaths from work-related injuries to no more than 4 per 100,000 full-time agricultural workers. There was an annual average of 6 deaths per 100,000 for the period, 1983 to 1987. The next issue that I will discuss relates directly to this objective. 3 Each Objective is parenthetically followed by an identifying number. This number uniquely identifies each Objective within the document: U.S. Department of Health and Human Services, Public Health Service. Healthy People 2000: National Health Promotion and Disease Prevention Objectives. 1990; DHHS Publication No. (PHS) 91450212, Washington, DC: Government Printing Office. Surgeon General's Conference on Agricultural Safety and Health - 1991 xvii Foreword AN "OCCUPATIONAL OBSCENITY One final issue that was raised at the Conference cannot go without special mention. Amidst expressions of anguish and pleas for reason, there was an overwhelming interest in a particular issue, namely the need to reduce the risk of fatalities related to tractor roll-overs. Deaths from tractor roll-overs are the leading cause of traumatic fatalities on the farm. There is no acceptable excuse for the persistence of this problem as deaths from tractor roll-overs are fully preventable. The problem justifies the term, "occupational obscenity." Twenty-seven speakers at the Conference addressed this problem. Categorized by the six principles that emerged as unifying concepts at the Conference, here is what they said: b CONTINUOUS IMPROVEMENT THROUGH PREVENTION. A good example of the need for such a model is the prevention of tractor roll-over deaths througlz the application of roll-over protective structures (ROPS) on both new and older tractors. The epidemiological evidence for the very significant risk posed by tractors without ROPS is clear. . . The data available from Sweden, which mandated such a program, makes it equally clear that ROPS can prevent almost all tractor roll-over deaths. An important question for this conference is whether an American intervention model can be developed that can produce a significant reduction of tractor roll-over deaths and injuries. A second question, with much broader ramifications, is, "Yf we cannot develop a U.S. model for a proven intervention on the single most important cause of agricultural mortality, how can we succeed in addressing less dramatic yet still impotiant causes of agricultural d&eases and injuries?" - Dr. James A. Merchant Director, Institute of Agricultural Medicine and Occupational Health The University of Iowa IJZ Sweden in 1959 the law was put forward concerning safeq frames (ROPS) in new tractors. It was also decided that employed agricultural workers were not allowed to work in tractors lacking such frames. Self-el?tployed farmers and family members for many years were excluded from this law and could use old tractors without frames in farm work A new tractor, of course, had this device. IJI 1983 the law was extended to include family farmers. It was later decided that even old tractors had to have frames if they were to be used in agn'cultural work The effect on fatalities due to tractor turn-over since the year of legtilation was striking. It is obvious that thti action from the authorities, unpopular as it might have been, has had quite a significant effect in preventing severe accidents. - Dr. Sverker Hogliind Director, Swedish Farmers Safety and Preventive Health Association Stockholm, Sweden b RECOGNIZE THENEEDS OFTHEPOPULATIONAT RISK. Even though the land is so jlat, we still have a tendency to have tractor roll-overs in the eastern part of the state . . . Tractor roll-overs are still a major source of fatalities in the state. - Rodney Gilmore Injury Control Program Manager North Dakota State Department of Public Health Bob Aherin said something about ROPS that really interested me. He said to ident@ the farmers with high risk exposure and to identify appropriate intervention strategies . . . As a farmer, this makes much more sense to me than suggesting that all farmers should put ROPS on all tractors. . . . XVIII Papers and Proceedings Foreword We need to start somewhere and give the farmer a realistic picture of the high-risk exposure with all tractors with end loaders or whatever the highest rirk is . . . I heard Wes Buchele address the issue of retrojits. By all means, guarding for the older equipment neea3 to be made accessible and marketed It is my personal feeling that dealers should not resell equipment without all protective shields. They have a responsibility to their customem to market the proper shielding for their own products. - Marilyn Adams President, Farm Safety for "Just Kids" Farm children have been injured and killed for years. I was too young to remember a tragic tractor roll-over accident that claimed the life of our neighbor's son, Years later I remember finding the yellowed and brittle newspaper articles about it that my mother had saved On looking back, I think that that accident may have bud a lot to do with the fact that my brothers were not expected to function as hired hands at a young age. . . When askeg `!lf cost were not a consideration, would you use roll-overprotection ?" 89percent said they woukl; 96percent would use safety shielding; and 50 percent would use day care. These figures may be slightly high. We all know it is good to have good in ten tions. - Cheryl Tevis Senior Farm Issue Editor Successful Farming Magazine We have had a great deal of discussion, in thk session, about ROPS. We have all seen the slide, many times, of the success of ROPS in Sweden. In 1985, we had a commitment by the North American tractor manufacturers to make ROPS standard on all tractors. With a few exceptions of tractors that are being imported into thk country and those that are for orchard applications, all tractors since that time are equipped with ROPS. By 1970, ROPS in this country became available OJZ virtually all major manufacturers'product lines. There was no demand for them. Therefore, we have a significant number of tractors in operation in the U.S. that were built in that interval between 1970 and 1985 that are not equipped with ROPS. I would suggest, in gross temzs, that there are about a million tractors that are equipped with ROPS or that have ROPS built into the cab. About a million tractors that are out there could have a ROPS installed on them but do not. Another million tractors that are in use were built prior to thir introduction of ROPS and here installation of ROPS becomes a real technological fisue. Now we should look at those two issues separately. IJZ putting ROPS onto tractors that were built prior to 1970, there are some significant technical issues. Will the tractor structure survive an impact with this ROPS attached? The structure was not built for that kind of use. New frames could be designect, possibly, to accommodate the design by sharing the load forward to the transmtision housing. There is now a need to develop that new structure. There were many applications for those old tractors where implements were attached to the same location that we would attach thti ROP structure. If you destroy that, you have destroyed the utility of that tractor. There is also the tisue of the economics ofpum'ng those ROPS OJI old tractors. If there is to be a program of that nature, it is going to have to start with the development of some pubic policy change that will create that demand Is anyone going to invest the time and effort to develop new designs unless there ti, in fact, a demand? The issue for tractors built in the interval between 1970 and 1985 where a ROPS can be installed becolnes an issue of how to create an environment where the public demands those ROPS. They are available. A demand undoubtedly could bring down the cost that was mentioned earlier. Until there is a demand, there will not be any initiative that will cause that to happen. It is the chicken and the egg situation. If you could decrease the cost, maybe you could increase the demand You Surgeon General's Conference on Agricultural Safety and Health - 1991 xix Foreword cannot decrease the cost, however, until there is a demand We are now again looking at what is a public policy issue of how you create that demand I would say to you that my brother is aware of the &sues of ROPS and tractor overturns. But fatal tmctor overtumr are a rare event (a farmer is far more likely to be killed in a car accident than a tractor overturn). Virtually all farmers are aware of the issue of fatal tractor 0veWm.s in the same sense that farmers (and the general public) are aware of the issue of cigarette smoking causing cancer. - L. Dale Baker Product Safety Engineer J.I. Case Company b SURVEILLANCETOMEASUREIMPROVEMENTS. For many conditions we are at different surveillance stages in this scheme. For one condition that we have heard much about, that of famt fatalities due to tractor roll-over, we have identified the problem, we large@ know the scope of the problem, and we know what needs to be done to target interventions. -Dr. Henry A, Anderson Chief, Section of Environmental Epidemiology Wisconsin Department of Health and Social Services For example, in 1958, Sweden instituted a law that any new tractor that wasproduced had to have roll-over protection. In the years thereafter, surveillance data indicate a decline in roll-over fatalities. In 1978 Sweden instituted another law that any tractor in use had to have roll-over protection, and the problem was eradicated - Dr. William E. Halperin Associate Director for Surveillance Division of Surveillance, Hazard Evaluations, and Field Studies National Institute for Occupational Safety and Health The Olmstead Agricultural Trauma Study provided the basis for the Regional Rural Injury Study, currently being conducted in a five-state region: Minnesota, Wuconsin, North Dakota, South Dakota, and Nebraska. Data collection covers a twelve-month period of time for over 4,000 rural households, utilizing computer-assisted telephone interviews. This effort will enable the identification of injury rates for each state and the region as well as multiple analytic substudies, including tractor-roll-avers and animal-human injuries. The project also includes application of the results to the development of intervention strategies, to be achieved by convening nationally recognized experts and the regional participants in the Agricultural Injury Intervention Strategy Workshop. - Dr. Susan Goodwin Gerberich Division of Environmental and Occupational Health School of Public Health, University of Minnesota, Minneapolis, Minnesota We will look at safety risk factors, injuries, ergonomics, roll-overs, power-take-offs, and secondary occupations. -Todd M. Frazier Chief, Surveillance Branch Division of Surveillance, Hazard Evaluations, and Field Studies National Institute for Occupational Safety and Health They (nurses) can ident@ that as a problem and trigger efforts to prevent it from happening again. Since they will be located in their own regions, they will often be able to identifi all cases of a given condition, tractor roll-overs or power take-off injuries. They can ident@ the scope of those problems, use that information to target intervention efforts, and after intervention efforts, evaluate how effective they have been . . . The Extension service havepeople who know how to retrofit trac- tors with roll-over protection, if that is something someone wants to do. - Dr. Eugene Freund Medical Officer, Surveillance Branch Division of Surveillance, Hazard Evaluations, and Field Studies National Institute for Occupational Safety and Health xx Papers and Proceedings Foreword w RESEARCH TO FIND ROOT CAUSES. Farm equipment accounted for 40 to 60percent of deaths and injuries in the majority of studies, followed very closely by livestock injuries and jalk Numerous types of farm machinery have been implicated in all sties. Since the majon@ offm machinery is associated with tractors, it stana to reason that injuries "involving" tractors were the most common type of machinery-related trauma. Tractor over-tunas, it appeared, were involved in the majority of agricultural fatalities. Many studies indicated that youth and the elderly were most often associated as an at-risk population , . . The studies varieci, though, when you compared those using statistics porn government agencies that were not gathering the appropriate and associated data with youth . . . The opportunity presents itselj to include some homespun theory. This happens to be a theory of mine: on family fam, older tractors and equipment are ofren reserved for general duty while newer pieces of machinery are delegated to more production types of tasks. The general duty may be more hazardous than the normal production tasks on farms. As a result, general duty fi often done by the youth or the elder&, The typical fmer, the principal operator, is using the newer machinery to plow and till the field, etc., while the older machinery may be relegated to cutting the fence rows or ditch banks and stationary operations that may be more hazardous than doingfield- related operations. As a result, when you combine the inexperience of youth and the diminished capacity that comes with aging (because the elderly or youth usually do this general duty) with the inherent danger of the equipment, you have an increasedpotential for trauma. . . Research on roll- over protection on older tractors should continue. - Dr. Thomas L. Bean Safety Leader, Ohio Cooperative Extension Service Ohio State University Dr. Bean stressed the need to install ROPS on farm tractors . . , "R OPS is a proven intervention strategy. Wlzy can we not implement it. 3" Is the problem the cost, the infrastructure, the regulation, or the legal system? - Penn A. Peters Project Leader U.S. Forest Service In the late 1950's and early 1960's, extensive research and development work was done by the industry to establish the eficacy of ROPS designs for the kinds of tractor overturns that can occur in normal farming and road transport. Manufacturers began supplying ROPS commercially in the late 1960's. The experience in both the United States and Europe has proven ROPS to be an effective sajev device. There is a need for additional research on small tractors' ROPS. The standard `protective zone" around the tractor operator, which controls the size of the ROPS envelope, was defined on the basis of the ergonomic data that existed in the 1950's and 1960's. The zone remains essentially un- changed today. The Equipment Manufacturers Institute (EMI) sponsored a literature review of the different protective zones used for the design of several kinds of vehicles, including aircraft, automobiles, racing cars, farm equipment, construction equipment, and mining equipment. This study, which was perjonned by Triodyne, Inc. of Skokie, Illinois, has been completed Publication will be through both the Society of Automotive Engineers (SAE) and the American Society of Agricultural Engineers (ASAE) before the end of 1991. The basic conclusion of the Triodyne study was that it did not appear, from the kindr of systems that are in place, that sufficient research had been done that could serve as the basis for making the protective zone of a ROPS, as specified by current standards, for smaller for small tractors. Small tractors are often used in low overhead clearance settingsin vineyards, orchards, storage buildings, and machine shed. Surgeon General's Conference on Agricultural Safety and Health - 1991 xxi Foreword The higher the profile of a ROPS relative to an overhead object such as a tree branch, the greater the likelihood that a farmer will not want to equip a tractor with ROPS or, if there is one on a tractor, to keep it in place. Clearly, there is potential safety value in making the ROPS as compact as possible without compromising protection in the event of a tip-over. As Murray Madsen mentioned in his presentation, one approach to addressing this situation is to make ROPS that can be raised or lowered They telescope or fold down for temporary use in the lowered position under low clearance conditions. There are some companies that have such ROPS on the market tooday. Industry's research capabilities concerning ROPS are limited to mechanical and structural aspects. There is little more to be done there with the exception of the small tractor ROPS. Accident data ident@ tractor roll-overs as the leading cause of machinery-related death on the f arm. Therefore, perhaps the most pressing challenge for behavioral researchers and health professionals is to find an effective way to ensure, short of compulsory measures such as regulation, that ROPS are installed and kept on tractors. EMI believes that behavioral research in this area holds promise of effecting a substantial reduction in roll-over injury and fatality rates. The starting point for such research, we submit, may be recognition that over one million of the approximately 3.6 million agricultural tractors in use today in the United States do have ROPS on them. There are over one million farmers who chose to equip their tractors with ROPS when they purchased t?tem. The question should be asked how these farmers arrived at their decision to equip the tractors with ROPS. Was it because of the Occupational Safety and Health Administration's (OSHA) rule? Was it because manufacturers were able to package the ROPS in a cab that was noise-insulated and isolated from vibration of the tractor. 3 It provided air conditioning, heating, and stereo; i.e., it was made so attractive in other respects that the farmer was willing to pay for the ROPS cab. Or were there other factors? The key to getting ROPS on the over-2.5 million tractors that do not now have them may indeed be found by examining the factors in the decisions of the approximately one million farmers who did decide to equip their tractors with ROPS. The third essential criterion is that a safety device must not by its presence, introduce different r&ks that would not exist without it. Murray Madsen referred to a study that showed that some accidents occurred because of an operator presence-type device. I am reminded of a situation that exbted several years ago when OSPi%, with all good intent, promulgated its ROPS rule for agriculture. As it turned out, there were some small tractors t?lat had backhoes mounted to the three-point hitch, with a separate seat for the operator affud to the backhoe frame behind the tractor. Without the ROPS there was not any problem. It was discovered that when a ROPS was installed on a tractor with the threepoint-hitch-mounted backhoe, a crush point between the elevating backhoe boom and the rigid ROPS structure was created A number of fatalities occurred because of that condition. The solution was to do away with the three-point-hitch-mounted backhoe or redesign the ROPS or both. A combination of these measures was implemented through various field reworkprograms to eliminate the hazard When tractor ROPS were being developed, manufacturers' test programs included actual roll-overs of tractors with experimental ROPS designs at different attitudes and speeds. There is a need in many cases, to verify that a new safety feature will be acceptable to the farmer. -John H. Crowley Director of Safety Programs Equipment Manufacturers Institute It has been learned in recent times that amuude measures do not correspond with behavioral criterions. The early attitudinal studies would evaluate a very general behavioral statement. An example of this would be when evaluating the potential purchase of ROPS on a tractor a subject xxii Papers and Proceedings Foreword might be asked to evaluate a statement such as, "Roll-overprotective structures are . " A more appropriate evaluative statement for predicting ROPS purchasing behavior would be to ask farmers their attitude toward buying roll-overprotective structures. The am'tude question would look as follows: "My buying a roll-overprotective structure in the next two years for one of my non- ROPS equipped tractors is ," The attituaZna1 question must match the corresponding behavioral criterion in terms of 1) action, 2) target, 3) context, and 4) time. In the previous example the action was "my buying," the target was "ROPS for one of my (the subject) non-ROPS equipped tractors, " the context was "general, n and time was "within the next two years. " In summary, there may be a substantial difference between people's amtt.&es toward objects (in this example, ROPS) and people's am*tudes toward behaviors associated with objects (in this example, buying ROPS). To predict behavior, this distinction is crucial An example of an issue that might benefit from Theory of Reasoned Action type of analysis would be the installing of ROPS on tractors. Tractor roll-overs are a major factor in farm work- related deaths. It is well known that if a tractor has a ROPS it almost eliminates the death potential in a tractor roll-over incident. But only about 30 percent of the farm tractors in the United States have a ROPS. Thus, at issue is what it would take to persuade farm tractor owners to install a ROPS on non-ROPS tractors. There have been significant educational programs to promote the purchase of ROPS among farm tractor owners. But there has been no signijicant increase in the retrofitting of ROPS on non-ROPS equipped tractors. If an analysis was conducted among US farm tractor operators utilizing the Theory of Reasoned Action, one could learn what intervention initiatives would be necessary to effect a significant change in this behavior. For example, it could be learned how much if anything farmers would be willing to spend for a ROPS, their general perception of the need for ROPS on their tractors, tractor use problems that they may encounter with ROPS, and so on. This type of information would provide focus for initiatives to deal with this issue rather than using the traditional `Shotgun" approach of trying anything and seeing if it works. - Dr. Robert Aherin Professor, Department of Agricultural Engineering University of Illinois b RESPECT PEOPLE WHILE CONTROLLINGTHEPROBLEMS. Again, economic realities make choices very dificult. Take for example, ROPS protection. Most farmers know the dangers and would willingly retrofit their tractors, but there is economic reality. - Ellen G. Widess Director of Health and Safety Policy, Children's Advocacy Institute Center for Public Interest Law "I think I am going to invest in (it) whatever it costs," although I did hear myself saying to my husband last night, "Honey, we have got to buy roll-over bars. " That is on the agenda. But we, with other income, can probably do that; but I knowpeople who are borrowing money to put bread on the table. -Judith Bortner Heffernan Executive Director of Heartland Nehvork for Town and Rural Ministries University of Missouri-Columbia I heard one presenter say that her family was going to buy the roll-over protective device for their tractor. I encourage her to follow through on this commitment. - Dr. Rice C. Leach Chief of Staff, Office of the Surgeon General When we looked at the tractor roll-over problem with Marshfield, we decided that there was no need for further research on the problem. What we decided we needed was a way to help farmers who wanted to retrofit older tractors with roll bars or other roll-overprotective devices to find those Surgeon General's Conference on Agricultural Safety and Health - 1991 XXIII Foreword "ROPS," as tltey are called So we asked Marshjield to develop and publish a catalog of all American manufacturers of `ROPS, " all products they produce and what make of tractor, model of tractor, and year of tractor they will build Then Marshfield sent the catalog to all extension agents in tJze country, so it is available where it is needed Producing that catalog is not the best step we could take as a society. As we have seen in the slide on the Swedish experience, tJze best step we could take would be to require "ROPS." But as an Office, it was the best we could do, -Jeffrey Human Director, Office of Rural Health Policy U.S. Public Health Service We have also seen ROPS development and the recent development of retractable or foldable ROPS for tlzose essential applications where you must go into a buil&ng that is shorter - not as tall as your tractor's ROPS. I would also say to those of you who wonder about ROPS that since 1985 virtually every tractor produced Aas been sold with a ROPS on it or right at the fingertips. Since 1970, virtually every tractor could have a ROPS put on it, and some have since I960. Consider, for example, Jzow to convince tlze owner of a 30-year-old tractor worth, at most, $1,000, to put a $500 ROPS OJZ it. Tile University of Illinois, NIOSH, and the University of Iowa are doing researclt to Jtelp find some of tlzose kinds of answers. A ROPS that provides protection and still meets tlze needs of users under limbs, vines, and rafters holds promise. It is likely that this kind of roll-over protection will produce more acceptable designs for the user. Perhaps it may not produce as much protection as users have become accustomed to with larger or more conventional roll-overprotective structures. Is tlzere an opportunity for validating acceptable ROPS for more compact tractors? - Murray Madsen Product Safety Engineer for Agricultural Equipment Deere and Company TJtere are also recommendations aimed at reducing specific hazards, such as the danger of injury or deatla in tractor roll-over or from moving machinery parts . . . OSHA also reviews existing standards tlzat apply to agriculture, such as the ROPS standard We look at wlzether tltese standards should be modified to reflect changing conditions in the United States, in the world, and in the industry. We need your Jzelp, tlzouglz, on reviewing and modibing these standards, if we are to Jtave good, common-sense safety standards. In another area, a member of our staff leas been comparing tlte new standard OJI ROPS for tractors and other vehicles, which was adopted by SAE, to the existing OSHA standard We have received design and test data from American tractor manufacturers and otlters. We have made a preliminary conclusion that the new SAE standard is equal to or exceeds the current OSHA standard and therefore, is acceptable to the agency. A final decision on this will be made slzortly. Hopefully, this will make it easier for American farm equipment manufacturers to compete in the European market. - Cynthia Douglass Deputy Assistant Secretary of Labor U.S. Occupational Safety and Health Administration b UNDERSTAND"THE SYSTEM"IN ORDERTO CONTROLTHEPROBLEMS. Look no furtlzer than tile agriculture-implement lobby here today, This lobby has blocked roll-over protection in tJtis country for 30 years with bee-jerk, protective, self-interested arguments tlzat continue to allow farmworkers to die in thk country, out of their narrow interest. That is wrong. Tire reason that it Jzappened i.s not because we have not done enough scientific research to document the problem. - Craig Merrilees Director, Consumer Pesticide Project xxiv Papers and Proceedings Foreword ROPS for tractors and tractor seat-belt use couldprevent the majoriv of tractor-related deaths. Vir- tually all new tractors sold in the United States have ROPS . . . Because of the relatively long life of tractors, most agricultural tractors in use do not have ROPS in place. Nearly half of the approximately 400 tractor-related deaths that occur each year in this nation involve roll-overs. How do we ensure that the older tractors and machines without these modem safety features get retrojitted with modern safety features when feasible or get taken out of use? The issue of how such updating and retrofitting is practical presents a significant challenge . . . Although more research and more data are needed to direct intervention, we know certain health and safev precautions work; ROPS work - Dr. Myron D. Johnsrud Administrator, Extension Setice U.S. Department of Agriculture Perhaps the best example of passive controls is ROPS. - Dr. David S. Pratt Director, New York Center for Agricultural Medicine and Health Cooperstown, NY There are some issues, the ROPS issue is the most typical one, that we can approach from a national perspective. - Dr. Dennis Murphy Professor, Penn State University The committee divided itself into working groups to develop suggestions and recommendations in the areas of training, and also in the need.s for standards like ROPS and machine guarding. In 1972, the full committee recommended its first standard They recommended that we do a ROPS rule for farm tractors. The first agricultural standard that OSHA issued under its normal rule-making was the ROPS standard We proposed that back in 1975, we finalized it in 197.5, and it becar?re effective in October, 1976. It dealt with all farm tractors made after October, 1976; they had to be equipped with the ROPS. The standard is based on the ASAE Standard, Jll-94. The complete text of that Standard was put into the OSHA standard Even though tractors were required to have ROPS, we continue to see deaths of tractor operators from roll-overs. We have seen seat belts cut off or cut out; seat belts were not used in several roll- over deaths. Obviously, we have not seen the results that the Swedes have achieved with tlteir standardization efforts. OSHA wants to see its standard evaluated We want to see this standard looked at very thoroughly to see why it is not working. What can we do to mod@ it, to make it work, to become more effective ? We know that seat belts are considered by many farmers and farmworkers as a hassle in hooking and unhooking, especially when you have to get off the tractor a number of times. The new ASAE Standard J2l-9.4, is a revision of this effort. We have said publicly that the standard is acceptable in meeting our ROPS standard that we require here. We have done that administratively. The International Standards Organization (ISO) is also involved in wn'ting standards for ROPS, and the IS0 Standards 5700 and 34-63 are additional new ROPS standards. Our ROPS standard is not as stringent as theirs. In our opinion, if you have a ROPS design that meets all the tests of the IS0 Standards, that will be acceptable in meeting the OSlZ4 Standard as well. -Thomas H. Seymour Fire Protection Engineer, Directorate of Safety Standards U.S. Occupational Safety and Health Administration Due to engineering advances in the last three decades, farm equipment manufacturers have incor- porated more safety devices on their equipment. Integral rotary shield for power take-off shafts and roll-over protective structures for tractors have been two major accomplishments in making farm machinery more user-safe. Since tractor roll-overs are involved in a large portion of agricultural fatalities, elimination of this type of incident alone would cause the death rate on Surgeon General's Conference on Agricultural Safety and Health - 1991 xxv Foreword American farms to plunge. But farmers themselves murt make the commitment to run a safe operation. When they see the dangers and learn the advantage, safety happens. In Nebraska, for example, university safety experts have conducted 450 tractor roll-over demonstrations since 1970 to convince farmers of the dangers. About 23,000 young people were trained in tractor safety. There have been two known fatalities in this group. The national average for a group that size would be five deaths. - Merlin Plagge President, Iowa Farm Bureau In conclusion, I wish to thank CAPT Melvin L. Myers for his hard work in planning and managing both the Surgeon General's Conference on Agricultural Safety and Health and the production of these Papers and Proceedings. I also wish to thank the rapporteurs, CAPT Robert F. Herrick, CAPT Stephen A. Olenchock, Mr. John R. Myers, CDR John E. Parker, and Dr. David L. Hard, who assisted with the concurrent sessions and the editing of the papers presented at those sessions. I wish to thank Ms. Katherine Wilson who coordinated the poster and video tape session md reviewed the abstracts from those posters for this publication. Many others who ilelped to make this Conference a success are named in the acknowledgements of this document. But most of all, it was the work of the 540 participants at this Conference who made it a success through honest engagement with the issues and interaction with others. Their names are listed by their respective state near the end of this document. My thanks to all for making this Conference a splendid success in our national movement to improve the safety and health of agricultural workers and their fami1ies.U J. Donald Millar, M.D., D.T.P.H. (Lond.) Assistant Surgeon General Director, National Institute for Occupational Safety and Health xxvi Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARM&FE 2000 . A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa THE PLANNING COMMITTEE Melvin L. Myers, M.P.A. - Chair Office of the Director NIOSH, CDC 1600 Clifton Rd, NE Atlanta, GA 30333 Robert W. Mason, Ph.D. Division of Standards Development and Technology Transfer, NIOSH, CDC 4676 Columbia Pkwy Cincinnati, OH 45213 Stephen A. Olenchock, Ph.D. Division of Respiratory Disease Studies, NIOSH, CDC 944 Chestnut Ridge Rd Morgantown, WV 26505 Katherine Wilson, M.P.H. Division for Chronic Disease Control and Community Intervention, NCCDPHP, CDC 3005 Chamblee-Tucker Rd Chamblee, GA 30341 Robert A. Wright Office of Vital and Health Statistics Systems, NCHS, CDC 6525 Belcrest Rd Hyattsville, MD 20782 Lawrence J. Doemeny, Ph.D. Division of Physical Sciences and Engineering, NIOSH, CDC 5555 Ridge Ave Cincinnati, OH 45226 Pantelis G. Rentos, Ph.D. Division of Training and Manpower Development NIOSH, CDC 4676 Columbia Pkwy Cincinnati, OH 45213 John R. Myers, M.S.F. Division of Safety Research NIOSH, CDC 944 Chestnut Ridge Rd Morgantown, WV 26505 John J. Coumbis, M.D. Oak Ridge Fellow, ATSDR 1600 Clifton Rd, NE Atlanta, GA 30333 Stephen M. Ostroff, M.D. Division of Bacterial and Mycotic Diseases, NCID, CDC 1600 Clifton Rd, NE Atlanta, GA 30333 Russell E. Savage, Ph.D Division of Biomedical and Behavioral Science, NIOSH, CDC 4676 Columbia Pkwy Cincinnati, OH 45213 Robert F. Herrick, Sc.D. Division of Surveillance, Hazard Evaluation, and Field Studies NIOSH, CDC 5555 Ridge Ave Cincinnati, OH 45226 Paul Burlack Division of Injury Control NCEHIC, CDC 2858 Woodcock Blvd Chamblee, GA 30341 William H. Gimson Financial Management Office OPS, CDC 255 E Paces Ferry Rd Atlanta, GA 30305 Surgeon General's Conference on Agricultural Safety and Health - 1991 xxvii The Planning Committee - ADVISORS TO THE PLANNING COMMWEE - John E. Parker, M.D. Division of Safety Research NIOSH, CDC 944 Chestnut Ridge Rd Morgantown, WV 26505 Bradley K. Rein, P.E. Extension Service, USDA Rm 3346, South 14th and Industrial Ave, SW Washington, DC 20250 Jeffrey H. Lancashire Office of the Director NIOSH, CDC 1600 Clifton Rd, NE Atlanta, GA 30333 Ann M. Cronin Office of the Director NIOSH, CDC 1600 Clifton Rd, NE Atlanta, GA 30333 David L Hard, Ph.D. Division of Safety Research NIOSH, CDC 944 Chestnut Ridge Rd Morgantown, WV 26505 Cathy J. Wasem, RN, MN Office of Rural Health Policy Health Resources and Services Administration 5600 Fishers Ln, Rm 14-22 Rockville, MD 20857 Vivian K. Morgan Division of Standards Development and Technology Transfer, NIOSH, CDC 4676 Columbia Pkwy Cincinnati, OH 45213 Stephen Mallinger OSHA, US Department of Labor Rm N3653 200 Constitution Ave, NW Washington, DC 20210 Dushanka V. Kleinman, D.D.S. Office of the Surgeon General USPHS, Rm 71OG 200 Independence Ave, SW Washington, DC 20201 Todd M. Frazier, Sc.M. Division of Surveillance, Hazard Evaluation, and Field Studies NIOSH, CDC 5555 Ridge Ave Cincinnati, OH 45226 . . . xxvlll Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARM&FE 2000 . A National Coalition for Local Act/on Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa ACKNOWLEDGEMENTS Convening and holding the Surgeon General's Conference on Agricultural Safety and Health was a team effort as was preparing these Papers and Proceedings. In addition to the planning committee and their advisors, the presenters, the panel moderators and rapporteurs, and panel members, we wish to thank the following staff to the Surgeon General, NIOSH staff, and editorial advisors for their diligent work for this Conference and for their help in the preparation of this document: For their willing and timely assistance from the Office of the Surgeon General, Dushanka V. Kleinman, D.D.S., who served as the principle liaison within the Office, Rice C. Leach, M.D., who maintained an open door for resolving the most pressing problems, and for assisting the Surgeon General, Elizabeth P. Schmidt, Theresa Hyatt, and Margaret Garikes. For their attention to detail and quality from NIOSH, Kimberly L. Barth for her diligent work in assembling and preparing much of the information that proceeded the con- ference and that is in this document including coordinating its changes; Elizabeth H. Dryden who coordinated with commitment and diplomacy the staff and the logistics of the conference with the contractor; Trevia K. Pereira for her early assistance to the planning committee; Renee L. Ross for her willing help in formatting the abstracts and appendixes of this document; Amy A. Huston, Julie A. Wasil, and Judy L. James for their assistance in making the many editorial changes during the progress of this document; Ann M. Cronin, Mary B. Griffin, Richie D. Dickerson, Kay Basile, Terry L. Stewart, Terri L. Sims, Kami L. Townsend, and Lunette IS. Utter, who helped with the logistics at the Conference; Janice M. Huy, Vivian K. Morgan, and Charlene B. Maloney for their professionalism in preparing and showing the Conference exhibit. For their assistance as editorial advisors from NIOSH, Newell E. Tozzer, Charlene B. Maloney, Shirley M. Carr, William E. Halperin, M.D., and Richard A. Lemen, Ph.D. For their added assistance as editorial advisors, Henry A. Anderson, M.D., Ph.D., Kelley J. Donham, D.V.M., Lorann Stallones, Ph.D., David S. Pratt, M.D., Walter J. Armbruster, Ph.D., Rice C. Leach, M.D., Cathy J. Wasem, RN, MN, and Valerie A. Wilk, M.S. And for her superb work as the contractor for this conference, Rosita Bachmann and to her associates.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 xxix Surgeon General's Conference on Agricultural Safety and Health FARM&FE 2000 . A National Coalition for Local Action Convened by the National institute for Occupational Safety and Health April 30 - May 3, 1997, Des Moines, Iowa TABLE OF CONTENTS iii National Farm Safety Week, 1991: A Proclamation f3y the President of the United States of America v Preface vii Foreword xxvii The Planning Committee xxix Acknowledgements xxxi Table of Contents By Antonia C. Novel/o, M.D. By J. Donald Millar, M.D. 1 Welcome from the Chair of the Conference By J. Donald Millar, M.D. 2 Welcome to Des Moines By John P. Dorrian 3 Welcome to Iowa By Christopher G. Atchison, M.P.A. THE POTENTIAL FOR A NATIONAL COALITION Moderator: Antonia C. Novel/o, M.D. `."""`".`.`.`.`.`.`.`.`.`.:.:.:.'.:.:.'. . . . . . . . . . . . . . . . . .,.....,,. ..,...,.., . . . . . . . . . . . . . . .............. ......*,....,...,,..,.....,.,.,.....,..,..............,,,.,,.,......., .,...,.,...,.........,.................. .,.....,...,. . . . . .._.............. . . . . .,.,.,. ,.,.r. .,.,.,. ,.,.,.. ,A.,..., ,.....i.., ./././..,.,.,C.,...,.,.,. ,a., ,a.... . ../....,.....,.,.....i ,.... . . ..l...,....._...i...... . ..I . . . . ..v .A.... .A.. ../. .A.... . ..C.. .A.... ..A . . . . . . . :.:.:.:.:.:.:.:.:.:i . . . . . . . . . . . . . . . . . . ,. :. . `.".`!`!`! . .A.. `.`.".".:.".:.:.`.:.`.:.......:.:.....:.:...:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.~:.:.:.: 7 Raising Safety and Health Consciousness among Farmers and Farmworkers By Ellen G. Widess, J.D. 17 Building Coalitions for Preventing Injury and Disease in Agriculture By Thomas M. Dean, M.D. 22 Disseminating Safety and Health Information through Education By J. Michael McGinnis, M.D. 28 Encouraging Action in Preventing Injury and Disease in Agriculture By Louis W. Sullivan, M.D. 30 Surgeon General Conferences: A Model for the Future By Antonia C. Novello, M.D. Surgeon General's Conference on Agricultural Safety and Health - 1991 xxxi Table of Contents LOOKING AHEAD TO THE NEXT CENTURY Moderator: J. Donald Miliar, M.D. . :i::::i::::::::::::::::::::::::::Yf:::::::::::::::::::~::::~::~~:::~:~~~::::::::::::~~~::::::::::~::::::::::.~:.:.:.:.:~.~:.:.:.:.: . . ..A . . . . . . ..A. .,.,....,.... ~ . . .A... . . . . . . A. ..A. ..A .., . . . ..A.. ..,.A,.....,....., . . . . ..y...................... ~ .,... ~ ,.,..,., ~..~~~,~~~~:~~~~~~~~~~~~~~~~~~~~ A. , .f . . . . . . . . . A......%. ..A <.,A.,.. .,.A_,..,. %.A., ..,.. ..>:...>: . . . . . . . . . . . :,a ,*.,.. .,.,. .A..,.... y . . . . T . . . . . . . . . . . . .,A. w . . . . . .,, . . . . *.. . . . . . . . ..y......., . . . . ,....P. a.. A.. ,A.. A.. 35 Remarks by the Chair of the Conference By J. Donald Millar, M.D. 36 Healthy People 2000 and Agriculture By Senator Tom Harkin 43 Building Infrastructures for Prevention By William L. Roper, M.D. 48 Charge to the Conference By Antonia C. Novel/o, M.D. QUESTIONS TO GUIDE THE NATIONAL AGENDA Moderator: Mark Timm ::::::::::::j::::::::::::::::::::::::::::::::::::::~::::::::::::::::::::::::::::::::::::::::::::::~:::.:.:.:.:.:.:.:.:.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . \.,.....,.....,...,., . . . . . .._...........i . . . . . . . i... .,:,:.~:.:.:.:.:.:.:.:.:~:.:.~~:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.~:~.:.:.:.:.:.:.:.:.:~:.:.:.:.:.:.:.:.:.:.~~~:.:.:.:~.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:.:~.~,:::::::::::~::::::::::::~:::~~:::::::~:::::~::::::::~::::::::::~::::~:::::~:::~~:::::::::~~ :,~,~,:.:,:.~,,.,.,,,.,.~,~.,,,~ ~ . . . . . . . . 55 Remarks by the National FFA President By Mark Timm 59 The Role of Public Policy in Agricultural Safety and Health By Joseph A. Kinney, M.P.A. 67 Surveillance for Agricultural Safety and Health By William E. Halperin, M.D. 73 Research for Agricultural Safety and Health l3y James A. Merchant, M.D. 86 Intervention for Agricultural Safety and Health By Myron D. Johnsrud, Ph.D. MEDICAL INTERVENTION PROBLEMS AND OPPORTUNITIES :::::::::::::::::.:.: ..l........_......i `;;;:`:`: ..__...._,,,,.,.,.,,,,,....,,,.,,,,,.,.,..,...................................................................... . . . . . . . . . . . . . . . . . . . . . . . . . . . ,: :.:,:. ~ .:.:.:.:.I:.:.):.:.:.:,:,:,:,:, 93 Rural Health Policy By Jeffrey Human, M.A. 97 Medical Intervention Problems and Opportunities in Rural Areas By Governor Robert D. Ray ISSUES THAT AFFECT THE NATIONAL AGENDA Moderator: Ronald D. Eckoff, M.D. IO5 Introductory Remarks By Ronald D. Eckoff, M.D. 107 The Agricultural Workforce By Leslie A. Whitener, Ph.D. 123 Attitudes and Risk Behavior in Agriculture By Pamela D. E/kind, Ph.D. 129 Industrial Crops of the Future By Daniel E. Kugler, Ph.D. 134 Biotechnology and Agriculture By Jane Rissler, Ph.D. xxxii Surgeon General's Conference on Agricultural Safety and Health - 1991 Table of Contents PROPOSALS FOR A NATIONAL AGENDA ::~.::::::::::::::::::::::::::::~~::~~~.~::~~~~~:::::::~::::::::::~:::~::::~.:::::~::::~~:~~::::::~~:~~.:.:.:.~:.:~.~~~. . . . . . . . . . . . . ..A . . . . . .., ..A qv.., . . .p . . . .A,.,. Y. ., . . . .~..~~~~~:~~...~,...:...~:.:.:..:,n:...:...:.:.:.:~.:.:.:...:,.:.:.:.. A. (.A. I(.,. . . . . . . . . ..A.. . . ,. ,.,A ,. . . .~ . . . . ,. . . . ., A., A... . . . . . ,. . ,..A A.,.. . . . . . <.> . . . . ..A............ . ..,. . ,. ,. h,.,,., ,, ..,,. ..,, . : :j....< ..A :A:(...; .,A. A. . . . . ,.y<.):(A:.:.:.:.:.:.:+:.:<.:.:+>:+:.:. .Q.. . . . . . . . ,. .......v....,.. .., . A . . . . 1. Surveillance - Agriculture-Related Diseases, Injuries, and Hazards Moderator: Henry A. Anderson, M.D. Rapporteur: Robert F. Herrick, Ph.D. . . . . . . . . . . _, ,, _, .._...,.,.(.(,.(/...,._.,.,.,.,.,...,.,.,.,,,.,.,.,.,...,...............,.,.,.....,.,.............. . . . . . . . . . . . . . . _.........,..., . . . . . . . . . . . . . . . . . . . . . . . . ,............ .,.a . . . . . . . . . . . n., _.........,.. . . . . . . . ,........., ._/ ,.........,...,._ . . . . . . . . . . . .._...... .,.,... ,.,.,.,...........,._ .,.,... ..,...,.,........._.... . . . ..,._/........., .,. ,l..,.,.i_........ ,.,........., . . . . . . . . . . . . . . . . . . . . . .._.... . . . . . . . . . . . . . . . ..i... ..A., .,.. 143 Surveillance: A Physician's Viewpoint l3y John J. May, M.D. 151 Chemical Hazards By Linda Rosenstock, M.D. 157 Respiratory Diseases By James A. Dosman, M.D. 161 Surveillance of Injuries in Agriculture Sy Susan G. Gerberich, Ph.D., et. al. 179 Musculoskeletal Disorders and Hazards By John J. Coumbis, M.D. 184 A Government Perspective I By Todd M. Frazier, Sc.M. 189 A Government Perspective II By Eugene Freund, Jr., M.D. 192 A Consumers' Perspective f3y Craig Merrilees, B.A. 199 An Agricultural Safety Perspective By Dennis J. Murphy, Ph.D. 2. Research - Chemical and Biological Hazards Moderator: Kelley J. Donham, D.V. M. Rapporteur: Stephen A. Olenchock, Ph.D. . . . . . . . . . . . . ..,...,.,.....,.,...,.......... . . . . . . . . . . . . . . . . . . . . . ,.... . . . . . . . . . ,.............,.,.... ..,.....,....... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .._............................................................................................................................ . . . . . . . . . . . .._.... . . . . . . . ../...............................................,.,...............,.,...............,.,...........,...........,.,.. /. . . . . . . . . . . . . . . . ...\... 204 Airborne Dusts By Susanna Von Essen, M.D. 216 Infectious Diseases By Russell W. Currier, D.V.M. 229 An Overview of Potential Health Hazards among Farmers from Use of Pesticides By Aaron Blair, Ph.D. 243 Gases, Liquids, Vapors, and Drugs By William Popendorf, Ph.D. 255 The Migrant Workers' Perspective By E. Roberta Ryder, B.A. 261 A Foundation's Perspective By Gene F. Graham, M.S. 267 A Clinical Perspective f3y Dean T. Stueland, M.D. Surgeon General's Conference on Agricultural Safety and Health - 1991 xmlll Table of Contents 3. Research - Mechanical and Physical Hazards Moderator: Lorann Stallones, Ph.D. ..,.,., ..,...,.......,.....,...................,.........,.................. _.... .,....... . . . . . . . . . .,. . . . . . . . . . . . ,.......... 5. . . . . . . . . . . . . . . . . . i... .,._.,.C,C.,..I.,. ..,., ,A.. i...., .,. ,.,.i....... V..,. ,...i... . . . . . ..i.. ..i...., . . . . . . . . . . . . . . . . . . . . . . . Rapporteur: John R. Myers, M.S.F. . . . . . . . . . ..v.. . . . . . . . . . . . . .../... . . . . . . . . . . . . . . . . . . . . . . . . . . . . _...... ..,.. .,.,... ..,~/.~,..........~....,~,~.~,.,~..,....~,..~.~,..~,~,.,~,.,....~..,..~,~,~.....~.~.~.......~,........., . . .._ .,.,. . . . . . . . . . . . . . . . . . .. 274 Farm Machinery and Vehicles By Thomas L. Bean, Ph.D. 278 Musculoskeletal Hazards By David Cochran, Ph.D. 285 Electrical Power By Robert L. McLymore, M.S. 293 Noise and Stress By Matthew Marvel, M.D. 2% Technology Transfer By Murray Madsen, P.E. 308 The Manufacturers' Perspective By John H. Crowley, M.B.A. 317 A Forestry Perspective By Penn A. Peters, P. E. 321 A Regulatory Perspective By Thomas H. Seymour, P.E. 4. Intervention - Agricultural Workers' Protection from Hazards Moderator: David S. Pratt M.D. Rapporteur: John E. Parker, M.D. ..i... . . . /.....,.......,.,../.....,.......,...........,.........,...,.......,...,...............,.......... . . . . . . . . I.. .,./,.......,.,.i,.,.......,.,...,.,.............,~,.,.,...........,.,.,.,.,.............,.,.,.,.,.,.,.....,.,.,.,.,.,.,.,...,.,.,.,.,.,.,...,.,.,.,.,...,...,.,.,.....,.,...,.............,.... . . . ..,....._.. ..,.....,.,.,.,.,... ,. 327 Farming Methods and Systems Analysis By Gary Erisman, Ph.D. 334 Ergonomics By Stephan Konz, Ph.D. 340 Personal Protective Equipment By Richard A. Fenske, Ph.D. 351 Machine Design By Sverker Hogliind, M.D. 357 Vector Control f3y Robert R. finger, Ph.D. 365 A Consulting Engineer's Perspective By Ray H. Crammond, P.E. 372 An Extension Specialist's Perspective By Rot/in D. Schnieder, M.S. 378 An Agricultural Engineering Perspective By L. Dale Baker, P.E. XXXiV Surgeon General's Conference on Agricultural Safety and Health - 1991 Table of Contents 5. Intervention - Safe Behaviors among Adults and Children Moderator: Walter J. Armbruster, Ph.D. Rapporteur: David L. Hard, Ph.D. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..,., ..v,.,...,. . . . . . . . ..v............ 383 Health Education 391 Vocational Agriculture 397 The Mass Media and Agriculture 405 Multilingual Training 412 County Health Education 419 A Rural Sociologist's Perspective 432 Young Farmers' Perspective 437 Farm Family Behavior Perspective f3y Rodney Gilmore, B.S., B.A. f3y Robert Graham, M.S. By Cheryl Tevis, M.A. By Malanie Zavala, B.S. By Larry Belmont, M.P.H. l3y Judith Bortner Heffernan, M.A. By Wayne Sprick By Robert Aherin, Ph.D. ELEMENTS OF A NATIONAL AGENDA Moderator: Richard A. Lemen, Ph.D. ::::::.:`:`":`:."`:`:`:`:`:`:`:`:':':':.::~:?.::::::::::::::::::::::~.::~::::::~:~:::::;~.~:;::::::::::::::::~:~.~:::::::::~~:~:.:.~:.:.:.:.:.: . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .\., . . . . . . . . . . . . . . ..`...`..."............................,~.~.,.,~,~.~,~. x.7 .`,;,..):.:,) :.,.f,,,,;,,,.,.i~.~.;r,.,. 2: ,:.:.: ,:.,., . . . . . . .,...,.,.. I .,...,./... . ,A., . . . . . ., A .,.. .A.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . A. ,A.. A., :.>z>:.:.: .):,:.:, :,:.~.~>>:~,:~: :,:, > :.:.r,,,.,.,,,.,.~vi~,, . . . . . . 0. n . . . . . . ,.. A.. A.. A.. . . .,., . . . . . . . 445 Surveillance - Agriculture-Related Diseases, Injuries, and Hazards By Henry A. Anderson, M.D. 448 Research - Chemical and Biological Hazards By Keliey J. Donham, D.V. M. 453 Research - Physical and Mechanical Hazards By Lorann Stallones, Ph.D. 457 Intervention - Agricultural Workers' Protection from Hazards By David S. Pratt, M.D. 462 Intervention - Safe Behaviors among Adults and Children By Walter J. Armbruster, Ph.D. 466 Report on Migrant and Seasonal Farmworkers By Valerie A. Wilk, M.S. surgeon General's Conference on Agricultural Safety and Health - 1991 Table of Contents 471 Outstanding FFA Poster By Rice C. Leach, M.D. 472 OSHA Initiatives in Agricultural Safety and Health 479 Sustainable Agriculture and Safety 485 The Farm Bureau's Continuing Commitment By Cynthia Douglass By Willis R. Eken By Merlin Plagge 489 A Victim's Perspective of the Conference By Marilyn Adams 492 Conference Summary By Rice C. Leach, M.D. MAKING CONNECTIONS Coordinator: Katherine Wilson, M.P.H. . . msPM?mY . . . . *p.#.$$..#$# 498 Poster Abstracts Co-coordinator: Ann M. Cronin 582 FFA Poster Abstracts 597 Video Presenters 620 International Participants 625 Metric System of Weights and Measures 627 The Surgeon General's Conferences on Occupational Health By Anne Mather 629 Excerpts from Diseases of Workers By Bernardino Ramazzini . . ,.,.....,.,...,....., . . . . ..~........,...,.,. ,.,.(,.,., ..,., .,.,.,.,. ..,.. .,.,.,. ,.,.. /v..,.,... ,.,., . . . ..A . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ..~.. . . . .., ,A.,... ii, c. CA.,. 637 INDEX Surgeon General's Conference on Agricultural Safety and Health - 1991 Surgeon General's Conference on Agricultural Safety and Health F~.&AFF 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa WELCOME FROM THE CHAIR OF THE CONFERENCE By J. Donald Millar, M.D. Director, National Institute for Occupational Safety and Health Assistant Surgeon General of the United States Public Health Service I am very delighted and proud to welcome you to this Surgeon General's Conference on Agricultural Safety and Health. The nickname is "FarmSafe 2000," and the theme is "a national coalition for local action." Now all of this is by way of saying that everybody here is interested in preventing the unnecessary wastage of life, limb, and health that is associated with the oldest and noblest occupation-agriculture. Be- yond that common interest, we are a very diverse group. I would wager that some of you never heard, for instance, of NIOSH, the National Institute for Occupational Safety and Health, before this meeting. That is not unexpected, because most of the pro- fessional life of NIOSH has been devoted to the problems of smokestack indus- tries-manufacturing, mining, and other occupations-but that is very rapidly chang- ing in this rapidly changing world of ours. We were created by the Occupational Safety and Health Act of 1970, which sought to "assure safe and healthful work- ing conditions for every working man and woman," So we are obliged at this point in our national history to turn our attention to all problems that create unsafe and unhealthful working conditions for men and women. That Act created two organizations you may have heard of OSHA and NIOSH; both are quite different organizations; both are in different parts of the Federal Gov- ernment, and you will hear from leaders of both during this week. OSHA is located in the Department of Labor and has responsibility, among other things,-for promulgating and enforcing occupational standards. NIOSH is in the Public Health Service, the Department of Health and Human Services, and is expected to exercise scien- tific leadership in this field. So we are expected to produce and disseminate scien- tific information that enables the preven- tion of occupational diseases and injuries. Among the things we do best is to convene people, such as at this conference, to bring people together so that they are able to share with each other useful scientific information, which can permit the practice of prevention in every setting where it can be done. So we were very eager when the Surgeon General called on us to sponsor this conference-the first of its kind in agricultural safely and health that has ever been convened.0 Dr. J. Donald Millar: And now it is my distinct pleasure to introduce the convener of this Confer- ence, the Surgeon General of the United States Public Health Service. She is the first woman and the first Puerto Rican to hold the position of Sur- geon General. She is a dynamic and vivacious leader in the war against death and disease. I give you the fourteenth Surgeon General of the United States, Dr. Antonia C. Novello: Surgeon General's Conference on Agricultural Safety and Health - 1991 7 Sugeon Gmml's Confsmnce on Agrkulfuml SaMy and HeaM FARMSAFE2OOO~ANaiionalCmlMn~rLocalAc~n Conwned by the National lnadtuh kr Occupational Sahty and lkmUh April 30 - h&y 3, 19Q1, Des Moines, law8 WELCOME TO DES MOINES, IOWA By John P. Donian Mayor, Cii of Des Moines Dr. Anton& C. Novello: Thank you Dr. Mlllar. Ladles and Gentlemen-l welcome you to the Surgeon General's Conference on Agricultural Safety and Health, the tenth Surgeon General's Conference on Occupational Health, and the first one in 50 years. The last one was convened in 1941, but I will speak further on that history later. I would now like to introduce Mr. Dorrlan, the mayor of Des Moines, Iowa. It Is a great pleasure for me to be able to introduce him. He Is a lifelong resident of Des MOin8S, and he has served in the city government since 1983. Fdlowing service as mayor pro tern, he was elected mayor in 1957. We also know that he currently serves as the Executive Dlrector of the Central Iowa Building Trades. Among his many public service activities, he currently ~8~8s on the Governor's Commlttee of Partnership for Economic Progress. Ladles and Gentleman, I would like to welcome Mr. Dorrian: Thank you very much. On behalf of myself and all the other members of the Des Moines City Council, I want to welcome you to the City of Des Moines, and a very spe- cial welcome to Dr. Novello. Thank you for that nice introduction. We are extremely proud of our city, and we hope that if it is your first visit to Des Moines you will be pleasantly surprised. If it has been awhile since you have been to the City of Des Moines, then you have seen some good changes take place. We are the capital city of the State of Iowa, and as the stewards of the capital city, we try to prepare the city well for everyone's visit. We have spent a lot of dollars on the Sky- walk System, for example. The weather is pretty good today, but there are days when people really appreciate that Skywalk Sys- tem. Several miles of it now exist, and it is very expensive to erect, but there is a pur- pose in mind. Sometimes it snows in Iowa, and sometimes it gets extremely warm with a little bit of humidity. So we need our Skywalk System. We have a lot of neat things that we hope 2 you are able to take in while you are here. We even have a horse track running out there; I do not know if any of you are famil- iar with that or not, but for every dollar that is bet out there my property taxes may not go up-if you have it in your heart to support the horse racing. I have not been out there myself much, but we have a lot of other neat things-the botanical center and the zoo, the libraries, the Governor's Mansion and the Capital Building. We just have a lot of attractions. We like to keep all these things going, and that is where you can help, if you would have it in your heart to do so. We hope that you will find a place to spend a dollar or two while you are here in our city. But really, we do hope that you have a good conference. I have to apologize because I have to leave. We do hope that you have a good confer- ence, and again a very special welcome to you to the capital city of Des Moines, Iowa. We are extremely proud to have all of you with us. We do hope that you have a good confer- ence. Enjoy yourself and come back often. Thank you.0 Papers and Proceedings Thank you, Dr. Novello. Before I officially I am pleased to welcome such a broach- welcome you on behalf of Governor based group of individuals to this confer- Branstad to Iowa, I want to acknowledge ence. Represented here today are individ- the work that Dr. J. Donald Millar, who uals from 40 states and several foreign opened this conference and is the Assistant countries, evidence that agricultural safety Surgeon General and Chair of this confer- and health is an issue that is not only na- ence, put into organizing this great event. tional but international in scope. Your On behalf of the people of Iowa, we thank attendance here demonstrates your com- you for bringing this conference here. mitment to agricultural safety and health. Mayor Dorrian has already welcomed you to Des Moines. On behalf of Governor Terry Branstad and the Iowa Department of Public Health, I want to welcome you to Iowa and to the Surgeon General's Conference on Agricultural Safety and Health. We, of course, believe it is quite ap- propriate for this conference to be held in Iowa, a leading agricultural state. Each year Iowa farmers produce more than $9 billion in crops and livestock. Twenty-five percent of America's pork and eight per- cent of the nation's grain-fed beef are raised in Iowa. Among the states, Iowa ranks second in the value of agricultural exports, and in 1988, Iowa ranked first in the nation in the production of red meat. Though everyone here today may know that agriculture is one of the most hazar- dous occupations there is, according to the Year 2000 Health Status Objectives, farmworkers suffered 14 injuries per 100,000 during the years 1983 through 1987. The national goal would be 6 in all occupations. So, you can see agricultural injuries are high even in the statistics that we know. The health objectives further state that agricultural worker deaths may be under- estimated because many farm work forces have fewer than 11 workers and are, there- fore, not identified by national data sys- tems. The National Safety Council has estimated a rate as high as 52.1 deaths per 100,000 agricultural workers. Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 o A National Coalition rbr Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa WELCOME TO IOWA By Christopher G. Atchison Director, Iowa Department of Public Health Dr. Antonia C. Novello: Governor Branstad was unable to attend the conference today. So, I would like to introduce Christopher G. Atchison, the Assistant Director of the Illinois Department of Public Health, who is here to speak in his behalf. Mr. Atchison has served as the Assistant Director of the Illinois Department of Health since 1987. As Assistant Director, he has been responsible for program development, legislative action and executive implementation of agency programs. He has also served as a chair of the Governor's Interagency AIDS Task Force and was involved in the establish- ment of the Center for Rural Health. In addition, as a member of the Illinois Public Health Association, he recently worked on a task force to restructure public health in Illinois according to the future of public health reported by the Institute of Medicine. Mr. Atchison has just been appointed as director of the Iowa Department of Public Health and his welcome to us today marks his maiden speech to this state. Please welcome Mr. Atchison: Surgeon General's Conference on Agricultural Safety and Health - 1991 3 Opening Remarks Until now, the hazards have been under- counted and largely ignored and under- funded, but that is changing as we can see when we look at the stated purposes of this conference-to raise consciousness, build coalitions, disseminate information, and encourage action to prevent injury and disease related to agriculture-certainly all very worthwhile goals. Nationally, we are beginning to develop surveillance systems that document the kinds of injuries that are occurring and where they are occurring--efforts that are just beginning to develop interventions and strategies, which will help prevent those injuries and fatalities. In Iowa, we recently finished the first year of a surveillance program to collect infor- mation about agricultural injuries and fatalities, the Sentinel Project Researching Agricultural Injury Notification Systems, which we simplified to called SPRAINS. SPRAINS is the only statewide surveil- lance program currently in existence, and we have been astounded by some of the figures we have gathered. We know that there are currently about 116,000 full- and part-time agricultural workers in the state; and there were over 2,000 injuries and over 83 fatalities record- ed in 1990. Eleven of these fatalities were children under the age of 15. Of the total fatalities, 51 percent were in the less-than- 20-year-old age group and the over-65 age group. In any other occupation, these people would not be working. However, in agriculture-related occupations, workers span the ages from childhood to the senior years; and apparently young workers and seniors are most vulnerable to fatal inju- ries. We must note, because farming has tradi- tionally been a family business, that it is not just the professional farmer, it is the farm family that is at risk for injury. Our statistics show that 70 percent of all inju- ries are suffered by farm family mem- bers-spouses, children, grandpas and grandmas helping out. The major causes or vectors of injury fall into three groups. Number one is machin- ery. Number two is animal-related. Num- ber three is falls and slips. Where do the injuries occur? Everywhere from the barn to the pasture. At least in Iowa, no clear pattern has emerged. Iowa is developing interventions and strat- egies by building broadbased collaborative efforts. Among the organizations involved in these collaborative ventures are State government, academia, farm organizations, and community-based organizations. The Governor has appointed a task force to look at our health and safety objectives for the year 2000. The purpose of this task force is to adopt objectives and measures that will guide the planning and allocation of resources throughout the decade, result- ing in: 1. Increasing the span of life in Iowa. 2. Reducing health disparities among Iowans. 3. Achieving access to prevention services for all Iowans by the year 2000. Recently I had the pleasure of meeting with Dr. Richard Remington, who chaired the Institute of Medicine's commission on the future of public health, and the Governor has appointed him the chair of our Year 2000 effort. Dr. Remington and 4 Papers and Proceedings Welcome to Iowa, April 30, 1991 I hope to build this planning process into the development of programs and projects across all agencies and communities, which are involved in the public health system in Iowa. We must note, because farming has tradi- tionally been a family business, that it is not just the professional farmer, it is the farm family that is at risk for injury. I Another major collaborative effort, the Iowa Center for Agricultural Safety and Health, ICASH, brings together key orga- nizations concerned with agricultural health and safety. ICASH is a partnership of the University of Iowa, Iowa State University, the Iowa Department of Public Health, and the Iowa Department of Agriculture and Land Stewardship. Its mission is to coordinate the state's resourc- es and to establish programs to improve the health and safety of farm families, farm workers, and the agricultural commu- nity. Some exciting projects ICASH has under- taken include the following: 1. The expansion of the Iowa Agricultural Health and Safety Service Project to a statewide network of hospitals. This project provides comprehensive occupa- tional health and safety services. 2. The development of an illness and inju- ry prevention program for livestock confinement operators. 3. A health and safety program for school classrooms and rural youth groups. 4. Sponsorship of a community-based project to increase awareness of farm machinery hazards. 5. The dissemination of information col- lected by the statewide agricultural injury surveillance program. Another collaborative effort is Work Safe Iowa. Work Safe Iowa has established an occupational medicine and associate pro- gram at the University of Iowa with the goal of promoting occupational safety and health through education and consultation. The program was designed to assist com- munity hospitals in implementing and strengthening their occupational medicine clinics and related outreach services. In addition, the community hospitals serve as a vehicle to integrate Work Safe Iowa services into local communities. The Iowa Center for Rural Health and its advisory committee represent another collaborative effort. The Center for Rural Health, located within the Office of Health Planning at the Iowa Department of Public Health, acts as a focal point for the state's efforts in preserving quality health care in Iowa's rural areas. The Center and its broadbased advisory committee strive to identify health needs, build rural coalitions, provide technical assistance to rural areas, administer grants for rural projects, and act as an advocate and information re- source with respect to rural health issues. The Occupational Health and Safety Nurs- es Program at the Iowa Department of Public Health is the tie between the state and the communities. This program builds on existing rural health programs and links the Health Department to rural health areas. Surgeon General's Conference on Agricultural Safety and Health - 1991 Opening Remarks Yet another community-based program is the Farm Family Risk Assessment and Education Program that is targeted at farm youth. It includes a farm family "safety- walkabout" training program where farni- lies learn to recognize existing farm haz- ards and receive assistance in changing the farm workplace into a safe environment. Finally, we know that if all prevention interventions have failed, we must turn to Emergency Medical Services (EMS). In Iowa, EMS is a community-based program, and 75 percent of the medical providers are volunteers. Medical treatment begins at the scene of an injury or illness and can make the criti- cal difference between life and death. EMS has become an even more critical issue to rural Iowa over the last decade, as our population has aged and access to health care has become a pressing concern. In the movie &Zd of Dreams, Iowa was memorialized when someone asked the hero, "Is this heaven?" and the hero re- sponds, "No, this is Iowa." You and I know that Iowa is not heaven; it is close, but it is not heaven, as our agricultural injury and fatality numbers certainly prove. That is why we must work toward making Iowa and the nation a safe and healthy place to live and work. Remember, even in the movie Field of Dreams, an injury to a farm family member was almost a tragedy. Helping prevent those injuries is our goal and our challenge at this conference. Once again, on behalf of Governor Branstad and the people of Iowa, welcome to Des Moines and to this conference and to this opportunity to move preventable injury programming out of the big cities and into rural America.0 Papers and Proceedings Surgeon General's Conference on Agricultural Sathty and Health FARM&FE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1997, Des Moines, Iowa RAISING SAFE7Y AND HEALTH CONSCIOUSNESS AMONG FARMERS AND FARM WORKERS By Ellen G. Wiakw, J.D. Director of Health and Safety Policy, Children's Advocacy Institute Center for Public Interest Law Dr. Antonia C. Novello: Now, we know that in 1990 this conference was authorized .by Congress with four purposes, which Mr. Atchison mentioned. The first topic is going to be addressed by Professor Ellen Widess, and she will speak to us on the first topic, which is raising consciousness. Professor Widess brings a breadth of experience to our conference that ranges from managing pesticide regulatory programs to protecting the safety and health of children. Professor Widess received a law degree from the University of California at Berkeley in 1974. Ms. Widess then served on the faculty post until 1978, when she became Chief of the California State Pesticide Regulatory Program within the Division of Occupational Health. From 1984 to 1986, she managed the Workers' Compensation Program for the University of California at Berkeley and later, from 1986 to 1988, managed a similar program for the Texas Department of Agriculture. Also, while in Texas, from 1986 to 1988, Professor , Widess directed the pesticide regulatory program for the Department of Agriculture. Last year, she was an adjunct professor of the University of Texas School of Law where she taught, with specific emphasis, on Toxic Torts and Occupational Health. Ellen Widess has come to us today from the Children's Advocacy Institute in San Francisco, where she is Director of Health and Safety Policy. She will speak at this moment on the topic, Raising Safety and Health Consciousness Among Farmers and Farm Workers. Professor Widess: I am very, very pleased to be here. When I was first asked to speak in the place of our new Secretary of Labor, Lynn Martin, I thought it was my fantasy come true. After working for the OSHA Program, I long had a fantasy of wanting to be the Secretary of Labor. Particularly after toiling, as Dr. Novello has indicated to you, for many years in these various lives trying to address the problems of farmers and farm workers' safety and health, I thought this would be a fabulous chance to clear up the jurisdic- tional confusion many of us have noted and to determine who protects agricultural workers, who should regulate pesticides and with what standards, and who, in fact, has responsibility for farm safety. That fantasy lasted only a few moments. Then I came to my senses. It dawned on me that were I really the Secretary of Labor, I would have to deliver. I might, in fact, make a few friends, but no doubt I would make more than an enemy or two and be saddled with all the con- straints of government. As one who has been a regulator for many years, I am delighted to come today to this conference as an advocate, openly advocating, for the interests of children, who are our future generation. I am reminded by the line from my old boss, Jim Hightower, former Agricultural Commissioner of Texas, "Ain't nothing in the middle of the road but dotted lines and dead armadillos." I hope today to be a little bit provocative, because I think it is time we got out of the middle of the road. This conference is an extremely hopeful Surgeon General's Conference on Agricultural Safety and Health - 1991 The Potential for a National Coalition beginning of a more promising future in this much-needed work. As Dr. Novello has indicated, I have had a checkered life. I would like to give you some perspective from my work, both in and out of regulatory life. I have worked for OSHA in one life and then for an agricultural department, retreating at vari- ous periods to academia-scarred from the regulatory battles-to come back and take stock of what have we accomplished in this regulatory arena. What were our successes? What are more viable options ? What have been the vari- ous creative solutions that we have de- vised? CONSCIOUSNESS-RAISING AMONG FARMERS AND FARM WORKERS I had the dubious honor of attempting to regulate pesticides in Texas, which is to most sane people pretty much a mission impossible. This is to try to somehow meet the needs of farmers while also pro- tecting workers, consumers, and the envi- ronment. That is a very tough bill. I think we took a number of very creative approaches to that mission, including pass- ing the nation's only right-to-know law. Though this law was billed as the "farmworker right-to-know law," it clearly provided critical information about pesti- cides and their health effects to thousands of farmers and farm families in Texas. The children often were applying pesti- cides where groundwater (and drinking water supply) came from contaminated well waters. They were affected by drift just as farm workers were. During those years, we also sought to change consciousness, not only among workers, but among the public who de- manded blemish-free produce. We devel- oped a model organic farming program, which would not only reorient farmers to reduce their chemical inputs, but also change consumer consciousness and pro- vide farmers with the technical assistance they needed and the economic assistance. I think that is one of the messages that I want to convey today. .We have to deal not only with the health and safety data we have-we have plenty of data-but we also have to deal in terms of raising conscious- ness among the populations of both farm- ers and farm workers. We have to realize that we deal with certain economic imper- atives, some realities in agriculture. Unless we also deal with those economic realities of their lives and their limited choices, we will fail in our efforts to im- prove health and safety. We have learned this in the industrial world, and we should apply that lesson as well in the agricultural world. Unless we also deal with those economic realities of their lives and their limited choices, we will fail in our efforts to im- prove health and safety. I Also, in my time in Texas, we focused (unusual for an agricultural department), on building and supporting a rural health program. As we sought to protect farm workers, we realized that we had to deal more basically with the overriding needs of all rural Texans: farmers, farm families, farm workers and their families, and their overriding, haunting lack of rural medical care in Texas. 8 Papers and Proceedings It leads the nation tith the highest rate of the rich San Joaquin agricultural valley. hospital closings, no OB-GYNs in most State epidemiologists were unable to corre- rural counties to deliver babies, dwindling late the cancers with specific pesticide use. emergency room facilities for farm injuries, So in a sense, it was a negative study. and few physicians trained in agricultural However, that study uncovered some other medicine or pesticide-poisoning treatment. realities, including the most horrifying So, all our efforts to promote agricultural statistics about malnutrition, lack of immu- safety and health and provide crop sheets nization, and lack of primary health care and good training materials on pesticides for farmworkers and rural poor, conditions would have little chance of success in the that characterize the Third World. We frontiers of rural Texas. tend not to believe these conditions exist in rural America. I was fortunate to work with a national coalition, The National Coalition of To best address how to raise health and Agricultural Safety and Health (NCASH), safety consciousness of farmers and and the National Rural Health farmworkers we must do several things: Association, because in working for worker and farmer protection, we realized that is b First, we have to understand the unique one part of a very looming and serious nature of this work force and the common national rural health problem. grounds and the differences. My thesis is that there is much more that these two We realized that we must deal directly worlds share in common than they differ with the basic needs of farmer, farm work- on. Basically they share powerlessness and ers, and their families and redirect state disenfranchisement in this country, eco- policies to meet these needs. Our efforts nomic and political powerlessness. That is to promote agricultural health and safety reflected in the lack of resources, research, were part of a much larger political and jurisdictional clarity, health and safety economic problem of the powerlessness of standards, training materials, and many farmers and farmworkers in the country. other things that other speakers will ad- dress throughout this conference. Now to my current role with the Children's Advocacy Institute, which provides a voice My thesis is that we need to build on that for children's well-being in California and common ground. If we do not get to the the nation. I see this as a continuum. essential root causes of that powerlessness and turn that around and empower farm- If we are not taking care of our children ers, farm workers, and their communities, and protecting future generations, we are a we will ultimately fail in our efforts to doomed society. And dealing with chil- improve health and safety. I will discuss dren is yet another face of rural poverty, some of the areas in common in a mo- disenfranchisement, and lack of access to ment. basic health care. b Second, I think we need to look at the An example is a recent epidemiological lessons that hopefully we have learned study by the California Department of from the industrial workers' struggle for Health Services of cancer clusters in health and safety and examine what has McFarland, a rural town in the heart of worked and whether that can be translated Raising Safety and Health Consciousness among Farmers and Farm Workers, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 9 The Potential for a National Coalition to the agricultural work force. Obviously, it is a different work force. We do not have workers who work continually in steel mills or petrochemical plants. We have rather independent, entrepre- neurial farmers who are not used to regu- lation as are industrial employers. Howev- er, there is a lot of commonality even in that. I think the key issues there are the collective action that has led to the im- provement of health and safety for indus- trial workers. Just as our conference theme is "a nation- al problem, local solutions," we need to look at what is nationally needed and a national minimum standard. \ Improvements such as the asbestos stan- dard or the cotton dust standard, or the right-to-know law for industrial workers, have not had to be fought out at every shop floor in every factory. There has been some national minimum standard of care, of humanity, of morality. Then, there has been the opportunity on the shop floor for local initiatives for work- ers by unions to do even better. Just as our conference theme is "a national prob- lem, local solutions," we need to look at what is nationally needed and a national minimum standard. We can not expect farmers and farmworkers to be fighting that out for themselves every day. b Finally, we need to seek ways to empow- er and ways that lead to local solutions. We have learned that for industrial work- ers as well. People have to have a stake in their own health and safety. Solutions 70 PaDers and Proceedinas have to fit local needs and use local talents and resources. In agricultural, even more than industrial workforces, a uniform national standard or prescription simply will not work. It will not work for the populations we are deal- ing with and the problems they face. WORKABLE SOLUTIONS I also want to encourage that we look for simple solutions and be very realistic about what has worked and what has not. A good example is in the area of farmworker protection. There is a tendency to talk and move to- ward increasingly more sophisticated per- sonal protective equipment for farm- workers to enable them to enter treated fields. We already know a lot about prob- lems in using this equipment. These are problems such as heat stress, availability of protective equipment, maintenance of it, worker attitudes, and the general impossi- bility of having that scheme work. We also have seen another example of the development of the field sanitation stan- dard, which took about 17 years to pro- vide, something as basic as toilets and water in the field. When you see that it has taken 17 years to get toilets in the fields and then you imagine the most com- plicated and sophisticated personal protec- tive equipment and worrying about the nightmare of enforcement, you really have to think: Is that the way we ought to be going? Is there not another solution? Can we not instead look for another way to farm, a way to use less toxic substances that may not require those regulation. Farmworkers, on the other kinds of protective measures that are hand, are obviously a lot less educated difficult to enforce and use? about those risks. They frequently have even fewer economic options and great There, too, we have a lot of issues in com- fear of exercising their right to protection mon. We have the real cost to farmers, on the job. farmworkers, and their families for cheap food in this country. Those costs are mea- Those may be the differences, but should sured in the mangled bodies and in the they divide the two populations? I think statistics that we have heard and will hear. that there is much more that they share in They are measured in the acute poison- common. Both farmers and farmworkers ings, which are grossly under-reported form the hidden, invisible work force of because workers are afraid of being de- America. ported or retaliated against, or have no idea of their rights. Agriculture has steadily become the most dangerous. occupation. It comprises less Moreover, we have no uniform national than 3 percent of the work force, yet has data base for reporting those illnesses and over 14 percent of work-related deaths. injuries. We have chronic risks that are There is a staggering lifetime risk of occu- yet to be measured, which are incalculable, pational death for farmworkers; the nonfa- whose long-term social costs, if we were to tal injuries are equally depressing. do a fair cost benefit analysis, would out- weigh the benefits of using some of the Yet there is depressing news, even with most toxic pesticides. non-reporting, of the degree of injury among farmworkers. We have in a 1987 In any case, there is the basis of a common Federal Government report, over 280,000 fight, and allies, and alliances. Even uriho- handicapped migrant and seasonal ly one alliances, unimagined strange bed- farmworkers and 60,000 handicapped de- fellows might come together on some of pendents, with one-third of those estimated these issues. to be work-related. Let me elaborate a bit more on the issue Children comprise a large percent of those of the unique agricultural work force. We injuries attributed to both farmers and are told constantly that agriculture is dif- farmworkers. And as Chris Atchison has ferent from the industrial work force and mentioned, an equally disturbing factor of obviously that is true. There are, in fact, the ill-health is the high injury rate suf- real differences that are cultural, racial, fered by our elderly. No, there is no re- and often those of class between farmers tirement in agriculture. No one can look and farmworkers. forward to early retirement. Farmers, based on the farm studies that It apparently is true that you cannot even have been conducted in Iowa and New look forward to a childhood in agriculture. York, indicate high concern about health Children are truly the invisible workers. In and safety and even fairly sophisticated my new incarnation, I am going to work understanding about those risks. There is hard on that because I think there is a also a serious and healthy antipathy for sense, not only among farmworkers and Raising Safety and Health Consciousness among Farmers and Farm Workers, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 77 The Potential for a National Coalition farmers but in the morality of this country, that we can not visit these same tragedies on our children. Even if we, as adults, are willing to take those risks or have no other options, we can not do this to our children. We want a better life for our future gener- ations. It certainly is true that both farmworkers and farmers want better lives, but both have few options. Child labor is not a matter of choice; it is a question of eco- nomic necessity both for farmworkers and farm families. Marilyn Adams, who will be speaking later, eloquently captured this in a recent video, Danger, ChiZdren at Risk, which highlighted child labor in several different sectors including children of farmworkers and farmers. She said: You would never hire a 10 or 12 year-old to work on your farm, but you let your own child work because you have to. You can not afford to hire one. Many farmworkers are also driven by eco- nomic necessity, the piece-rate system that characterizes much of corporate agricul- ture in America. There are children in the fields working side-by-side with their par- ents. Though the health and safety stan- dards do not adequately protect children, they work in the fields to help families make a living. On the farmer's side, we know that agricul- ture is the most dangerous work. Again, economic realities make choices very diffi- cult. Take for example, ROPS (roll-over protective structures) protection. Most farmers know the dangers and would will- ingly retrofit their tractors, but there is economic reality. Farmers have to choose between continu- ing survival and retrofitting or paying the mortgage on the farm. Taking the little bit of money that is left over these days in the struggling farm economy to pay for safety equipment to protect themselves and their children is a difficult choice. The point is that hazards do not recognize the lines between farmers and farmworkers. The safety and health haz- ards cross over those lines. A good exam- ple of that is the issue of parathion and whether it should continue to be used. The EPA has indicated that it may finally act to discontinue parathion's use. This is not a mystery pesticide. There is a well-developed body of literature on para- thion as the most documented cause of worker death and the cause of a very high percentage of children's deaths in children six and under. Despite the known risks, we have continued to use parathion for over 25 years. Yet the hazards are not only visited on farmworkers and their chil- dren, but also on farmers and surrounding communities. In California, a recent study demonstrated that parathion was deposited by fog in the San Joaquin Valley. It drifted significant distances away from the original site of application; affected other farmers' crops; and contaminated the soil, the drinking water, and other rural communities. The point is that parathion is not just a hazard that affects farmworkers, but is also a hazard to farmers and their families. Finally, in terms of this work force that faces such political and economic powerlessness, we face a problem of our trying to turn this around and raise con- sciousness, Either we have people who are unaware of the risks, and we have to edu- 12 Papers and Proceedings cate them, or they know them but are er to act on that information, on that absolutely unable to do anything about knowledge. For industrial workers, the them because of economic reality. fight for health and safety is best when there is collective, unified action. Again, we look at industrial workers' fights for safety and health and we see a stark Generally it comes from unionized work contrast. Farming is unlike industry, where forces that have some economic power, are the costs of safety and health are eventual- not afraid, and have independent means to ly borne by the industry and factored into have their own health and safety profes- the cost of production. sionals advocate for others beyond them- selves. That collective force for industrial We have not chosen, in this country, to workers has been the key ingredient of factor safety and health into the costs of political and economic power to push gov- preparing our food. The costs, essentially, ernment and industry. Not that this has are borne by farmers, farmworkers, and been an easy fight, we have many exam- their families. ples where workers have had to be the "canaries." Further, we have farmers and farmworkers who are fairly remote and isolated, spread What about the fight for knowledge? That out all over the country. They may be may worry some of you, and maybe it migrants or they may be non-citizens. All should because the fight for knowledge in all, we have no basis for real political and the raising of consciousness definitely constituency or clout. Neither farmers nor means increasing demands. One option farmworkers are validated citizens. might be more regulation. I think we need Though they feed the nation, they are to look very carefully at what will work, is generally left out hungry. needed, and is most effective. LESSONS LEARNED The lesson that we have Iearned from occupational safety and health in the in- Now let us look at the lessons that we dustrial world is that often the most effec- have learned from our history of fighting tive safety and health programs do not for occupational safety and health in indus- require or depend on complete regulation. try- We maybe do not need police officers everywhere in every work force. Given As I mentioned, the first lesson to apply to this economic climate, we simply do not the agricultural work force is that we have have the governmental resources, nor will to give people a stake in improving their we ever. We have to come up with some- own safety and health. The first critical thing that is effective and relevant. step is to give people information because information is obviously the basis for What I am suggesting in terms of raising awareness, for consciousness. health and safety consciousness is to give people the information and tools to allow But even more important, information such them to make their own decisions and to as crop sheets, safety information sheets, allow them to come up with their own pamphlets, videos, training programs, etc., solutions. In industry that has meant sell- will not do without giving people the pow- ing certain minimum standards-for exam- Raising Safety and Health Consciousness among Farmers and Farm Workers, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 13 The Potential for a National Coalition ple, machine guarding or carcinogen stan- dards. Many workers have been able to bargain or even more than that to affect bottom line. In agriculture that means setting of some minimum safety and health standards that could then allow the dissemination of in- formation to unleash local wisdom, re- sources, and initiatives. These kinds of alliances might come up with new ideas-for example, re-examining our pesti- cide policy, our agricultural policy, or our attitudes and policies about child labor. I am excited about the new OSHA initia- tive and the direction it is taking in terms of giving people more information and consultation, which is the first step. The next step is the power to act on it. A TALE OF TWO CITIES I would like to close with a tale of two cit- ies-two different cases that I would like to present, which have to do with the mean- ing and success of empowerment. The first case involves a pesticide poison- ing of a large crew in the Salinas Valley of California in 1978. Now this was not a case of the small farm that, I think, is de- scribed most commonly in this conference. This was a fairly typical corporate agricul- tural operation that is common in Califor- nia and in other states. This is a different and very important agricultural model, because no one is ultimately responsible for worker protection. In this case, there was an absentee land- owner, a farm manager, a marketing coop- erative who hired an irrigator, a pesticide applicator, and finally, a crew leader to bring in labor. No one talked to each other, No one had any idea how the whole thing fit together. As a result, a large crew of workers, in- cluding a matriarch, her father of 70, her two children under 12, a sister in her first trimester of pregnancy, and a host of other workers, entered a field that had been sprayed only 6 hours before with two of the most toxic pesticides, Phosdrin and Phosphamidon. There is a legal reentry of 48 hours. These workers were in the fields, by mis- take, through no one's conscious endanger- ment or recklessness. An inevitable mis- take happened because of the nature of that kind of agriculture. What happened. 3 The workers became severely poisoned, but no one knew the signs and symptoms of pesticide poisoning. Even the crew leader was sick, but kept on working. Because the workers were de- pendent on what they could make per bushel of cauliflower, they kept on work- ing. This happened even though one worker was unconscious, others were vom- iting, and many were severely sick. The aftermath of this case is important in terms of a lesson that we can learn about raising health and safety consciousness among workers. The workers were severe- ly poisoned and the recovery was much longer than anyone expected. The pesti- cide poisoning taught us a lesson, again by workers being "canaries," of the effects of organophosphate poisoning and the slow regeneration of cholinesterase. The children working in the fields had most severe and persistent symptoms, and even a year later were describing symp- toms of sweating and nightmares from their exposures. 14 Papers and Proceedings One of the most important things that train workers about the health risks and saved these workers and made a real dif- ference was that the workers were protect- how to protect themselves, empowerment, ed and kept out of further re-exposure to and economic power in order to use that pesticides. In this case, there was immedi- knowledge-giving them the chance, for ate assistance by rural legal assistance example, to be out on workers' compensa- tion in order to recover. people who taught the workers about their rights, who taught and empowered them to take advantage of programs that are avail- One regulatory change that shifted the able to all other workers. These are pro- balance was the posting of fields. There grams such as workers' compensation and was a realization that you can not always unemployment insurance. depend on perfect knowledge. In this case, even the crew leader did not know the These rights, incidentally, are not granted fields had been sprayed and everyone to all farmworkers in all states, but were walked in equally ignorant. Mistakes hap- extended in California. That made the pen. difference. Those workers did not have to go back to work immediately, which would Eleven years later, another large crew of have exacerbated their health effects. 80 workers similarly walked into a field long before the legal reentry period. They The medical care has to be characterized had never been trained in pesticide poison- as some of the finest in this country. The ing and were not fortunate enough to have immediacy of care, knowledge about pesti- fields posted. cide poisoning and tracking of the workers was impeccable. While a fortunate occur- Ironically the applicator, in this case, was a rence for those workers, this is, unfortu- relative of the farm manager; he himself was affected. The farmer also bore anoth- nately, not a common one. er serious loss, because his crops could not And finally, the workers who were poi- be sold. Unwilling to take the risk of soned in this episode were trained about having crops with over-residues, all of that the effects of pesticide poisoning. The produce was withdrawn, next time they were in a field that had been sprayed and they began to experience So, there were losses, serious medical, the symptoms of organic phosphate poison- personal losses for the farm workers in terms of their health. Economic losses ing-pin-point pupils, nausea, dizziness, and so forth-they left the fields. were suffered by those farm workers be- cause they too were working piece-rate. They realized what was happening to them When they had to stop because they were and could stop it. They did not need an poisoned, they lost their day's work. OSHA or an agriculture inspector on the fields. They were their own protectors. The Tampa Register reported on a woman who said she kept on working although she Other lessons that we learned from that knew it was dangerous because she had case, that are important to translate more bills to pay. That was simply a fact of life. generically, were the obvious importance She refused incidently to give her full of good rural health care, the necessity to name for fear of losing her job. This is, Surgeon General's Conference on Agricultural Safety and Health - 1991 75 Raising Safety and Health Consciousness among Farmers and Farm Workers, April 30, 1991 The Potential for a National Coalition again, an economic reality of the life of farm workers. The lesson is we have 11 years later an inevitable risk, one that could have been predicted-the same pesticide and same lack of training. Most importantly, this farmworker crew had been trained about the signs and symptoms of pesticide poi- soning. Thus they were aware and protect- ed the next time they were forced to reen- ter a treated field before the legal reentry interval. That leads me to the lesson that we learned in passing the right-to-know law for farmworkers and farmers. This law was initially fought by farmers who felt it was an unnecessary, burdensome regula- tion that would have a serious economic impact on agriculture with no measurable benefit. Many farmers came to believe the law and training program had benefits for farmers and their families as well. The reality is that both farmworkers and farmers have a right and a need to know about the effects of pesticides. Those hazards are visited in both worlds. We found that by requiring that farmers give workers crop sheets about the various pesticides registered for different crops, we nourished the beginning of an awareness, in farmworkers, about the risks that they had to take. There are choices they have to make for themselves and their families. More surprising and encouraging, it also changed the consciousness of farmers. When they saw a list of pesticides ranging from the most toxic to least toxic pesticides available to be used on a particular crop, farmers realized they had choices. The choices are not only to protect their workers but to protect their families as well. Their families were often applying the pesticides and it was their ground wa- ter. They were uniformly concerned about protection of the water and the protection of future generations. I am still haunted by the images in the video that I have mentioned, Danger: Kids at Risk. It points out very clearly that children, from both farmworker and farm families, are at peril and that we have really denied them a future. It is a huge and, I think, an unacceptable sacrifice that farmers and farmworkers have had to make. One of the speakers in this video ends with a message that is very powerful. We need it if we are to be successful in raising con- sciousness of both these populations. It is a message told by a teacher who works with migrant children, but it applies equal- ly to children of farm families. It is this: You must tell the children, You are important. You are American citizens and entitled to something impor- tant. We must fight for the future of our chil- dren; otherwise we will fail as parents, as communities, and as a society. I also listened to the "Farmers' Hotline," which was developed by the Texas Depart- ment of Agriculture to help farmers and their families on the brink of suicide, de- pressed about economic conditions beyond their control. It is time that we stopped blaming the victims, farmers and farmworkers, and stopped allowing them to blame themselves. We must provide them the means to protect themselves.0 76 Papers and Proceedings Thank you. It certainly is an honor to be invited to speak to this distinguished group. However, when I was asked to address the group regarding coalitions, I wondered if I was really the one. That is not, certainly, my area of expertise. I am a country doctor who has been in a small town in South Dakota for about 13 years. I am not a political organizer or an expert in conflict resolution and certainly not an expert in any of the various techni- cal aspects of agricultural safety. On the other hand, I do know something about agricultural injuries. I grew up on a farm and as I was looking back on some of these experiences, I recalled at least four times when I personally survived potential- ly fatal agricultural injuries. Certainly it brings home the significance of this issue. I remember the time when, as a teenager, we were cutting silage, and I was driving down the road with a fully-loaded silage wagon, as fast as the old "M" Farmhall Surgeon General's Confenmce on AQtkultum/ Sahty and Health F~WSAFE 2000 o A National Coalition fir Looal Action Convened by the National lnsdtuta for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa BUILDING COALITIONS FOR PREVENTING INJURY AND DISEASE IN AGRICULTURE By Thomas Dean, M.D. President, National Rural Health Association Dr. Antonia C. Novello: Our next speaker is going to be Dr. Thomas Dean, and he has distinguished himself in the field of rural health. He served in the U.S. Public Health Service as part of the National Health Service Corps, from 1975 to 1983, and he received a commendation medal. Dr. Dean's years with the Public Health Service were served as staff physician and later as a medical director of the Frontier Medical Services in Hyden, Kentucky. In 1978, he returned to his home state of South Dakota in Wessington Springs, to serve as medical director at Tri County Health Care. He has remained there as medical director since leaving the public health service. He is active in many professional activities in South Dakota, and he is on the Executive Committee, since 1987, of the National Rural Health Association. He currently serves as its president. Let me introduce Dr. Thomas Dean, to describe the second purpose of this conference, Bui@g Coalitions For Preventing lnjuty and Decease in Agriculture. Dr. Dean: would go. The tractor began to drift to the right, and I turned to the left. The tractor continued to go to the right and pretty soon we were off the road and ended up crossways in the ditch; I hit the embankment so hard that it broke the front end out from underneath the tractor. A pin had fallen out of the steering col- umn, and how I avoided rolling over, I have no idea. I remember another time when we were going to a local horse show, and we had to go out in the pasture to catch one of the horses. My dad and I went out and caught the horse, and I was walking home leading the horse when all of a sudden something spooked this young colt. He took off and, without me being totally aware of what was going on, pulled the coil of rope tight around my hand. Pretty soon I was down on my face sailing through the grass behind this horse. For- tunately it rained that morning and so it was not too bad until the horse decided to Surgeon General's Conference on Agricultural Safety and Health - 1991 17 The Potential for a National Coalition go between the fence and a tree; the two were only about 18 inches apart. For reasons that I do not completely under- stand, just before the horse pulled me between the fence and the tree he stopped. At that point my father caught up, and things were okay. It really does, I think, bring home the fact that these are real issues. I do not believe I was particularly wild, and I do not think our farm was any more dangerous than the average one. I suspect anyone who has grown up in an environment like that probably could re- late similar sorts of experiences. So, as I look back, trying to think what I could contribute to this group, I would hope that maybe I can bring some per- spective, some understanding of farmers and farm communities, some firsthand experience as I have just mentioned about the importance of the issue. Finally, I think I can offer some experiences with a coalition that has experienced some suc- cess, namely the National Rural Health Association (NRHA), which truly is a coalition of some very disparate organiza- tions and interests. I think the success that our association has had can be attributed in large part to the fact that it is a coalition. Certainly all of the people that we represent have their own professional organizations who are able to speak and, in many ways, active in speaking for their interests. But NRHA has enjoyed a considerable amount of success simply because we were able to bring together a group of people with very diverse backgrounds and interests and focus on a single issue. That, in turn, has given credibility to the arguments and the efforts that I think have really paid off and have helped to produce some movement for the betterment of health services in rural areas. Recently we have become affiliated with the National Coalition for Agricultural Safety and Health, NCASH, which several speakers have already mentioned. I would mention just a brief commercial. There is a brochure, a little flyer, that will be out at the front desk, which describes NCASH and also tomorrow evening, at 6:00 in the Council Bluffs Room, there will be a reception for anyone interested in closer involvement with the National Coalition for Agricultural Safety and Health. If any of you are interested in getting more information, Gary Kukulka from the NRHA staff is here, as well as David Pratt and Kelley Donham, who have both been very involved in this effort. They can certainly give you further details about the activities of NCASH. But, to get back to the issue of coalition building, the question is, Why is it that we are focused on coalitions? What is it about the problems that we are facing today, which brings us in this direction? I certainly believe that it is a well-placed emphasis, and I believe it is well-placed because of the nature of the barriers that we face. Certainly our barriers are not lack of knowledge. We, no doubt, can use more knowledge, but we have a great deal of information about the problems we face. It is not lack of skills. We have a great many skilled, dedicated people who have been concerned about these issues for some time. These skills can be improved, but that is not the barri- er that blocks us. 18 Papers and Proceedings Even resources or lack of resources is not the major barrier. We can always use 4. Certainly by far the most important more resources but we have substantial issue in any effective coalition is that we resources, if we can mobilize them. I think have effective and energetic leadership. our biggest problem is the coordination, That is why we are here today. direction and implementation of the things that we already know. We certainly face a tremendous diversity of challenges and a tremendous variety of It is not what to do. Our question is really different problems, but if we are going to how to do it. That is how the issue and make progress, we really need to have the the significance of coalitions evolved. leadership to bring about a vision of where we want to get to. I think an analogy is The dictionary defines a coalition as: the process of assembling a jigsaw puzzle. We have all the pieces, but unless we can a temporary alliance of factions for some come up with a vision, the big picture that specific purpose. is on the front of the box, it is not likely that we are going to be very effective at I think that clearly is the goal that we are pulling together our activities. trying to accomplish. I do not know that it needs to be temporary, but we certainly That is what this conference is designed to need to bring together the disparate fac- focus on and certainly the main thing that tions that are involved in these issues. we hope will come out of it. I believe the Surgeon General and her staff at NIOSH deserve tremendous credit and our thanks Examining what brings about an effective coalition, I think there are at least four for putting this process in motion. characteristics and probably others: In trying to understand this situation a 1. There needs to be a unifying issue. little more, I would like to spend a couple Clearly we have that. I think the fact of minutes looking at a somewhat analo- that this size of group would come to- gous situation that NRHA has been in- gether testifies to the fact that this is a volved in over the last several years. Dur- ing that time, in our concern about main- powerful issue. taining health services in rural communi- 2. We need a desire to bring about change ties, it has become increasingly apparent that the preservation of rural health servic- and, with that, a willingness to compro- mise on some of our own personal es and the development of the communi- agendas in order to accomplish a larger ties in which they exist go hand in hand. goal. Certainly if the community is not coordi- nated and working, the health services will 3. We need to have some appreciation or not be coordinated and working. some feeling that, in fact, action and One of the things that has come out of this change are possible. Coalitions do not hang together in stalemates, but if we realization is several projects around the have the sense that real change and country that focus on improving health improvement can come about, coalitions services through community organization. can be extremely effective. The one that I would like to quote from is referred to as the Community Health Ser- Building Coalitions for Preventing Injury and Disease in Agriculture, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 19 The Potential for a National Coalition vices Development model, which was a project funded by the Kellogg Foundation, and currently active in the State of Washington. The goal was to help communities whose health services were deteriorating by focus- ing on and organizing the strengths of the community itself. They went into commu- nities where, in many cases, the health services were falling apart, and they have come out with a number of fairly striking successes, at least on the preliminary eval- uation. The particular report that I am going to cite now was published as a working paper from the WAMI Rural Research Pro- ject-their working paper #ll. Anyway, in reviewing their successes, they looked at six elements, which were predictors of suc- cess. 1. Clearly, the quality of local leadership. 2. The breadth of involvement of local stakeholders. Certainly ownership of this issue and local involvement are critical if we are going to have any kind of effective response. 3. Community commitment. Their conclu- sion was that in many cases a situation of helplessness and a culture of depen- dence had evolved, which really effec- tively neutralized any response to efforts and unless that attitude could be over- come, success was very unlikely. 4. Teamwork within the community. 5. Comprehensive, complete and honest identification of problems within the sys tern. 6. Availability of concurrent education in order to provide the necessary skills to respond. I would say that the situation that we face and that will be addressed in this confer- ence is quite analogous to that. Certainly all of those issues are relevant. Apprecia- tion of their existence and their presence will predict the success of any coalitions that we evolve. Self-reliance and self-determination are bedrock values of rural people, but unfor- tunately over time many of these have atrophied as outside problems have led to a sense of frustration and helplessness. We need to convince rural people that this energy can be rekindled, and we have to show them that even in this complex world they have a critical role and that what they do really does make a difference. I would challenge you to go forth in these deliberations with a sense of urgency and with an understanding that every day lives are lost because families are being devas- tated and futures are being ruined be- cause of our failure in the past to build these coalitions. As we focus on the development of coali- tions, I would say that we really need to look in two different directions. b We need to build the coalitions within the professional community. We have a diverse group of professionals that are involved in these concerns-the safety pro- fessionals, public health professionals, and the medical community. 20 Papers and Proceedings Building Coalitions for Preventing Injury and Disease in Agriculture, April 30, 1991 We have to put our professional egos aside and certainly, speaking as a physician, I know that there are many professional egos involved. My profession clearly has more than its share. b Second, and probably more importantly, we need to build the bridges between the professional community and the people on the farms. They need to understand that there is real concern and that there is help available and that what they have to con- tribute is important. I would certainly echo the concerns that we must not depend on regulation. If there is any group that hates regulation more than doctors, it is farmers; and abso- lutely the quickest way to wreck any pro- gram, or at least to reduce cooperation among the participants, would be to pro- vide increased regulation. In final analysis, I would say that the effec- tiveness of anything we do will be deter- mined by our own honest desire to im- prove the lot of the people that we are dealing with. It will depend extensively on our ability to put aside our own egos and professional pride to be sure that we can work together and move toward the im- provement that we are seeking. Coalition building is not just the best way, it really is the only way. I would challenge you to go forth in these deliberations with a sense of urgency and with an understand- ing that every day lives are lost because families are being devastated and futures are being ruined because of our failure in the past to build these coalitions.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 27 Thank you very much, Dr. Novello. I would like to begin by commending Sur- geon General Novello for her leadership in sponsoring this conference. She has often said that she must be the Surgeon General of all the people, and has certainly fol- lowed that up by addressing issues that are important to all Americans, and especially to those Americans who have been disad- vantaged. I think that this Surgeon General's Conference on Agricultural Safety and Health is indicative of that leadership and both Surgeon General Novello and Assistant Surgeon General Millar deserve our thanks in that regard. I would like to thank you for inviting me to join you at this very important confer- ence. Farming remains one of the most hazardous occupations in our nation. The annual death rate for farmworkers in America is five times as high as the com- Surgeon General's Conference on Agricultural Safety and Health FARA.&WE 2000 . A National Coalition for Local Action Convened by the National Institute for Occupational Safety end Health April 30 - May 3, 7991, Des Moines, Iowa DISSEMINATING SAFEW AND HEALTH INFORMATION THROUGH EDUCATION By J. Michael McGinnk, M.D. Deputy Assistant Secretary for Health Director, Office of Disease Prevention and Health Promotion Assistant Surgeon General Dr. Antonia C. Novello: Now I would like to introduce Dr. J. Michael McGinnis. I am very pleased that he is going to address this conference. Dr. McGinnis serves as Deputy Assistant Secretary for Health, and holds the rank of Assistant Surgeon General. He has served as the Director of the Office of Disease Prevention and Health Promotion since 1977. Dr. McGinnis is a Fellow of the American College of Epidemiology and the American College of Preventive Medicine, and has held faculty appointments at Duke University and George Washington University. His contributions include the initiation and development of Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention, Healthy People 2000: National Health Promotion and Disease Prevention Objectives, and the Dietary Guidelines fqr Americans, which was jointly issued by the U.S. Department of Health and Human Services and the US. Department of Agricul- ture. In addition, he has collaborated with the National Institute for Occupational Safety and Health in the mid-1980s on the project, The Future of Work and Health. In 1988, he also developed The Surgeon General's Report on Nutrition and Health. It is with great honor that I introduce Dr. McGinnis to speak on the third purpose of this conference, Disseminating Safety and Health information Through Education. Dr. McGinnis: bined death rate for all other workers. Every day nearly 500 agricultural workers in America suffer disabling injuries, and almost half of these injuries result in per- manent impairment. Since these troubling statistics are affected by a number of factors, the health and safety of agricultural workers is especially vulnerable. One of the major problems stems from the decentralized nature of the workforce. Because farmers live in rural areas and have traditionally worked independently, their health and safety needs have not been adequately addressed. Furthermore, because many farm work forces have fewer than 11 workers, they are not identified by national data systems and their burden of suffering therefore may be underestimated. 22 Papers and Proceedings A second factor is the issue of economic In my comments today, I would like to disincentives. Because there is no simple echo many of the themes that were raised way to spread the economic risk as large by Ms. Widess and Dr. Dean by illustrating corporations or other industries can do, the some examples of how those themes can costs of implementing many safety mea- play out by virtue of successes from other sures are passed directly on to farmers. public health sectors in which public edu- cation and behavior change have proved to The final factor involves those health prob- be a very important tools. I would like to lems that adversely affect agricultural share with you examples of the impact of workers. Though trauma is the most behavioral factors on a number of our prominent health problem for leading health problems. farmworkers, respiratory diseases, other sequelae of pesticide toxicity, certain can- Several years ago, the Carter Center of cers, dermatitis, noise-related hearing loss, Emory University, in collaboration with the and stress-related mental disorders are all Centers for Disease Control, undertook a problems that agricultural workers must project called CZosing the Gap, which ex- face. Though these health problems are amined the burden of a variety of the extremely diverse in the way they affect leading killers in our society. It found that individual farmers and their families, they behavioral factors played a significant role do have a major commonality. in 55 percent of heart disease deaths, 60 percent of cancer deaths, and 70 percent of motor vehicle deaths. Fortunately, because the prominent role of behavior in health threats is not novel In fact, across all causes of death, and in or unique, some of the lessons that can be comparison to genetic factors, environmen- gleaned from other public health areas tal factors, and factors related to the lack may be germane to the kinds of approach- of access to appropriate treatment facili- es that we seek to establish for agricultur- ties, behavior contributed to almost al health and safety. one-half of all premature deaths from all causes in our society. The leading causes are by now well known to all of us, as a result of the work of Surgeon General Behavior plays a prominent role in both Novello and her predecessors. the onset and the management of many occupational injuries and diseases. There- Of the 2.1 million deaths each year in our fore, motivating behavior change must be a society, tobacco accounts for approximately part of any approach to the solutions that 400,000 deaths each year. The impact of we seek. Fortunately, because the promi- factors related to the imbalance between nent role of behavior in health threats is diet and activity accounts for another not novel or unique, some of the lessons 300,000 to 400,000 deaths. that can be gleaned from other public health areas may be germane to the kinds Alcohol contributes to 100,000 deaths each of approaches that we seek to establish for year, including 20,000 deaths related to agricultural health and safety. alcohol's impact on motor vehicle opera- tion. It is clear by these numbers that behavioral choices have an enormous im- Disseminating Safety and Health Information through Education, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 23 The Potential for a National Coalition pact on our society's health profile, includ- ing the health profile of agricultural work- ers in our country. The good news is that we have made a great deal of progress in the past several decades. Tobacco use among males, for example, has declined from 54 percent in 1964 (at the time the first Surgeon General's report on tobacco and health was released) down to approximately 30 percent today, almost half of what it was when the campaign against tobacco was initiated. The changes with respect to diet are less dramatic. Though the average percentage of calories for dietary fat intake is still as high as 36 percent, there has been a dra- matic shift away from saturated fat con- sumption, resulting in risk reduction for heart disease. Finally, we have also seen progress in the area of alcohol. Cirrhosis rates are down, and alcohol-related motor vehicle fatali- ties have declined. There is greater aware- ness of the problems related to alcohol, and I suspect that the awareness will accel- erate as a result of the special focus and attention that Surgeon General Novello has drawn to that issue. These kinds of changes are not serendipi- tous; they are the result of specific and targeted campaigns. Some of these cam- paigns have been local in nature and very carefully controlled. I would like to share with you two important examples of com- munity mobilization to reduce behavioral risks, which improved the health prospects of those communities. Both examples were carefully controlled studies offering a scientific approach, and both focused on cardiovascular disease prevention through targeting multiple risks simultaneously. These kinds of multiple risk factor interventions can also be ap- plied to improving the health of our agri- cultural workers. The Stanford Five-City Project addressed coronary heart disease risks, such as smok- ing, dietary habits, and blood pressure control. The campaign used a comprehen- sive mass media intervention strate- gy-television, radio, and newspapers-in combination with direct education provid- ed in classes, community-level contests, and school-based programs. As a result, reduction in coronary heart disease risk in the experimental cities was nearly 20 per- cent greater than the secular trends of the control cities. The other example, the North Karelia Study in Finland, used environmental change (i.e., by increasing the availability of low-fat foods and designing non-smok- ing areas) in addition to mass media and direct education. As a result, the overall coronary heart disease mortality in the target populations was reduced by almost 25 percent. In addition to these carefully controlled experiments of a community wide nature, there have been some large-scale national campaigns that have had a tremendous impact on the entire nation. The Surgeon General's campaign against tobacco, initi- ated by Terry Luther, SG, in 1964, is per- haps the most prominent example of a suc- cessful national campaign. Other examples include the initiation of the National High Blood Pressure Educ- ation Program in 1972 and the initiation in the early 1980s of the National Cholesterol Education Program, both by our National Heart, Lung, and Blood 24 Papers and Proceedings Institute. Programs growing out of grass- roots efforts have also .had a tremendous impact on behavioral change. For example, Mothers Against Drunk Driving (MADD) has provided important impetus in efforts to reduce the terrible tragedy of alcohol-related automobile What have we learned from these efforts that might be useful to the dissemination of agricultural health and safety informa- tion? First and foremost, we have learned that the dissemination of information alone is not enough. Knowledge is power, but education alone will not accomplish the task. fatalities among our young people. Conse- quently, we have seen some real gains in overcoming the problems related to motor In order to succeed, we need to change the vehicles and alcohol. entire environment, including the physical environment as well as the social environ- ment. The social environment contributes Indeed, all of these efforts mobilized every aspect of community life-schools, commu- to shaping people's perspectives and there- fore their risks. nity organizations, voluntary organizations, professional societies, and worksites-in a We heard from Ms. Widess about the coalition to address those problems. As Don Millar would point out, occupationally importance of the regulatory processes in insuring that we have provided a safe envi- based programs have also contributed substantially to making the major inroads ronment for farmworkers with respect to pesticide use. We heard from Dr. Dean that we have seen against high blood pres- sure and tobacco smoking, as well as alco- about the importance of safety standards as well as public education efforts. Each hol. of these are critical to success, and each was used in the successful public education As a result, coronary heart disease mor- tality has declined by about 40 percent in campaigns launched to reduce cardiovascu- lar risk. For example, non-smoking areas the last 15 years, stroke mortality has declined by 55 percent, and auto fatality mandated through clean air laws passed at the local level have given tremendous rates among children have declined by 22 impetus to our gains against tobacco. percent in the last ten years alone. These are striking examples of success stories: The provision of lower-fat food changes, success of public education efforts, with their roots at the community level. Due to not a regulatory measure, but a very im- these accomplishments, overall childhood portant environmentally oriented initiative on the part of industry, has helped people and adult mortality rates have decreased. Specifically in 1980, the Surgeon General targeted a 20 percent reduction in child- to make changes that are important to their daily lives. The engineering and availability of better auto passenger re- hood mortality and a 25 percent reduction straints has allowed the improvements that in adult mortality to be accomplished over we have seen with respect to use of seat the decade of the 1980's, by 1990. Both of belts, in particular for our children, and these goals have been met, and done so has allowed the consequent improvements largely through public education efforts. in mortality in that regard. It is clear that the approach must be bal- anced between health protection on the Disseminating Safety and Health Information through Education, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 25 The Potential for a National Coalition one hand and health promotion on the other. It is crucial to remember, however, that health promotion can make a tremen- dous difference. I would like to spend my last few minutes, therefore, talking about health promotion. The health promotion sciences are not tremendously well-developed, but we do know that prior to behavior change, there must be changes in knowledge, in attitudes, and in beliefs. For changes in knowledge and in attitudes to occur, we need messag- es that are credible, that are reinforced from a variety of perspectives, and that are sustained over time. In other words, we need to know the facts, we need to build coalitions, and we need to stay with it. Credibility of a campaign comes from improving data sources, from deepening the analysis of those data, and from involv- ing leadership, such as your involvement with the Surgeon General in this public health effort on improving agricultural safety and health. I would like to give special emphasis to the issue of data sources, because they are so vital to insuring that the messages that we give are credible. We heard from Mr. Atchison earlier of the discrepancies that exist in our current data sources. When we know that some estimates de- scribe 14 deaths per 100,000 agricultural workers, whereas others indicate that there may be as many as 50 deaths per 100,000 agricultural workers, it is evident that we need to have better data on which to shape our policies and programs. Improv- ing data systems, especially for agricultural workers, needs to be a priority for the future. We also clearly need to recruit allies to help us disseminate the information. We need to involve schools, employers, retail- ers, and the media. We need to involve farm equipment manufacturers and com- munity leaders. The establishment of solid, locally based coalitions is critical to gains in agricultural safety and health, just as they have been critical to the gains that we have seen in other areas of public health in recent decades. Even knowledge, attitudes, and changes therein, while necessary, may not be suffi- cient to accomplish the kinds of gains that we would like to see. People also need to believe that these issues are directly and personally relevant to themselves. The message needs to be brought home. Whether it is brought home to families through children in school settings or whether it is brought home to people through interactions with health providers taking a more careful history of individual risk, it is clear that we need to find ways to make these risks more relevant to the individuals who are at greatest risk. It is no accident that the biggest gains in public health recently have been made in areas where individual risks have been defined in the form of a number (e.g., cholesterol level or a blood pressure read- ing). It should be entirely possible to develop a health hazard appraisal instru- ment that can be used to better character- ize the risk of individual farm settings, and we need to work on new ideas. In summary, know the facts, build coali- tions, stay with it, and bring it home. It is a tested formula. It has worked, and it can work in agricultural safety and health. 26 Papers and Proceedings Disseminating Safety and Health Information through Education, April 30, 1991 HeaZthy People 2000 is a statement of na- tional goals and objectives for the year 2000, and I am delighted, Mr. Atchison, that you have taken this on in a very sub- stantial way here in Iowa. Richard Remington is going to provide tremendous leadership, and we will profit throughout the nation in the kind of model that you will be developing here in Iowa. Healthy People 2000 envisions the year 2000 with nearly a third fewer farm inju- ries and deaths than currently occur, but it also envisions as a means to achieving these goals, greater commitment on the part of our health providers, schools, manufacturers, and states to the problem of agricultural safety and health. It envisions greater national attention to the issue. It envisions a situation in which we can provide an example to the world for improvements in agricultural safety and health, just as we have provided an exam- ple to the global community in improve- ments against cardiovascular disease. I believe that it is a vision that can be at- tained in this Surgeon General's Confer- ence on Agricultural Safety and Health as an important step to forming the coalition that can make it happen.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 27 Surgeon General's Conference on Agricultural Safety and Health FARM&FE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health &xi/ 30 - May 3, 1991, Des Moines, Iowa ENCOURAGING ACTION IN PREVENTING INJURY AND DISEASE IN AGRICULTURE - A Video Message - By Louis W; Sullivan, M.D. Secretary of Health and Human Services Dr. Antonia C. Novello: Dr. Louis Sullivan, our Secretary of Health, was going to come to this meeting, but because of scheduling - you would not believe how many places we have to go when we are in jobs like this, and he has to be in many more than anyone can ever dream of - he could 1 not make it; but, he sent a video message for you all, and I would like to show that for you: Hello, I am Dr. Louis Sullivan, Secretary tenfold can also be a. powerful, tragic of Health and Human Services. Thank threat to health and well-being. you for inviting me to participate in your conference-I regret that my schedule did The seriousness of agricultural injury and not allow me to attend. disease demands national attention. Suc- cessful improvements, however, will be It is fitting to hold this conference in Des rooted solidly in local initiatives. Your Moines, For many years, Iowa has been at theme-"A National Coalition for Local the forefront of efforts to improve agricul- Action"-establishes the ideal framework tural safety. This state has produced many national leaders in rural health. In fact, Former Iowa Governor Robert Ray is currently an advisor to me as chair of the National Advisory Committee on Rural Health. The seriousness of agricultural injury and disease demands national attention. The advances in technology during the past few decades have given today's agricultural workers a tremendous advantage unimagined by the workers of yesteryear. But those advances have come at a price: the technology that increases productivity for addressing the problems of agricultural occupational hazards. Agricultural workers have one of the high- est rates of occupational fatality in the country. Although they represent only two percent of the nation's work force, they rank fourth highest in the number of work- related traumatic fatalities. The risks of agricultural work do not fall equally across all types of work, nor among the workers themselves. For example, loggers have an especially high risk of death with more than 200 deaths per 100,000 workers, a rate nearly 30 times the general private- sector fatality rate. 28 Papers and Proceedings Encouraging Action in Preventing Injury and Disease in Agriculture: A Video Message, April 30, 1991 There is also a clear disparity among pop- ulation groups. Hispanic and black agri- cultural workers face an occupational fatal- ity rating 20 to 30 percent higher than white populations. Other minorities are more than twice as likely to die while working at an agricultural job than in an- other profession. The key to making those strategies ef- fective-the critical, vital factor that will determine our success in lowering the risks of agricultural work-is local initia- tives and efforts. However, the very definition of oc- cupationaZ hazards means that it is possible to reduce many of the risks involved. Our first and strongest attack on occupational hazards should be prevention. Improved working conditions, use of safety devices, and more extensive educational efforts will lower job-related fatalities. It is estimated that tractors are involved in more than three-quarters of agriculture- related deaths, most of which occur as a result of tractor rollovers. Roll bars and other preventive structures can be very effective in limiting death and injury to tractor operators, but often such safety measures are not used. To encourage farmers to use preventive structures, the Marshfield Center, an Health and Human Services (HHS)-funded rural health research center in Marshfield, Wisconsin, has published a guide to give farmers information on where to find roll bars and how to `use them to minimize the risks of injury in rollovers. Efforts to reduce job-related exposure to chemicals should also be more effective. It is estimated that 20,000 people suffer pes- ticide poisoning each year. Often other economical alternatives-such as crop rota- tion and biological pest control-can signifi- cantly reduce the risks of exposure. The key to making those strategies effec- tive-the critical, vital factor that will deter- mine our success in lowering the risks of agricultural work.-is local initiatives and efforts. This conference is already a milestone in developing efforts to save lives and pre- serve health. By thinking nationally and acting locally, we can make agricultural work in America. safer and healthier for everyone.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 29 Surgeon General's Conference on Agricukml Safety and Health FAR&WE 2000 o A National Coalition for Local Action Convened by the National institute for Occupational Safety and Health April 30 - May 3, 7997, Des Moines, lowa SURGEON GENERAL CONFERENCES: A MODEL FOR THE FUTURE By Antonia C. Novello, M.D. Surgeon General of the United States Public Health Service Thank you. As they said in the movie "Field of Dreams," "We have built it, and they have come." I would like to thank Dr. Millar, Mel Myers, and the rest of NIOSH, as well as the people of Iowa for helping organize this event. I am honored to be the first Surgeon General to hold a Con- ference on Occupational Health in 50 years. I imagine the last Conference was probably set up much differently than this one. I am sure it was much more of a "low key" affair, without all the new communications technology that has come along in the last several years. Of course, the last Surgeon General's Conference was not even video- taped, so it is possible that back then the Public Health Corps' Commissioned Offi- cers could probably get away with not wearing their uniforms, since no one would find out! At any rate, it is about time we had anoth- er one of these Conferences. And it is my hope that we do not have to wait another 50 years to have the next one, because I am not real sure what my schedule will look like at that time. The last Conference was held in the year 1941, the same year the United States entered World War II. Fifty years later, 30 we finally have the opportunity to hold another Conference-just after we have ended the Persian Gulf War. However, in between those two wars, another war has raged continuously for those of us in the Public Health Service. The war against disease and injury. WHY THIS CONFERENCE IS IMPORTANT TO ME Ever since I became Surgeon General, it has been written and said many times that I will have a lot of difficulty trying to be like Dr. Koop. That is OK, because I would never be able to grow a beard like him. It is also OK, because it is my desire to set my owlt agenda as Surgeon General. Although Dr. Koop was very successful in redefining the role of Surgeon General by bringing a lot of visib:ility to public health priorities-priorities, which I will continue to pursue-it is my prerogative to establish new priorities as well. Today's Conference on Agricultural Safety and Health marks a perfect occasion for me to do that. In addition to being frequently compared with Dr. Koop, a lot has been made of the fact that I am the first woman and Hispan- ic to hold this position. I can not lie to you-1 am both! However, as a woman and Papers and Proceedings Surgeon General Conferences: A Model for the Future, April 30, 1991 a Hispanic, there are aspects about this conference, which are very important to me. As a woman-as well as a pediatrician-it greatly concerns me that women and chil- dren are so often the victims of farm inju- ries and fatalities. These injuries and fatalities occur because farming is fre- quently a family occupation, where every- one participates. As a woman, I totally agree with the phi- losophy of Marilyn Adams' group Farm Safety for "Just Kids," who say that the one person on a farm who can play the most pivotal role in educating farmers and farm children about the dangers of working on a farm is the woman. She can most easily influence her husband and her chil- dren-either in a nice way, or if necessary, in a not so nice way! In tomorrow's "Charge to the Conference," I will more strongly express my concerns about the dangers to farm children. These are my concerns as a woman. As a Hispanic, I am well aware of the safety and health problems of the migrant work- er, many of whom are also Hispanic: o Out of the 50 States in this country, 48 of them rely heavily on migrant workers for help during he peak harvest seasons. o These workers have very poor access to health care facilities and infant mortali- ty is very high, estimated to be 50 per 1000. o Due to water shortages on many of these desert-area farms, these workers are often forced to drink irrigation water, which may be contaminated with farm chemicals or infectious agents. o Crop dusting planes often swoop down from the sky and spray toxic pesticides onto fields where many of these migrant workers are forced to sleep. Many chemicals are known to cause problems such as sterility and miscarriage. o Finally, injuries and illnesses to these workers are grossly under-reported to safety and health officials, primarily due to: 1. Language ba.rriers. 2. Fear of job--loss. 3. An overall lack of worker education. I 7 As a woman, I totally agree with the philosophy of Marilyn Adams' group Farm Safety for "Just Kids," who say that the one person on a farm who can play the most pivotal role in educating farmers and farm children about the dangers of working on a farm is the woman. We must take more initiative in educating these workers. It is a situation we are continuing to learn more about all the time, as shown by Dr. Sullivan's comments we just heard about Black farm workers and their high risk of tuberculosis. Surgeon General's Conference on Agricultural Safety and Health - 1991 37 The Potential for a National Coalition Therefore, safety and health among mi- grant workers, women, and children are all issues that I care about, not only as your Surgeon General, but as a woman and Hispanic. This is why this Conference is so important. BACKGROUND ON THE SURGEON GENERAL'SCONFERENCEON OCCUPATIONAL HEALTH I will now provide a little history on the Surgeon General's Conference on Occupa- tional Health. This is the 10th Conference in U.S. history. The first conference was held on May 20, 1925 by the Surgeon Gen- eral of that period, Dr. Hugh S. Cumming, who called a Conference to discuss the problem of tetraethyl lead-a deadly occu- pational poison. Attending that first Con- ference were industrialists, chemists, labor representatives, and physicians. Surgeon General Cumming held another Conference in 1926, in which the first cooperative agreement on toxic substances was reached. A third Conference, on the health hazards of radium dial painting, was held in 1928, and six more were held over the course of the next 13 years (Other Conferences dealt with: methanol; carbon tetrachloride and similar volatile chlorinat- ed liquid hydrocarbons; carbon tetrachlo- ride fire extinguishers; aniline oil; carbon disulfide; benzol; occupational cancer; and chronic mercurial poisoning in the hatting industry-better known as the "mad hatter" syndrome). CHARACTERISTICS OF THIS CONFERENCE Dr. Alice Hamilton, the famous industrial hygiene pioneer and the first U.S. physi- cian to devote her career to occupational safety and health, was so encouraged by these Conferences that she wrote: it was to me both surprising and hearten- ing to see men of such widely separated backgrounds and interests... meet in a spirit of reasonableness and genuine de- sire to get at the real *facts and deal prac- tical& with the problem. That is true today, as well. I look around the room and see people from many points on the spectrum of society, and this is why the theme of the Conference is called "A National Coalition for Local Action." Safety and health issues in agriculture must be handled differently than safety and health issues in other occupational fields. Although people involved in the produc- tion of food and fiber are the largest single occupational group in the U.S., they are also a very isolated group. Not only be- cause they live in rural areas far away from the noise and chaos of the urban environ- ment, but also because they are isolated when it comes to prot.ecting themselves. There is no internal voice among the farm community to represent them, and there is no external voice to represent them either. This is something the farm community has in common with the children of the United States; children have no voice among 32 Papers and Proceedings themselves to represent them, and no Three people in particular deserve special external group to speak for them either. recognition for their involvement with NCASH: Mr. Carrol Bolen, with Pioneer Children, like farmers, are isolated. This H-Bred and the Executive Director of the is why I chose to be a pediatrician. Iowa 4-H Foundation, Ms. Lu Jean Cole, the Director for Community Investment for So, it is important that we address the Pioneer H-Bred, and Mr. Tom Urban, problems of the farming community begin- Chairman and President of Pioneer Hi- ning at the local level, although this is a Bred International, Inc. Could Mr. Bolen, national problem. This is certainly a Ms. Cole, and Mr. Urban please stand and unique approach to solving a public health be recognized? problem, and I am hopeful this is only the beginning. CONCLUDING REMARKS Actually, there is a precedent for this Con- In Puerto Rico where I grew up, farming ference. In September 1988, a Conference was the dominant way of life for many was held by a group, which ultimately be- generations-as it was here in America. came NCASH-the National Coalition for Puerto Rico is much different now. A Agricultural Safety and Health. That Con- program known. as "Operation Bootstrap" ference focused on four main objectives: restructured and revitalized the Puerto Rican economy, transforming it from an Summarizing research and health and agricultural economy to a manufacturing safety programs. economy. Integrating the viewpoints of farmers Although farming is no longer the major and farm workers, the private sector, way of life in Puerto Rico, there are still and public institutions. parts of Puerto Rico where farming still exists, just as there are parts of the United Identifying service needs and policy States where fa.rming is still a major indus- issues for the family farm. try. Iowa is certainly one of those places. Communicating the results to legisla- Although the farming population has de- tors, policy makers, federal/State agen- creased over the years*, these are still the cies, farm groups, farm families, and the people who we rely on for our food. The general public. 1989 Bureau of Labor Statistics reports that the injury and illness rate in the agri- That 1988 Conference is how the "National culture, forestry, and fishing industry is Coalition for Local Action" began. With- estimated to be about 11 injuries and ill- out their hard work, it is unlikely we could nesses per 100 full-time workers, making it have ever pulled this event off. the third most hazardous industry in the country. With the number of farms and Surgeon General Conferences: A Model for the Future, April 30, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 33 The Potential for a National Coalition farm workers declining, this high injury and illness rate is particularly alarming because it poses a threat to the backbone of food production in America. The key to success for this "National Coalition for Local Action" we are building here is communication. There are many different representatives involved in this building process: farmers, physicians, chemical company representatives, farm machinery manufacturers, as well as repre- sentatives from government and academic institutions. Naturally, there is going to be a great many philosophical differences between these groups. What we need to do is not dwell negatively on the things we disagree on, and instead focus positively on the things we do agree on, and build from there. Only then, will this local action serve the national purpose. This is our "Field of Dreams." If we build it, they will come.0 *The number of farms in Iowa shrunk from 119,000 in 1980 to 105,000 in 1989 (according to the 1990 Statistical Abstract of the United States). Accordingly, farm employment has also dwindled in the last decade. In 1980, the farm employment population stood at approximately 3.7 million in the U.S. By 1988, that number decreased to 2.9 million. 34 Papers and Proceedings Surgeon General's Conference on Agricultural Satbty and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 7991, Des Moines, Iowa REMARKS BY THE CHAIR OF THE CONFERENCE By J. Donald iWEar, M.D. Director, National Institute for Occupational Safety and Health Assistant Surgeon General The National Institute for Occupational there begins a full 18 pages of names of Safety and Health, part of the Centers for people who have made this conference Disease Control, and I am very, very de- possible. At your leisure look through; as lighted to welcome you again to this you recognize these people during your Surgeon General's Conference for Agricul- time here just say thank you to them per- tural Safety and Health. Is it not a great sonally. There are lots of folks represent- day in Iowa! It is beautiful out there. And ed, from many walks of life; many from just think how fortunate all the farmers of NIOSH, many from outside of NIOSH. It Iowa are that they get to spend the day is to them that we owe the success of this outside today. It is wonderful! conference. I want to thank you again for coming. Is there anybody here from Amesworth or thereabouts? My wife and I drove over and we had a little automobile problem there or about there, and the good folk at the Amesworth Amoco Station were very helpful to us. So I just wanted to say thank you. Any of you from that area drop by and tell them that here is one very grateful Public Health Service officer who appreci- ates their help. It is really good to be here. You know, this is the heartland, not only geographical- ly, but in many ways philosophically, be- cause here amidst the good people in the center of our country who still pursue farming as a primary occupation is the reservoir of many traditional American values-things that have made this country the great nation that it is; all the more reason why we should be here again, the second day of the conference, focusing on how to make their quality of life even bet- ter and more productive. There are two people there whose names you will not see. One is Dr. James Merchant, from the University of Iowa, who has demonstrated great national lead- ership in this field and who, along with Dr. Pratt, came to Atlanta one day and encour- aged this meeting and many other things related to agricultural safety and health. We appreciate that leadership, and we are glad to be responsive to it. The other is one of our speakers this morning, Senator Harkin, who provided legislative encour- agement for us to convene in this session. I would like you to, at this point, look in your program, if you have it, at page 27; So you will want to remember these people with gratitude for having initiated-having helped us all to initiate-this conference. The three speakers that I am pleased to introduce this morning all have roots in traditional agricultural states-people who have a good feel for the land. Whether or not they, themselves, may have ever oper- ated behind a plow or on a tractor or what- ever, each of the,m brings to this a sense of the appreciation of human worth that I think is so important in public health.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 35 Surgeon General's Conference on Agricultural SarXy and Health FARMSWE 2000 o A National Coalition Ibr Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa HEALTHY PEOPLE 2000 AND AGRICULTURE By Tom Harkin U.S. Senator, State of Iowa Dr. J. Donald Miiiar: I would like to introduce Senator Tom Harkin, a senator from the State of Iowa. Last fail, in Iowa City, he and I shared a platform at the annual meeting there for occupational medicine. Senator Harkin's father was a coal miner. His mother was an immigrant from Yugoslavia. He worked his way through school here in Iowa and then served as a pilot in the U.S. Navy from 1962 to 1967. in 1970, he was appointed as a staff assistant to the U.S. House Select Committee on U.S. Involvement in Southeast Asia. in 1972, he received his law degree from Catholic University in Washington, D.C., and was elected a U.S. Congressman from Iowa in 1974. Through the years, he has pursued what I think is a very fascinating practice, and that is a series of workdays on which he works a full day side-by-side with an Iowan. Last fail he worked his 100th such day, and it was on an Iowa farm. He was elected U.S. Senator in 1984 and again, as you know, was re-elected in 1990. On both the House and Senate Agriculture Committees, he has been an outspoken advocate for America's farm families. Since 1989 he has chaired the Senate Appropriations Subcommittee on Labor, Human Services, and Education on which, again, he has advocated improved agricultural safety and health. As his record shows, he has been able to effectively represent citizens from both major parties while becoming known as a man who has the courage of his convictions. I present to you Senator Harkin: Thanks, Dr. Millar, for that generous intro- toward preventing and curing disease with duction. But I am not sure I deserve all great leadership at CDC. You and those that praise. that work for you are making it possible for us to meet the health care challenges It kind of reminds me of what Mark Twain facing this nation. once said. He said, You'll go to heaven for your charity, unless you go somewhere else for your exaggeration. It is good to be home. I am proud to see Iowa host such an important conference. I see a lot of familiar faces out there today. I would like to thank the Centers for Dis- ease Control (CDC) for inviting me to speak here this morning. I am honored to share the stage with such world-class health care leaders, like Dr. Millar, who is fighting for the safety of working people all over America; and Dr. Novello, the Sur- geon General, who tells it like it is and gets the job done. I have been very impressed with your work and your leadership, Dr. Novello. And of course, Dr. Roper, who is leading the fight Well, I will not s'peak to you too long this morning. Here in Iowa, we do not waste time with a lot of words. We say what we mean, and get on with it. I am here today because there is a crisis in rural America: a real crisis. It goes be- yond droughts and low commodity prices, beyond floods and infestation. It strikes at the heart of the American farmer. It is a crisis about how we protect the people who put food in our homes and what we can do to help them. Quite 36 Papers and Proceedings frankly, our farmers are dying. Not just o Why cannot many farmers afford basic here in Iowa, but everywhere, in farms and health care and hospital expenses once fields all over this country. they are sick:? We are here today to say American farm families should not have the second high- est fatality rates in the nation. That 170,000 disabling farm injuries each year is a national tragedy. And that 300 children killed on farms each year is a national disgrace. o And why carmot we prevent it all from happening in the first place? It is not our place to ask why it took so long for this discussion to start. That will not solve anything. Last year in Iowa alone, 83 people died on farms, 16 of them children. Over 2,000 more were injured, including 439 children. Dwelling on the. failed policies of the past will not keep a young child out of a grain elevator today. It will not teach farmers planting beans or corn about the dangers of pesticides. What we learn here this week, what we take back to our towns and hospitals and community centers, may save thousands of lives. You know, it is funny that we call them farmers. Just "farmers." Because they are so much more than that. Sure, they farm. Use what you learn here this week to fight to make our farms safer places. And nev- er stop searching for answers. The stakes are too high to settle for anything less. The work certainly will not end here at this conference. But the discussion must begin here. It is a discussion that needs to start by asking the simple question, WYY? They plant, and seed the harvest; they buy combines, sell crops, fix broken tractors, tend sick animals, and help bring life into the world. They are meteorologists, soil experts, businessmen and women, carpen- ters, mechanics, and laborers. And they perform a hundred separate tasks each day in a hundred different locations. o Why are so many farmers and their children losing their hands, their fing- ers, and their lives performing routine chores every day? o Why are farmers and their kids sick so often, afflicted by acute illness? Farmers are working longer days, with more mechanization, bigger machines, and more complex machines. Bigger farms have collapsed planting seasons. Farmers rush to get everything done. Their win- dows for harvest are smaller. They work harder and faster. Is it any wonder that safety needs to be talked about? o Why do cancer, chronic lung disease, arthritis, and hearing loss cripple so many farm families? There are those that look at this kind of farm work and say: o Why cannot most farmers get a drink of water after a long, hard day without worrying about contamination? We cannot do anything. Our money can be better spent in other places. Studying farm injuries and farm safety is a waste of time. Healthy People 2000 and Agriculture, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 37 Looking Ahead to the Next Century Well, tell that to Richard Zeman. Richard is an Iowa farmer. He lives in Bode, Iowa with his family. He has always lived in Bode. He was born and raised on the same farm that he is on now. One September after- noon 14 years ago, Richard was chopping silage with one of those big choppers that shoots the debris into a wagon behind it. Richard's brother was following in the wagon. Richard was going along, and some weeds got caught in the chopper. He stepped out of his tractor, leaving it still running, circled around front, and stomped down on the weeds to pull them out. But something happened that Richard had not planned. The chopper started to move again. It took the weeds, and caught Richard's pant leg with them. He strug- gled to get free, but the machine pulled him in. By the time his brother pulled him out seven minutes later, Richard's right leg was nearly severed from the knee down. He survived. But here he was, 34 years old, five kids, and forced to wear a fake leg the rest of his life. Let me tell you, it is pretty hard to farm with a false leg. But Richard still farms today. Sure, he moves slower. He cannot play the softball and volleyball he used to, but he gets by okay. That is, as long as the back spasms for which he has had two operations do not cause him too much pain, or his leg stem does not blister too much. Richard says that if there had been some education then, or if he had heard a brief word or two about safety, he would have thought twice. He probably would not have done what he did. And he would have his leg. In fact, he would probably be playing third base for the local softball team. How many Richard Zemans are there out there? I know you are probably thinking, Sure Harkin, we know that happened. But that was a long time ago. Things like that do not happen anymore. Well, sure, and I say let me tell you anoth- er story. Let me tell you about my friend Marilyn Adams. Marilyn is an Iowa farmer. She and her husband, Darrell, have been farming the same land in Earlham for many years. Marilyn's son, Keith, loved the farm. He always helped his dad in the fields and around the barn. Of course, he also loved going to church, and riding his bike, and playing down at the pond. He had a pet frog. And he planned on being a minister, even at age 11. Then one fall afternoon in 1986, Keith went out to help his dad. While his father was out working in the field, Keith worked on the grain wagon closer to the house. After a while, Keith's dad came back with a load of grain. He called Keith's name but got no answer. He looked around and could not find his son a.nywhere. Eventu- ally, something caught his eye. Mr. Adams went closer to the grain wagon to look around. He found his ll-year-old boy suffocated at the bottom of the wagon. To this day, the Adamses do not know how Keith fell in. The grain just sucked him to the bottom, like a whirlpool. 38 Papers and Proceedings Marilyn Adams was distraught, as you might imagine. A year went by, and while still hurt, she realized not enough was being done to promote safety to kids on farms. In October, 1987, she formed Farm Safety for "Just Kids," an education pro- gram to teach kids about farm safety. A month ago, I went on a farm safety tour in Union, Iowa, at the Martin family farm, Reginal and Melody. They have three kids. There was something very special about the tour. Mr. Martin did not show me around. His two boys did-Bryce and Paul, both less than 10 years old. They had both been through the "Just Kids" program and knew all the dangerous places to stay away from. So when people tell me that we cannot do anything to make our farms safer places, I say they are wrong. Too many of my friends have been hurt for us to turn our backs. We can do more, and we must do more, and as long as I am in Washington, that is what I am going to fight for. And you can count on it. I am in kind of a unique position. Three years ago, I took over as chairman of the Senate subcommittee that funds health programs in this country. Until then, there had never been a focus on farm safety. Well, we changed all that. In 1990, we got $11.5 million for the Centers for Disease Control to begin a farm health and safety initiative program. We increased that amount to $19.5 million in the 1991 bill, and we hope to increase it more for next year. Healthy People 2000 and Agriculture, May 1, 1991 I am happy to say that $2.2 million has gone to the University of Iowa, Iowa State University, the Iowa State Department of Health, and to a network of 14 Iowa hospi- tals where they battle against farm disease and disability every day. The farm safety program is made up of three parts. The first part focuses on iden- tifying problems. The second part focuses on research. And the third part focuses on prevention and early intervention. We have seen early intervention work outside our farms and fields in other areas of soci- ety- We know, for instance, that a woman given prenatal care while pregnant is 90 percent likely to have a healthy baby. If we help that poor kid with Head Start, WIG, and school lunch programs, the child is more likely to stay healthy, to stay in school, and to go on to become a productive citizen. That is why Marilyn Adams' program is such a good idea. It reaches kids during that stage when it is so easy for them to learn. So they can recognize health haz- ards and can teach others about them. Early intervention and prevention works in other places, too. Let me tell you about a few projects. At Mercy Hospital here in Des Moines, for instance, we have started a cancer screen- ing project for farmers, so cancer is detect- ed early. Research has found that farmers have higher rates of leukemia, Hodgkin's disease, and lymphoma, as well as cancer of the lip, skin, stomach, prostate, and brain. We know that pesticide toxicity causes many more problems. You will hear a lot about cancer and chronic disease over the next few days. Surgeon General's Conference on Agricultural Safety and Health - 1991 39 Looking Ahead to the Next Century We do not understand all the problems and causes, but we have learned a lot. Through projects like those at Mercy Hos- pital, we can detect cancer early. And through community outreach pro- grams, we can educate farmers to the dan- gers when we discover them-community outreach programs like the Nurses in Ru- ral Hospitals program, another project we started in order to get public health nurses into communities and rural hospitals and Parent-Teacher Association (PTA) meet- ings and everywhere that they will make a difference. These nurses go out and look for injuries in farm communities. They are trained to recognize trends in medical histories, and to educate farm families to different risks. The project just started. Currently, we have these nurses in many states throughout the country. And we will be increasing that amount. We have also got to continue our efforts to provide farmers like Richard Zeman with safety tips, so they think twice before doing certain things. We know that taking shields off equipment can be dangerous, but many farmers do so because they inter- fere with cleaning. We know that it is not safe to go near moving parts on a machine, but many take the risk to save time, or they just miss the danger. We know that kids should not go in a grain bin when the elevator is running. There are dangers on tractors and around other machines. Heck, when I was a kid, I used to ride on the fender of the tractor all the time. We just did not know it was dangerous. Well, it is, and more people need to be reminded that saving time may mean risk- ing lives. Above all, we need to stop peo- ple from thinking that farm injuries are just "part of the job." That is kind of like a traffic cop accepting a. traffic accident as "part of the job," or a construction worker accepting a fall from a tall building as "part of the job." There are things that can and must be done to prevent illness, disease, and dis- ability, and not only on our farms and in our rural communities. Early intervention and prevention must reach into all aspects of American society in every city and town. You know, we spend more than $700 bil- lion on health care in this country-and we are not getting our money's worth. We do not need to spend more on health care. We just need to spend it better. Experts say that over half of that amount is spent on preventable illnesses. Yet, of the more than $700 billion, only a small fraction is spent on prevention. Well, my mother taught me the same thing your mother taught you: an ounce of pre- vention is worth a pound of cure. If that is true, then what is a pound of prevention worth? Everybody is talking about how to patch and fix and mend people, and that is important. But it is also important to talk about how to prevent injury, disease, and disability in the first place. Well, my mother taught me the same thing your mother taught you: an ounce of prevention is worth a pound of cure. I 40 Papers and Proceedings Imagine if Americans took care of their cars like they take care of their bodies. What would you say if I bought a new car, drove it off the lot, never checked the oil, never checked the water, never tuned it up. Just drove. And then, one day the engine seizes, I call the mechanic, he tells me that I need a new engine, so I say, okay, just put one in. You would think I was a little crazy. Fact is, most of us spend more to maintain our cars than we do to maintain our bod- ies. Most people put more effort into watering their lawns to prevent browning than they do into taking care of their health to prevent costly and life-threaten- ing illness later. Any farmer will tell you that you fix the fence before the horse escapes, not after. Earlier this year, I introduced seven bills-called "Prevention First" to focus our attention on prevention and get rid of some of the anomalies in our system. I would like to talk about a few of these anomalies on both sides of life. o MAMMOGRAMS - 1 in 9 will develop breast cancer in their lifetime. - Of those, 1 in 4 will die. - 500 alone will die in Iowa this year. b Anomaly: - Spend $15,000 for mastectomies. - Spend up to $50,000 for chemotherapy. - Too often a woman dies. Healthy People 2000 and Agriculture, May 1, 1991 - But we will not spend $75 for mammograms. I HAD TWO SISTERS DIE. o LOW BIRTHWEIGHT BABIES - Spend $2,000 to care for them; gladly pay it. b Anomaly: - But we will not spend less than $500 for 9 months for prenatal care. . LEAD POISONING - Thought problem was gone b Anomaly: - 28-month old Wisconsin boy died- -calcium depleted. - Will not spend $7 billion to treat prob- lems. o CENTERS FOR DISEASE CONTROL - Need to commit more to research. w Anomaly: - Spent more on military research in last 27 months. On our farms, in our factories, in our schoolyards and boardrooms, we need to make "Prevention First" our motto for health care in the 90's. On our farms, in our factories, in our schoolyards and boardrooms, we need to make "Prevention First" our motto for Surgeon General's Conference on Agricultural Safety and Health - 1991 41 Looking Ahead to the Next Century health care in the 90's. We will not solve every problem in the first year. For some problems, we may never find a solution. But we can save a lot of lives and a lot of money. I am counting on you first, to learn, then to educate. Take what you learn here back to farmers and hospitals in every community. Get the word out. Talk to people. Because when you come down to it, we are the ones that will make a difference. And we will stop this crisis before there are more tragedies on our farms. Above all, let us help protect the most valuable product that comes off our farms: our children. Let us teach them right so their children do not experience any of the problems we see today. There is a lot of work to do. And we have got to start now. I want to see America where farmers do not have to accept injury and illness and disease as "part of the job." As long as I am privileged to work for you in Washington, that is the kind of America I will be fighting for. And you can count on it!0 42 Papers and Proceedings Senator Harkin, I am speaking for myself and all of the Centers for Disease Control (CDC) and especially the National Insti- tute for Occupational Safety and Health (NIOSH) in saying we are honored to be in your home state for this important con- ference. Iowa has already given a great deal towards focusing national attention on the health needs of farmers, farm workers, and their families, and paving a way to attend to these needs. Back in the fall of 1988, Des Moines host- ed what turned out to be the seminal con- ference on this topic, "Agricultural Occupa- tional and Environmental Health: Policy Strategies for the Future." It resulted in the creation of the National Coalition for Agricultural Safety and Health, and a "Report to the Nation," which summarized the findings and recommendations of the conference. An Iowan, Jim Merchant of the coalition, with several of his colleagues, Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute lor Occupational Sat&y and Health April 30 - May 3, 1991, Des Moines, Iowa BUILDING INFRASTRUCTURES FOR PREVENTION By William L. Roper, M.D., M.P.H. Director, Centers for Disease Control Dr. J. Donald Millar: I am sure that nobody will appreciate that kind of attitude more than the next speaker, my boss, Dr. William L. Roper, who is the Director for the Centers for Disease Control, which is the nation's prevention agency. As Director of CDC since 1996, Dr. Roper has shown, again, true national leadership in emphasizing that this country must have prevention in order to deal with many aspects of the health care problem. Dr. Roper served in a variety of positions before coming to CDC in 1990. He received his medical degree from the University of Alabama School of Medicine, in 1974, and subsequently a Master of Public Health from that university in 1981. He completed a residency in pediatrics at the University of Colorado Medical Center in 1977. He has served as a local health officer, a county health officer in Alabama, and also later as assistant state health officer. During that period, he also served in several faculty positions at the University of Alabama. From 1982 to 1983, he was a White House Fellow in the White House Office of Policy Development, with responsibility for health policy. He then served as special assistant to the President for health policy-that is the President of the United States-until 1986, when he served as administrator of the Health Care Financing Administration, the agency that is responsible for Medicare and Medicaid. From 1986 to 1989, Dr. Roper served as Deputy Assistant to the President for all domestic policy and as Director of the White House Office of Policy Development. In the time that he has been Director of CDC, it has been very clear to all of us there that Dr. Roper is a man who is moved by human misery and who seeks always to act decisively to help. I am very happy to present Dr. William Roper: presented this report to my predecessor at CDC and now my boss, Jim Mason, in December of that year. The presentation and report were persua- sive. A CDC work group, headed by Don Millar, was quickly formed and plans for action followed. For the enactment of these plans we have to thank Iowa's Sena- tor Harkin, who provided the political leadership in Washington to fund CDC's plans. So we gratefully recognize Iowa's profound role in bringing us to this point, and on into a better future, which we are here this week t.o help create. As you know, CDC is the nation's preven- tion agency, so with the theme of my pre- sentation today, "Building Infrastructures for Prevention," I would also like to recog- nize another Iowan important to public health, Dr. Richard Remington. He chaired an Institute of Medicine (IOM) Surgeon General's Conference on Agricultural Safety and Health - 1991 43 Looking Ahead to the Next Century committee to study The Future of Public Health. The findings and recommendations of his committee, published in a 1988 IOM re- port under the same title, represent a lucid appraisal of the state of our public health infrastructure and what is needed. I be- lieve it will prove influential for all of us in this field and hopefully it will receive some attention outside the field as well. However, the building of infrastructures has undoubtedly had as great a role as wars in history. The construction of first, railways, and then highways, and the shore- to-shore electrification and communica- tions programs all have had revolutionary, long-term effects. The greatness of this country owes much to these achievements. Likewise, the building of the current public health infrastructure has had profound impact. I define this infrastructure as the system of individuals and institutions that, when working effectively together, promote and protect the health of the people. This infrastructure is made up of people, materials, strategies, and facilities. Among a host of achievements, our public health infrastructure has led to generally sanitary conditions in our cities and towns, progress in cleaning our air and water, the control of a host of communicable diseases, and an overall reduction in smoking. What we are hearing these days, however, is that our progress in public health has to some extent lost its footing and missed a few steps. Having addressed the most public crises of yesteryear, we are finding ourselves challenged by an enormous range of scientifically and socially complicated problems for which public outrage and political will are far from automatic. The public health concerns in agriculture make a case in point. You will be hearing many statistics of injury and disease over the course of this conference. The public health needs of those living and working on farms have been largely neglected. It is not surprising. When the general public thinks of life on the farm, it conjures up a wholesome, perhaps hard but also idyllic picture of self-sufficiency and freedom from urban stressors and pollution. The statistics, from CDC and others, have only recently been collected. The govern- ment policies and media attention are still largely focused on the medical care side of the equation; we are providing incentives for health care practitioners to work in rural areas, and reporting about the finan- cial straits and closings of rural hospitals. There has been little prevention activity or interest. Social factors concerning farm populations and their constituency groups have been equally important. The coalition's 1988 report cited the character of independence among people of farm populations, their sense of responsibility, and consequently a lack of organization or unions to represent farm families and workers. I understand there has been growing concern among farmers about toxins but I suspect injuries have always been, and are still, considered by many to be a condition of the way of life. I would add to this t.he admirable trait of farmers to make the most of what they have, such as old equipment, making it last. Given also the financial rigors, it follows that farm constituency groups have pursued issues of economics and freedom 44 Papers and Proceedings from restrictive regulations, rather than health. In the past, when leaders in public health considered agriculture, they might have reasoned that the EPA is responsible for the safe use of agricultural chemicals and the Agricultural Extension Service has safety responsibility, and not pursued the subject further. -I As the theme of this meeting, "National Coalition for Local Action," clearly por- tends, the foundation of our public health system, as it functions in agricul- ture and other sectors, must be the local public health agency. This brings me back to "building infrastruc- tures." Dr. Remington's IOM committee defined the mission of public health as "fulfilling society's interest in assuring con- ditions in which [all] people can be healthy." There are various infrastructures in agriculture that have a role in pursuing this mission. Not only are USDA, EPA, and DOL need- ed, there is need for contributions from the public education system, rural hospi- tals, academic centers, agriculture-related businesses, volunteers, and community- based organizations such as Marilyn Adams' Farm Safety for "Just Kids." AI1 of the individuals and institutions that have or could have involvement are needed, work- ing effectively together towards our public health mission. But it is time now that the public health The CDC-NACHO study also brought us agency become centrally involved with all an important understanding of the resourc- of these partners. Surveillance, epidemiol- es available to local health departments ogy, environmental and industrial hygiene, outside of metropolitan areas. The re- Building Infrastructures for Prevention, May 1, 1991 safety engineering, these are public health prevention disciplines. The responsibility for leadership in assuring healthy condi- tions of life for our citizens lies with us. In this context, I am going to emphasize in the rest of my remarks a view of our pub- lic health system and how it will have to be strengthened, or some important aspects of how to build an infrastructure for preven- tion. The hope is that, working with you in the Agricultural Extension Service, the FFA, and in other organizations active and concerned in this area, we can build an infrastructure able to assure that agriculture's workers and families can be healthy. Not that public health agen- cies-federal, state, or local-are going to "take over," but that we will together build the system, the infrastructure, successfully to meet the problems of farm safety and health. As the theme of this meeting, "National Coalition for Local Action," clearly por- tends, the foundation of our public health system, as it functions in agriculture and other sectors, must be the local public health agency. Most of the opportunity to enhance health occurs locally. Yet, as CDC found in working with the National Association of County Health Officials (NACHO) to inventory local health units, even state agencies are gener- ally once removed from communities. In our survey, we found that only 17 percent of county health departments were actually an arm of the state health department, and 41 percent reported themselves totally independent. Surgeon General's Conference on Agricultural Safety and Health - 1991 45 Looking Ahead to the Next Century sources at the local health department are insufficient. About half of the jurisdictions with a popu- lation of fewer than 50,000 have a local health officer who is a physician. A small majority of these jurisdictions have a full- time health officer. They may have a handful of employees, most commonly including a clerical posi- tion, a registered nurse, and an engineer or sanitarian, in that order. The budgets of these local health departments range from tens of thousands to a few hundred thou- sand dollars. Included in these budgets are Medicaid reimbursements for personal health care. Here we begin to see the picture of a local, rural health department where per- haps a single public health nurse is trying to meet a range of competing demands, including personal health needs such as immunizations, tuberculosis control, child health, and sexually transmitted disease control; environmental health demands such as safe water supply and sewage; and other functions such as food and milk control. What resources can this lone rural nurse, with a clerical assistant, bring to bear on occupational safety and health on the farm, for example? According to the CDC- NACHO study, four out of five local health departments in jurisdictions with populations of fewer than 50,000 report, in effect, "none." What is the answer then, if this foundation of the public health system, the local health department, may not be equipped to expand its activity to address the prob- lems of the 9O's-injury control, occupation- al and environmental issues, chronic dis- eases, smoking and nutrition, to name a few? The answer is not only enhancing resources quantitatively, but directing them to the rising demands, and where there is need or opportunity, capturing resources and assistance existing outside of the health department and even outside of government (raising coalitions). In a word, what is needed at all levels of the public health system is "leadership." Leadership will build infrastructures for prevention. See agricultural safety and health as a reason for strengthening this nation's public health system. We have various complementary means of leadership by which to accomplish our end. First among these is advocacy to ensure that we have the resources and participa- tion we need. Without articulate commumcation of our mission and the challenges that stand in its way, public health will not achieve the prominence required. Advocacy is an opportunity for public health in agriculture because of the insight and eloquence of many of the participants here today. How- ever, public health advocacy must be unre- lenting and, I emphasize, must occur at all levels. In democracy, the most powerful advocacy swells from the community up. Local health departments should assume the community leadership role-setting forth the health agenda, building the necessary networks and alliances, mobilizing support, putting together public and private re- sources for common health purposes. It is the job of the rest of us in public health, whether we be state or Federal or outside of either, to encourage and empower these conmumity agencies to take on their lead- ership. 46 Papers and Proceedings Building Infrastructures for Prevention, May 1, 1991 If infrastructure is comprised of people, materials, strategies and facilities, the highest priority among these must be the people, the public health work force. After advocacy, human resources are im- portant-public health is primarily people, not technology. I would hope all of you here will join in supporting public health education, par- ticularly of students of health professions. Taking the training of physicians for exam- ple, 99 percent of the curriculum in our medical schools today teaches curative medicine, nat prevention. In building infrastructures for prevention, we ought to think of our children as the most important infrastructure of all! We will always be striving to make our com- munities safer and more healthful. But raising generations with enough awareness to live healthy lives among the hazards around us and the hazards of choice is something we can and should achieve. Building infrastructures requires advocacy, training, education . . . three other aspects in urgent need of attention are informa- tion, funding, and management and policy development. In bringing public health to agriculture, we are beginning in the right direction. The information is needed at all levels, from the community to the nation. We are working with several states, including Iowa, to obtain this information and make it available. The use of our funds in this program, and the management and policy making involved, are directed to build infrastructures for prevention. Looking forward, where we demonstrate success. This may sound very optirmstic. The agricultural program CDC is leading is relatively small and much of the work is ahead of us. We have our first egg, and we are already counting flocks of chickens. However, we are expecting this program to grQW. We have this coalition we are building. We have, and this is what I have been trying to convey about building infrastruc- tures for prevention, a great deal of oppor- tunity before us. In whatever capacity we find ourselves, we can exert leadership to build a public he.alth system of public and private means that serves our agricultural work force and their families. In their report, the Committee for the Study of the Future of Public Health refer- enced de Toqueville as identifying an American political tendency to "organize actions around specific issues." The point being made was that issue-specific political groundswells can build or fragment our public health system. A general consensus on the mission and organization of our public health system is needed behind such groundswells if we are going to build a system to serve, for the long-term, a whole country of healthy people. We have ourselves here just such an issue as De Toqueville was referring to in the 19th century. We have recognized that there is "a problem out on the farm," and we have begun to assemble our forces. Let us use the opportunity we have created to build a public health system that will work.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 47 Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 9 A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1997, Des Moines, Iowa A CHARGE TO THE CONFERENCE By Antonia C. Novello, M.D., M.P.H. Surgeon General of the U.S. Public Health Service Dr. J. Donald Millar: Well, what you did not read in USA Today yesterday, you are about to see through the miracle of video communications: A Video Introduction: Good Science and Good Sense -That is the motto of Dr. Antonia Novello, who in March 1990 became the first woman and the first Hispanic to become Surgeon General of the United States Public Health Service. The road to success for Dr. Novello began in her hometown of Fajardo, Puerto Rico, the center of a region long known for its production of sugar. After receiving her B.S. and M.D. from the University of Puerto Rico, Dr. Novello moved on to the University of Michigan in Ann Arbor, where she served her pediatric internship and residency. She also completed her subspecialty training in pediatric nephrology at Michigan, and later at Georgetown University, and then went on to earn a Masters in Public Health from the Johns Hopkins University. After several years working in the private practice of pediatrics and nephrology, Dr. Novello entered the Public Health Service with the National Institutes of Health, where she eventually became Deputy Director of Child Health and Human Development. Dr. Novello has served on several major public health committees and organizations over the years and has received a long list of prestigious awards in the process. Since her historic appointment as Surgeon General, Dr. Novello has made issues such as childhood immunization, pediatric AIDS, and childhood injuries among the top priorities on her agenda as the nation's number one public health spokesperson. Dr. Antonia Novello . . . the 14th Surgeon General of the United States: - Edited and narrated by Jeffrey H. Lancashire Greetings. I am glad to be here with you this morning as I welcome you to the Sur- geon General's Conference on Agricultural Safety and Health. about them whenever and whenever possi- ble. It seems somehow fitting, then, that I have just returned from addressing the Third National Injury Control Conference in Denver, at which a national agenda for injury control was drafted, and from a symposium on trauma in Texas, where four states came together to work on the pre- vention of bead, neck, and spine injuries. As the Surgeon General of this country, I represent all of the citizens of this Nation. But as a pediatrician, I am especially con- cerned about the health of our Nation's children, for they are our most important resource and they represent our future. The theme of this conference-FarmSafe 2000, A National Coalition for Local Action -is a serious topic. One that I know we have all placed on the top of our agendas. As Surgeon General, I never thought that much would be focused on the subject of injuries-but because they are one of the leading causes of death in this country for all age groups, I will continue to speak out 48 I am concerned about the health of our Nation's children. The more I talk about their health, the more I must tell you that it is very important for parents to recog- nize the dangers that their children face with regard to injuries. We know that politically, children have no voice and therefore no power, yet they comprise one-quarter of the U.S. popula- Papers and Proceedings tion today, or about 64 million. As citizens of the Nation, we must assess, help, plan, and then act-it is our duty to build a stronger foundation for our young people and for their parents. We must speak for those who cannot speak for themselves-for those who are not with us today-it is their right to live full and rewarding lives, and it is our responsibility to do all that we can to make those lives the best they can be. As I said: Injuries are the leading cause of death in children today, with non-fatal inju- ries out numbering fatal injuries. An- nually, injuries claim the lives of over 22,000 children between the ages of O- 19. Each year, an estimated 600,000 child- ren are hospitalized and almost 16 million more are seen in emergency rooms for their injuries. The toll of injuries on the young is devastating; they suffer more deaths from injuries from the first year of life through the age of 19, than from all diseases combined. Injuries are also the leading cause of disability, with more than 30,000 chil- dren suffering permanent disabilities each year. While the effects of such disabilities on children's development, daily living, and future productivity are great, the financial, emotional, and social effects on the family are enormous. Sadly enough, the number of reported injuries suffered by our chil- dren has not really changed much over the past twenty years. If we, at least acknowledge that injuries occur and can be prevented-then maybe Charge ta the Conference, May 1, 1991 injuries as a public health problem in this United States whether in farm country or in some Eastern State neighborhoods will receive the attention, focus, and resources commensurate with their magnitude. The picture is worse for parents who are farmers where additional hazards are faced by their children. For example: Over 24,000 children are estimated to be injured each year on farms; 5000 of them suffering serious injuries. One out of five of all deaths occurring on farms are for children under the age of 16. A Cornell University study shows that children on farms under 14 years old were more than three time as likely to be injured, when compared to others working on the farm. Similarly, a Mayo Clinic study found that there were two ages where farm children were most vulnerable to injury; age four, because kids could go any- where on their own, and were not scared of anything-and the other dan- gerous age was 14, when children- especially boys-began to take on major farming chores. Sixty-five percent of farm boys drive tractors before the age of 12. By law, they are permitted to drive a tractor down the highway. If the tractor flips over or is struck by another car, and the child is injured or killed-this is not reported as a workplace accident. The long-term emotional toll and inju- ries are enormous: A 1984 Wisconsin study placed the cost for a serious farm injury at $140,000 and the total hospital Surgeon General's Conference on Agricultural Safety and Health - 1991 49 Looking Ahead to the Next Century and rehabilitation costs for farm inju- ries were estimated to be about $2.5 billion dollars. All of us here today know that we have many problems that we must deal with. The realities we face vary form lives lost to long-term disabilities. As we heard yester- day: 50 Agriculture is among the Nation's most hazardous occupations. We know that death rates, hover a- round 50 deaths per 100,000 workers, while the annual death rate for all other industries combined is only 11 deaths per 100,000. We know that in 1986, 1600 agricul- tural deaths occurred, including approx- imately 300 children that were killed while engaged in farm-related activities. We know that about 170,000 disabling farm injuries occur each year, and about half of all that survive them are permanently disabled. We also know that farms and other agricultural operations are predomi- nantly small businesses. We also know that agricultural work is typically conducted in remote areas away from emergency medical or spe- cialized diagnostic services. We know that agricultural equipment is typically over 15 years old, still in wide use and frequently does not include safety technology that would protect the operator. You may say, why are injuries such a prob- lem in this country. 3 Well, I believe sever- al reasons apply here. . First, the term "accidents" still connotes randomness, unpredictability, and prevent- ability. These connotations prevent institu- tions, the public, and educators from ap- proaching injury prevention in a scientific manner. Injuries need to be visualized as a problem of public health-allowing for us to deal with them the same way we approach disease and subsequent disease prevention wherever they may occur. b Second, I believe there is a lack of inter- est and knowledge of the field by the gen- eral public, as well as by some law makers. People in the rest of the United States might not realize that injuries that happen in farm country have an effect on the country as a whole. b And third, but not least, there is a gener- al lack of morbidity and mortality data, which hinders prevention efforts that sometimes can be most effective. Obviously, we need to come together to work this problem through. It is not just a problem that happens in farm country, it is a problem that happens everywhere. We as united citizens must. bring it to the fore- front. For example: o The U.S. Department of Agriculture reports that there are 13.1 million per- sons in the United States that derive some of their income from farming, and an additional 6 million dependents. These workers and their families ex- perience a disproportionate share of inju- Papers and Proceedings Charge to the Conference, May 1, 1991 ries and diseases associated with numerous chemical, biological, and physical hazards. Occupational Lung Diseases In 1988, agriculture had the sixth highest work-related lung disease rate in this coun- try. Types of lung diseases ranged from: allergic, to asthma and acute responses to toxic or irritating grain fumigants. Musculoskeletal Disorders Another disease entity that is prevalent is degenerative musculoskeletal disorders. They result form chronic exposure to farm machinery vibrating, or to repetitive trau- ma associated with farm work. The most noticeable for these are reported as low back pain, hip arthrosis, and degenerative arthritis of the knee and upper extremities. Migrant workers are typically involved in work that involves frequent hand and wrist movements, awkward working positions, and a dependence on manual lifting, which may be conducive to carpel tunnel syn- drome and low back injuries. Occupational Cancer Regarding cancer, epidemiological studies of farmers have uncovered consistent ex- cesses of hematologic cancers, including leukemia, Hodgkin's disease, non- Hodgkin's lymphoma, and multiple myelo- ma, as well as cancers of the lip, skin, stomach, prostate, and brain. Causative agricultural exposures have not been conclusively identified, but agents of concern include nitrates, pesticides, viruses, antigenic stimulants, and various fuels, oils, and solvents. Excess cancers of the lip and skin are linked to increased exposure to the sun's ultraviolet radiation. Severe Traumatic Injuries Severe occupational traumatic injuries usually occur suddenly on the job and are either fatal or require immediate medical care. These injuries affect, in substantial numbers, children under the age of 16 and the elderly 65 and older. Machinery, especially farm tractors, are a major cause of death to agricultural work- ers. Others result from inadequate farm building design and livestock handling. Of the estimated 1,500 machinery-related deaths annually among all occupations, more than half involve farm equipment. Cardiovascular Diseases Another serious disease associated with agriculture is heat stroke. Agricultural workers are at the highest risk of devel- oping this compared to all other workers, including miners and construction workers. One associated risk factor is the lack of available drinking water, which affects at least one-fifth of labor-intensive farmwork nationwide. Reproductive Disorders Workplace exposures can adversely affect the male and female reproductive systems, and as a consequence interfere with fetal development, and children's health. Pesti- cides may cause reproductive failure in either men or women, genetic damage, or miscarriage. Surgeon General's Conference on Agricultural Safety and Health - 1991 57 Looking Ahead to the Next Century Moreover, the nature of agricultural work and the physiological changes of pregnancy put the pregnant farmworker at increased risk of health problems for both herself and her baby. Neurotoxic Disorders Neurotoxic disorders present problems for the farmers as well. Approximately 10,000 people in this country suffer acute poison- ing by organophosphate insecticides annu- ally. These pesticides affect the nervous system, and up to not, the long-term neu- rologic consequences are known. Noise-Induced Hearing Loss Regarding noise, noise-induced hearing loss is a well-documented result of expo- sure to farm machinery noise, especially tractor noise. Approximately 323,000 agri- cultural workers are exposed to potentially hazardous noise levels. Such hearing loss has been found to affect a quarter of youn- ger farmers and fully one-half of older ones. Significant numbers of those affected have been found to develop a communication handicap by age 30. Dermatological Conditions Epidemiological data indicate that derma- tological conditions caused by ultraviolet radiation, plant materials, soils, fertilizers, pesticides, and agents causing zoonotic infection are very common among United States farm workers. In 1984, these disorders comprised over two-thirds of the occupational illnesses among crop production workers. Skin disorders in this group were over five times more common than among all pri- vate sector employees combined, and near- ly three times that of manufacturing em- ployees. Psychological Disorders Additionally, farmers, farm family mem- bers, and other rural inhabitants are not exempted from stress-related psychological disorders, especially depression. Some of these psychological disorders appear to be related to isolation, economic hardship, weather conditions, or labor status. Infectious Diseases In addition, some infectious diseases, which are agriculture-related, vary form one part of the country to another. Some others, such as those related to poor sani- tation, like dysentery, hepatitis, typhoid fever, and intestinal ailments, are common- ly spread by using the same eating and drinking utensils, drinking non-potable water, and from fecal-oral contaminating due to the lack of toilet and handwashing facilities. Others, like parasitic infections - estimat- ed to be 20 times that of either the general U.S. population or even other rural or poor urban populations, are epidemic among migrant farm workers. Such is also the case for tuberculosis. For migrant workers, this is an occupational problem, and not an imported disease. The disease is 3,000 times more prevalent among black migrants than the general population as a whole. 52 Papers and Proceedings So now that I have disseminated the infor- mation, and you are aware of the problem, what do we do? First, and most importantly, parents who farm need to know what the dangers are. Second, parents must then educate their children about these dangers. Ignorance- like knowledge can remain forever. The country is ready and the time is ripe to move the national agenda forward re- garding injury control. The key to any success we might realize, however, lies in our ability to come together, first at the local level, and then at the Federal level. And this is why we are here today-to ex- plore what is needed to facilitate and pro- mote this common goal, and work together in making it a reality. In order to accomplish this, we need to return to some of the basic aspects of public health and management. o We must work to raise the conscious- ness of the public and alert the commu- nity leaders about critical issues. . We must also build coalitions-partner- ships between health, education, envi- ronment, labor, and agriculture cornmu- nities. We must begin to disseminate the appro- priate information, and we must as a con- sequence of such information, encourage action to prevent injuries. Ultimately, my goal is to motivate all of you to reduce agriculture-related diseases and injuries, by prevention. If we are to be successful in this endeavor, we must tackle the problem head on. Charge to the Conference, May 1, 1991 My wish is that this Conference will set a milestone in saving lives and preserving health. To accomplish this, Dr. Millar and I hope to convene a follow-up conference in the near future to develop a national strategy for the prevention of agricultural- related diseases and injuries. But until then I must tell you that it is my belief that in agricultural safety and health, prevention begins and ends with the fami- ly, and so, the family should be one of our main targets as we fulfill the charge I have given to this Conference. The key to any success we might realize, however, lies in our ability to come to- gether, first at the local level, and then at the Federal level. There was a famous 19th century Puerto Rican literary figure, Eugenio Maria de Hostos, who considered the family to be the cornerstone of society. He said: . . . as members of a family, we are so closely bound to it by gratitude that we recognize its effects from the cradle to the grave. If we are born, we owe it to the family; if we grow up, it is through the protection of the family; if we are educated, it is the work of the family; when we are with the family we work for it, away from it we long for it; we are happy in the family and for its sake; if we are unfortunate, we regret it for the sake of the family; ill, we fear death for its sake, and in dying, we long for it. With all this in mind, your deliberations here will set the stage for the work that needs to be done in this field. You have the responsibility of building a firm foun- Surgeon General's Conference on Agricultural Safety and Health - 1991 53 Looking Ahead to the Next Century dation for our future actions in the coming decade. Your networking and coalition building will set the partnerships that need to be maintained. This may be the tenth Surgeon General's conference on occupational safety and health, but this is just the beginning of our work together. Appropriately enough, today, May lst, is traditionally viewed in agriculture as a "day of fertility." Hopefully, today will mark the day for our National Coalition for Local Action to grow stronger. I trust that will be the case. We know that changes do not come easy- they take commitment, partnership, and dedication. It is apparent to me that this group is serious about injuries, and their impact on the lives of all our citizens. It also seems to me that we know what to do and how to do it. Now we, together, must do it. Only when this is done will this local ac- tion serve the national purpose. Friends, this is our "Field of Dreams." If we build it, they will come. I know we can, I know we will. Thank you, and God Bless.0 54 Papers and Proceedings OPENING REMARKS of you can probably relate to what I am talking about. Good morning, and thank you for that kind introduction, Dr. Millar. But, I am from a rural community, and I can stand up here, as many have, and It is a pleasure to be here. I have a back- ground similar to that of many people who have taken this podium. Senator Harkin stood up here and said he was from a small town. relate to you story after story of my experi- ences with working with agriculture-the experiences of discing a loo-acre field at the age of 10, or planting at the age of 11, or maybe even driving a grain truck with 7% tons of grain at the age of 14. Well, I am also from a small town, the town of Fillmore, Indiana, a rural commu- nity. Sometimes when I am talking across the country, in cities such as Los Angeles, Oklahoma City, Iowa City, talking about a small town, I say, "You know Fillmore is so small that when you drive into Fillmore there is no need for a turn signal because everybody knows where you are going any- way." I will be honest with you: at that point in my life I did not give it a second thought. By the same token, most of you involved in agriculture know that it is a way of life, and it is a respected way of life. I feel that the objectives being accomplished here and the directions that we are heading are definitely right. I think it is one of the few places in the Dr. Millar, you talked about my involve- country that you can dial the wrong num- ment in the FFA. The FFA is the nation's ber and still talk for thirty minutes. Many largest intercurricular student youth orga- Surgeon Gefleral's Conference on Agticu/tural Sat&y and Health FARMWE 2000 9 A National Coalition for Local Action Convened by the National Institute for Occupational SaWy and Health April 30 - May 3, 1991, Des Moines, Iowa REMARKS BY THE NATIONAL FFA PRESIDENT By Mark Timm President, National FFA Organization Dr. J. Donald Millar: One of the great things about this conference to me is that there are so many young people here. We are very, very pleased with that aspect, and oftentimes in public health meetings there are not a lot of young people around. It seems to me that we have not made prevention and public health all that attractive to young people. But this is a field that compels the imagination of youth as well as the rest of us. So it is a great pleasure for;me, at this point in the conference, to introduce you to a young national leader, Mark Timm, who is the national president, FFA. Mark is president for 1990-91. He is 19 years old, and he serves over 387,000 FFA members in over 7,600 local chapters nationwide, including the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. These FFA members are preparing for careers in the science, business, and technology of agriculture. Mr. Timm was State FFA president in Indiana last year and is a National FFA scholarship recipient. He is currently on a one-year leave of absence from Purdue Univer- sity-my wife and I drove through West Lafayette just two days ago-where he is studying sales and marketing with sights on working for an agricultural company in the future. During his year as FFA president, he will travel more than 200,000 miles, making hundreds of appearances on behalf of the FFA. It is my very great pleasure to introduce Mark to you: Surgeon General's Conference on Agricultural Safety and Health - 1991 55 Questions to Guide the National Agenda nization-nearly 400,000 FFA members nationwide. And serving as national presi- dent is a tremendous honor. It is a great opportunity, but it is even a greater re- sponsibility, because, as the speakers have stood up here and talked abbut the role of youth in America there are not very many opportunities for youth to speak out and speak to adults. I have been given the chance to represent a large portion of the youth in America and the youth in agriculture. It gives me great delight to see the young people in our organization out here. I do not know if you have had the chance to notice, but there is more than just my jacket running around here. There are seven chapters from all across this country. Dr. Roper talked about leadership. Well, our organization is based on agriculture. That is the backbone of this organization. But, equally important, our students are interested in developing their leadership, their personal, and their academic skills, through agriculture. We are teaching them not only to be stewards of the land but to be the future leaders of our communities, of our state, of our country, and eventually even of our world. I would like to share with you some of the leadership that we are showing in the area of safety. We have a National Chapter Safety Award Program. This year, at our National Conventidn, we honored over 150 chapters for outstanding accomplishments in the area of safety. Thirty-six chapters received gold recogni- tion, and out of those 36, seven were cho- sen to attend this conference. Those seven chapters are going to be putting on poster 56 displays tomorrow afternoon in the poster display demonstration. I want to share with you, just to highlight some of the safety areas that we work on or that we address as an organization, because, you see, our primary goal as a national safety award program is just like the goal that your theme states. It is a national coalition for local action. This year, at our National Convention, we honored over 150 chapters for outstanding accomplishments in the area of safety. It is a national award program centered at the local level. What we do is assess the needs of the community. The chapter assesses the needs of the community, and some of those needs that we address are National Farm Safety Week; Farm Safety for Just Kids, which you have heard about; chemical safety for farmers; water quality testing; and all-terrain vehicle (ATV) and three-wheeler seminars. Chapters even address areas such as boat- ing safety; holiday awareness programs such as the testing of candy on Halloween; fire-prevention safety; home safety, farm machinery operations, and hazardous grain hauling; chain-saw safety; restricted use for pesticides; CPR classes and substance abuse awareness. So, we are touching several areas in safety, focusing primarily on agriculture, which is our backbone, but also other areas of safety. Not only do we have our National Safety Award Program, but we also are infusing safety into our curriculum-agricultural education. We have initiated programs in areas such as food safety and environmen- Papers and Proceedings tal safety. As a matter of fact, one of our most recent programs was food safety-a 1. Surveillance-Agriculture-related Dis- ease, Injuries, and Hazards. $300,000 project that business has picked up and is willing to sponsor, and we plan to start developing the actual curriculum this summer. 2. Research-Biological and Chemical Hazards. 3. Research-Physical and Mechanical We will be writing the curriculum and will Hazards. be spreading it across the country, with 400 workshops, trying to educate our teachers 4. Intervention-Agricultural Workers' of agriculture education and the home Protection from Hazards. economic teachers about food safety, all the way from the production of food to the 5. Intervention-Safe Behaviors among processing of the food. So we are covering Adults and Children. a wide range, a wide spectrum, of food safety. We will educate teachers on food safety, then they will educate the people that make it count, and that is the young A presentation panel will deliver talks on a variety of issues. Tomorrow, after a morn- ing plenary session, a concurrent session people in America. will reconvene to hear discussion panels comment on today's presentations. The I would like to close on my statements concurrent session will reconvene again about the FFA and our role in safety by after lunch tomorrow, to hear public com- quoting what one of the chapters that are ment and to address the points to be re- represented here-the Stockton Chapter of ported back to the full conference on Fri- Missouri-said in their safety award appli- day morning. cation: Health is not everything, but you're dead without it. [REMARKS AT THE CONCLUSION OF THE SESSION] [REMARKS AFTER THE FIRST SPEAKER] Before we conclude, I would like to thank them for giving me the opportunity to come here, and I would also like to say that, as the population of the rural com- The rest of this session will frame the work munity declines, so does our membership of the conference around three activities: in the FFA, the organization that I repre- surveillance, research, and intervention. sent. However, our urban membership has Each of the three following speakers will drastically increased, so we are involving a pose questions related to each of these much more diverse group of young people activities, which will be addressed by five interested in agriculture. concurrent sessions. I get the chance, as I travel across the One session will address surveillance; two country, to represent youth in agriculture, will address research; and two will address and I want to share with you one quick intervention. These five concurrent ses- sions will convene this afternoon. The five story before we conclude. That is, a spe- sessions are: cial place that I have found off the coast of Questions to Guide the National Agenda, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 57 Questions to Guide the National Agenda Alaska. It is a special place called the Diomede Islands. Why it is so special is because the Intema- tional Date Line is found to run right down between the Diomede Islands. Not only that, but one side of the islands is owned by the Soviet Union and the other side is owned by the United States. Not only does America need its young, but young people need your help, support, guidance, and leadership. I So you can sit on one side of the island and look across and it would be the 28th of the month, and on the other side of the island it would be the 29th. On a clear day, when you look across these islands, not only would you see another perspective on life, since the Soviets value the posses- sions they have and we as Americans value freedom-but on a clear day you can even see tomorrow. If you really think about that-the ability to see into the future-1 wish I had the ability to see in the future right now because, let me tell you, I see a tremendously bright future in this industry of agriculture. I am proud to say that I am a part of agri- culture and proud to be here representing this organization, representing youth in agriculture. With that, I would like to leave you with one final statement on behalf of the youth, and that is that Ameri- ca needs youth because youth represents the future of the state of this country and of the existence of everybody. Not only does America need its young, but young people need your help, support, guidance, and leadership.0 58 Papers and Proceedings Surgeon General's Conference on Agricultural Sakty and Health FARM&FE 2000 . A National Coalition for Local Action Convened by the National Institute for Occupational Satkty and Heatth April 30 - May 3, 1991, Des Moines, Iowa THE ROLE OF PUBLIC POLICY IN AGRICULTURAL SAFE7Y AND HEALTH Joseph A. Enney, M.P.A. Executive Director, National Safe Workplace Institute Mr. Mark Timm: Our first speaker this morning is Mr. Joseph A. Kinney, Executive Director of the National Safe Workplace Institute, located in Chicago. Mr. Kinney spent his youth and entire professional career closely linked to agriculture. He grew up in Kansas working on farms and ranches and was deeply involved in breeding Charlette cattle when he was a college student at Illinois State University. Mr. Kinney holds a Purple Heart from service in Vietnam. He later spent five years working on agriculture in the United States Senate, and an additional five years as staff director for the committee on agriculture in the National Governor's Association. He spent a significant amount of time living and working with farm families in several states, including Idaho, North Carolina, Minnesota, Alaska, and California. He holds graduate degrees from the Maximal School of Citizen- ship and Public Affairs, and from the University of Pennsylvania. In 1987, Mr. Kinney founded the National Safe Workplace Institute, which is a not-for-profit organization devoted to making oc- cupational safety and health a higher priority for the private and public sectors. Both Mr. Kinney's background and his interest in safety uniquely qualifies him to speak on the topic, The Role of Public Policy in Agricultural Safety and Health. Mr. Kinney: Good morning. It is really a privilege for me to be here today to address the Sur- geon General's Conference and to discuss the role of public policy in agricultural safety and health. As you have just heard, I have had two careers. My first career was in agriculture. In fact, about 10 years ago or so I had the opportunity to address an agribusiness audience in Dallas, and one of the old ranchers in the audience got up and made a little speech and at the end of it he said, "And son, how long you been involved in agriculture?" I said, "Sir, 30 years. Next question, please." So, you know, I feel like I've been around it a fair bit of my life, since I was about 32 when I spoke in Dal- las. Throughout my life, I have developed a deep appreciation for the role that our farmers and ranchers play in the produc- tion of the food and fiber of this country. They clearly are our backbone. Without them, we would have nothing. In fact, if you look at our economies and compare them with many of the economies in the industrialized world, one of the real strengths we have is our efficiency in food and fiber production. It is because of people like Mark. We all really owe them a lot. As Mark said, I spent a lot of time living and learning from farmers and ranchers. I have cured tobacco in Harnett County, North Carolina. I used to be involved in all aspects of grain and livestock produc- tion in Illinois. Certainly I have baled my share of hay in Kansas. I have tended ranges in Wind River, in Wyoming. My least favorite job was culling potatoes in Idaho. But I took those jobs because working in Washington, you tend to be sort of isolated and insulated from reality, and so when I would meet an interesting farm- er I would ask him, "Well, can I come and Surgeon General's Conference on Agricultural Safety and Health - 1991 59 Questions to Guide the National Agenda work for you for a week and learn what you do?" That is how I did it. I actually was injured once. I had a very severe laceration to my left leg and was stitched by a "vet." When we design our surveillance systems, it is clear that we have got to include veterinarians because I was stitched by a vet. I have got a lot of ugly scars, but it is the ugliest. But it was a very valuable experience because it taught me that farmers like to rely on their own community. I would be very surprised if there is not some resistance to NIOSH. b Certainly one of the things that I learned in my years in Washington was that the agricultural community is strongly resis- tant to OSHA. I think that will have to change. Clearly, farmers are a unique group. Farmers tend to work until the job is done. They do not know a g-to-5 day. But it is also clear that agriculture defies easy generalization. Throughout my life, and I am 42 now, there have been two consistent themes. The first is that our farms and ranches tend to grow in size, almost year by year. The little house on the prairie, near where I grew up in Kansas, now looks a lot more like Dallas. b The second theme is that we are spen- ding a lot of money-a significant amount of money-on supporting farm incomes from the Federal treasury. I think that is very important to understand, because I know farmers-and we will talk a little bit about this today-want to resist any kind of intrusions by external forces. But what farmers need to understand-and rural people need to understand-is that there is a significant public investment in what they do and, therefore, there is a significant Frankly, there would be more public in- volvement if it were not for the farm lob- by. Having met with many farm organiza- tions, I can tell you that at least in the past they have resisted involvement. I think that is going to change. In fact, I think we will begin to see more public involvement in these issues in the near future. I mean involvement beyond the sort of touchy- feely things of education and beyond research issues. There are any number of areas that we could see develop. public interest in their health and well-being. My interest in occupational safety and health stemmed from the death of my brother, Paul, from a scaffold collapse in Colorado. Since I have been involved, I have had a peripheral interest in agricul- tural safety. At the Institute, we have written about it. We have talked about it a little bit. We are doing a rather compre- hensive analysis of options for public invol- vement on job safety. I will touch a little bit on that today. Frankly, there would be more public involvement if it were not for the farm lobby. I You have heard plenty about the size and magnitude of this problem. You know, the National Safety Council puts out data and, based on this data, agriculture has had persistently high levels of injury relative to other regulated areas. I guess the lesson we could learn from that is that the free market and, perhaps, many educational approaches are not working. We need to look more aggressively to other approach- es. 60 Papers and Proceedings The Role of Public Policy in Agricultural Safety and Health, May 1, 1991 I would like to show you a couple of trans- parencies that I put together here so we can get a sense of who is involved and what is involved. Farmers like to talk about target prices. People in public health like to talk about target groups. When we look at this issue, we need to understand that there is more involved than the men and women who own and operate farm enterprises. There are chil- dren. There are farmworkers. There are all different categories of people. Sector Agriculture Mining Workers Covered by OSHA Dollars Spent Per Worker $0.30 $181.68 $4.34 U.S. Department of Agriculture's Commitment to Agricultural Safety and Health, FY 1991: b Extension Service-distributed on a formula basis with $19,000 to each state: $970,000 c Competitive Grant Program: $1 ,ooo,ooo Source: Prof. William Field, Purdue University. 1 Ygure 1. Federal Dollars (Fiscal Year 1987) Spent on Occupational Safety and Health. Now, potentially there are all sorts of laws that could be applied in this area-child labor laws, criminal prosecutions for not only fatalities and homicides, but batteries and injuries. There is obviously the possi- bility of citations. Right now there is a rider on the appropriations bill that keeps OSHA from inspecting injuries or fatalities on farms. Of course, there is Workers' Compensation, and, finally, there are injury lawsuits. To this point the public involvement has largely been limited to research and educa- tion migrant protection, and health servic- es. Of course, there is the sanitation stan- dard. But the involvement of both states and the Federal Government has been quite limited. 1. Surveillance $5,745,816 . Farm Family Health and Hazard Survey. . Occupational Health and Safety Surveillance Through Health Departments. 2. Research $6,217,817 b Applied Preventive Research. w Education and Training Programs. 3. intervention $6,676,367 . Cooperative Agreement Program for Agricultural Health Promotion Systems. b Demonstration Cancer Control Projects for Farmers. Source: NIOSH. Figure 2. National institute for Occupational Safety and Health-Agricultural Safety and Health Program. In fact, if we look at Figure 1, we can see that these data are a little old; but, I am told by the producer of it, Bill Field of Purdue University, that the data really have not changed that much. As you can see, occupational safety and health expen- ditures equal about thirty cents per farmer. Perhaps that is what they think their lives are worth, but we spend a substantial amount of money, for miners, and a small amount of money for regular industrial workers. The Agriculture Department's commitment is now essentially limited to a $975,000 fund distributed equally to states. Perhaps we are going to hear that the U.S. Depart- ment of Agriculture (USDA) is also going to spend a million dollars in competitive grants that will be committed by the end of this fiscal year. Surgeon General's Conference on Agricultural Safety and Health - 1991 61 Questions to Guide the National Agenda Figure 2 shows NIOSH programs that are multi-year programs. It looks like a lot of money. NIOSH spends $X3-$19 million dollars. In reality, it is quite little. In Figure 3 what we wanted to measure, in terms of budgetary expenditures, is the commitment that we have to occupational safety and health in America. Total feder- al workplace health spending involves the budgets for NIOSH, for the Occupational Safety and Health Administration (OSHA), and for the Mine Safety and Health Ad- ministration (MSHA). In 1981, we spent one dollar out of each $1,579 of the Federal budget for these programs-not very much. By 1991, that amount of money had dropped to just a one dollar out of each $2,408. I `igure 3. Workplace Safety and Health Regulatory, Total Amount How Many Federal Workplace Required to Dollars Spent for Fiscal Health Keep Pace Each Dollar Spent on Year Spending with Inflation' Workplace Health' Gil $4,294 n/a $1,579 1983 $4,165 $4,854 $1,941 1985 $4,356 $5,234 $2,172 1987 $4,524 $5,493 $2,219 1989 $4,807 $987 $2,212 1991' $5,447 $6,512 $2,408 o Estimate. ' Inflation data based on calendar years; 7997 figure is an estimate. ' Another way of expressing this statistic: Number of federal dollars spent for every sing/e dollar spent on the combined budgets of OSHA, MSHA, and NIOSH. Sources: Inflation Data-Bureau of Labor Statistics, Budget Figures-Cffice of Management and Budget. Compiled by the National Safe Workplace Institute. Research, and Education Spending-Adjusted for inflation and as a Share of Federal Budget, Selected Years (in millions). What this chart represents to me is a di- minished and decreasing commitment to workplace safety relative to other budget priorities. There is no way around that. We have also looked at this and you know, we have looked at occupational health versus EPA, we have looked at this versus the National Institutes of Health and a lot of other measurements. Clearly, our com- mitment to occupational health in this country-workplace health-is going down. Now in Figure 4, we looked at workplace health compared to the national defense. Total Fiscal Workplace National Year Health* Defense &tiJ 1981 $429.4 $157,513 366.9 1983 416.5 209,903 504.0 1985 435.6 252,748 580.2 1987 452.4 281,999 623.3 1989 480.7 290,361 604.0 1991'. 544.7 298,910 o ** 548.8 *includes combined budgets of the Occupational Safety and Health Administration, Mine Safety and Health Administration, and National Institute for Occupational Safety and Health. `*Estimate `**Pts-Desert Storm Source: Cffice of Management and Budget. Compiled by the National Safe Workplace Institute. :igure 4. Comparison of Total Workplace Heait Spending Versus National Defense Spending, Selected YE!XS (in hundreds of millions of dollars). In 1981, as you can see, we valued our national defense 367 times more than we valued the health and safety of workers in America. That is what these data say to me. By 1987, the ratio had grown to 623 times. In 1991, it dropped to 548 times. But, of course, that was before Desert Storm. No one seems to know what is going to happen to the defense budget. I think we are going to have to add some- where in the neighborhood of $40 billion plus. So, the 548 times figure will be much closer to 600 and something. 62 Papers and Proceedings In fact, if you look on Figure 5, at work- extension friends and they were telling me place health spending compared to farm how poorly the USDA agriculture research income stabilization, in 1981 we supported budget has been doing. My friends, you farm income 23 times more than we sup- have been doing much better than NIOSH, ported workplace health. OSHA, and MSHA, as you can clearly see in this Figure 6. Please do not misunderstand what I am saying, I have worked hard on the farm What these figures suggest to me, at least bills of 1973, 1977, and 1981, and I certain- at a superficial level, is that there may be ly know all the arguments for target prices more room to do more things at USDA. and price support loans and all the various USDA programs. Of course, that raises a significant question I think they are very I hope will be worked out in the next year valuable. These are income transfers to or two. The question is how we might best farmers. Clearly, the dollar amounts fluc- coordinate and work together. I think tuate up and down depending on what there is room for both agencies to be in- commodity prices are doing, but never- volved in this area. In fact, I think they al- theless it is interesting to compare price ready are. The Extension Safety programs supports and workplace health spending. go back a hundred years-a long, long time. Total Farm Total Agriculture Fiscal Workplace income Fiscal Workplace Research & yri%TJ Health* Stabilization &l&l yeaJ Health' Services Ratio 1981 $429.4 $ 9,783 22.8 1981 $429.4 $1,540 3.6 1983 416.5 14,344 34.4 1983 $416.5 $1,578 3.8 1985 435.6 21,323 49.0 1985 $435.6 $1,813 4.2 1987 452.4 29,606 65.4 1987 $452.4 $1,864 4.1 1989 480.7 14,817 30.8 1989 $480.7 $1,964 4.1 1991 o * 544.7 9,761 17.9 1991 o * $544.7 $2,404 4.4 &ludes combined budoets of the Occuoationai Safety and *includes combined budgets of the Occupational Safety and Health Administration, Mine Safety and Health Administration, Health Administration, Mine Safety and Health Administration, and National institute for Occupational Safety and Health. and National Institute for Occupational Safety and Health. -Estimate. "Estimate. Source: Office of Management and Budget. Source: Office of Management and Budget. Compiled by the National Safe Workplace Institute. Compiled by the National Safe Workplace institute. Ygure 5. Comparison of Total Workplace Healt :igure 6. Comparison of Total Workplace Health Spending Versus Farm Income Stabilization Spen- Spending Versus Agriculture Research and Services, ding, Selected Years (in hundreds of millions of dollars). Selected Y&V.S (in hundreds of millions of dollars). Figure 6 compares total workplace health The next figure, Figure 7, is what my four- spending to agricultural research and ser- year-old son would call a "big nasty." vices of selected years, basically every These are the kinds of public sanctions other year from 1981 to 1991. that can be taken against job-safety viola- tors. As you can see, the agricultural research and services budget is growing at a faster b First, if you look at the economic rate than workplace health. I was having literature, the most costly part of OSHA's breakfast this morning with some of my involvement with business is not in fines, The Role of Public Policy in Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 63 Questions to Guide the National Agenda but clearly in the inspection process. There are many studies on that. b Second, there are civil penalties, and they were recently increased by a substantial magnitude. b Third, there are criminal penalties. There is legislation in the Congress now to increase the amount of time we can spend in jail for knowingly and willfully tolerating workplace conditions that result in the death of a worker. The government has recently put one person in jail, under the OSHA Act. It was a South Dakota con- tractor and the incident involved excava- tion fatalities. I have no idea how many people die in excavation fatalities on farms and ranches, but I am sure it is a substan- tial number. b Fourth is Workers' Compensation premi- um increases. b Fifth is a seldom-used tool, un- fortunately. Hopefully, it will be used more in the future. It is simply an injunc- tion to stop people from doing what they are doing. b Sixth is the loss of eligibility to partici- pate in public programs. The most recent example is that of a construction company called S.A. Healey, a Chicago company that had a bad safety record with many violations. So far, they have lost a $78 million con- tract in Los Angeles on which they are the low bidder in, because of their safety re- cord. They lost a $37 million contract in Milwaukee, where they were the low bid- der, because of their safety record. They are the low bidder in an approximately $200 million contract in another New Eng- 64 land state where my organization is active- ly trying to knock them out. I. Potential target groups: b Farmers. b Farm Families (spouse, children). b Farm Children engaged in farm work. b Farm Workers, Permanent, Full-Time, Year-Round. b Farm Workers, Permanent, Part-Time, Year-Round. b Farm Workers, Seasonal, Part- or Full-Time. t Migrants. 2. Applicable laws: b Child labor laws. b Federal criminal prosecution: homicide, willful violation. > State homicide or battery prosecution. b Citations for violations by the Occupational Safety and Health Administration or corresponding state agency. b Workers' Compensation. b Injury law suits. - Compiled by the National Safe Workplace Institute. ?gure 7. Target Groups and Laws that Could Be Used To Regulate Agriculture Safety and Health. One of the possibilities that we could see, frankly, in the agricultural area, is the possibility of cross-compliance. One of the models that we might look at in terms of public intervention and farm safety would be a farm safety audit. If farmers did not pass their audits or make corrections within a specified period of time, they could lose eligibility for price support programs, soil-conservation pro- grams, farm loan programs, farmers' home programs-whatever programs exist, and there are plenty of them. Papers and Proceedings The Role of Public Policy in Agricultural Safety and Health, May 1, 1991 Another area where I think we will see some intervention, very soon, of a criminal nature is children on farm equipment. Mark Timm talked about his involvement as a youth. I could tell the same stories. One is a recent event; a 21-month-old was killed while helping his father when he fell under the wheel of a tractor that his six-year-old sister was driving. According to Bill Field, at Purdue, the fact that 300 kids die each year on farms-kids below the age of 15-is supported by a similar study at the Univer- sity of Tennessee. In recent years, we have documented three-year-olds who were killed in Nebras- ka and Texas who were actually classified as industrial deaths. Let me say one thing. This 300 number may be substantially larger in proportion to population than the numbers of 15-year-olds who are killed-murdered-in big cities because of drugs. If that does not make your blood boil, I think you should go out and have your temperature checked. There is no way that anybody with half a conscience, looking at these numbers and looking at these stories, can sit and not say that this is not potential child labor abuse. We have been responding to increasing inquiries from prosecutors in various cities who have been looking into bringing child labor abuse charges in farm accidents. It has not happened, but I am certain that it will happen in the next few years. Sunday there was a story on CNN-maybe many of you saw it-about a guy named Dominguez in Miami who is going to jail because his kid did not have a seat belt fastened. In fact, the kid was sitting in his mamma's lap, if I remember the story cor- rectly. They had a crash, and the kid was killed. So the father is being prosecuted. Frankly, there is not a dime's worth of difference, in my view, between the Dominguez in Miami and the man in Visalia, California. The last area where I think there is going to be some involvement, as shown in Fig- ure 8, has always been a dynamic area. There are only 12 states in the United States where farmworkers are recognized as workers under workers' compensation. Coveraae States Same as other Workers . . . . . Arizona, California, Colorado, Connecticut, Hawaii, Louisiana, Massachusetts, Montana, New Hampshire, New Jersey, Ohio, and Oregon (12). Voluntary . . . . Alabama, Arkansas, Idaho, Indiana, Kansas, Kentucky, Mississippi, Nebraska, Nevada, New Mexico, North Dakota, Rhode Island, South Carolina, and Tennessee (14). Limited . . . . . Alaska, Delaware, Florida, Georgia, Illinois, Iowa, Maine, Maryland, Michigan, Minnesota, Missouri, New York, North Carolina, Oklahoma, Pennsylvania, South Dakota, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, and Wyoming (24) -Compiled by the National Safe Workplace Institute with the Assistance of the Farmworker Justice Fund. :igure 6. Workers' Compensation Coverage c Agricultural Workers. Workers' compensation is a no-fault injury program. When you create workers' com- pensation programs, you can not sue your employer for injury. Voluntary really means no program. I am sure-1 do not have any studies but I am sure-that the vast majority of farmers in those states have no workers' compensation insurance. Are there any studies on this subject that you know of? Surgeon General's Conference on Agricultural Safety and Health - 1991 65 Questions to Guide the National Agenda About how many farmers have workers' compensation insurance in the states where it is voluntary ? It would be a good study to do. In these other states-24 states-it is limited, like in Georgia. Farmers who work for the Department of Corrections are covered, but all other farmers are excluded. There are all sorts of different restrictions. We have all the data. We have analyzed the laws. That is the story! Let me say that what we are now recommending to farmworkers who are injured, especially in the states with volun- tary programs where there is no compensa- tion coverage, is to sue. Sue the living "Bejesus" out of the farmer for whom you work. This is the only way that we are going to get the attention of people in states where workers compensation is limited and farm- ers are not covered-sue. It is only recourse the injured have. What has happened historically? To use the terms of economists, the economics of these injuries have been externalized. Who pays for injury in the case of the farmworker or migrant? I can tell you who pays for it. It is the families. It is the local public charities. It is the public hospitals. It is not the farmer. And, of course, if the farmer can external ize the cost and risk to other forces in society, it is rational for that farmer to do so. I am not going to sit up here and just tell you exactly what is going to happen when and where. I do not know. But, believe me, it is moving toward public interven- tions. I hope what that says to each and every one of you out here is that you need to begin to get realistic about how you would like to see these issues addressed. Our country spends more per capita for the education of the young than any other nation, save Switzerland. We spend lots of money to prepare young people for life. Cities help educate farm kids. There is also public investment in human lives, and we need to do more to protect those lives in agriculture. I am sorry if some of you people feel, as my son proba- bly would feel, that I have come and been the "big nasty" here today, but I think that it is time that we begin to look at this and realize that we have got to do something about farm safety.0 66 Papers and Proceedings Public health surveillance is central to the process of disease prevention. Surveillance systems are vital tools in targeting the resources of the public health system and in evaluating program effectiveness. The Institute of Medicine report The Fu- ture @Public Health' found the core functions of public health to be as- sessment, policy development, and assur- ance of the availability of services. Sur- veillance is intrinsic to the assessment function and essential for proper policy development and assurance of service availability. An ongoing national dialogue is needed on the role of public health education in trai- ning future public health professionals; graduates of schools of public health are acknowledging the need for more books and course materials designed to prepare students for public health practice. State and local public health agencies, in partic- ular, have recognized this need as they recruit and hire new professional staff. There is growing recognition of the role of surveillance conducted by agencies of Surgeon General's Conference on Agricultural SaWy and Health FARM&FE 2000 o A National Coalition for Local Action Convened by the National institute for Occupational Safety and Health April 30 - May 3, 7991, Des Moines, lowa SURVEILLANCE FOR AGRICULTURAL SAFETY AND HEALTH William E. Halperin, M.D. National Institute for Occupational Safety and Health Mr. Mark Timm: Our next speaker is Dr. William Halperin. He is the Associate Director for Surveil- lance, Division of Surveillance, Hazard Evaluation, and Technical Assistance, at NIOSH in Cincinnati. Dr. Halperin received his Master's in Public Health and M.D. from Harvard. In 1975 he became an Epidemic Intelligence Officer at the Centers for Disease Control. In 1979 he became the Chief of Industrywide Studies Branch at NIOSH. Dr. Halperin has served on numerous professional and expert committees. He currently serves on the Committee on Risk Assessment Methodology at the National Research Council. Dr. Halperin has published over 100 scientific papers, editorials, and letters to editors. His epidemiological investigations include herbicides, dioxin, and biotechnology. He was a co-author on perhaps the most popular paper in occupational health in the last 10 years-the Sentinel Health Event A Framework for Occupational Health Surveillance and Education. That leads to Dr. William Halperin's topic today, Surveillance for Agricultural Safety and Health. Dr. Halperin: government as well as by industry and labor to advance the mission of public health-"to fulfill society's interest in assur- ing conditions in which people can be healthy."' Although surveillance is an essential ele- ment of the practice of public health, the subject is rarely taught in schools of public health or fully discussed in textbooks of public health or of epidemiology. This gap reflects the diverging cultures of public health between schools of public health and public health practitioners, a diver- gence recently addressed in a report of the Institute of Medicine, The Future of Public Health. The essence of the motivation for public health was captured by the 16th century poet John Donne, who unfortunately came to the wrong conclusion about surveillance. Donne wrote: No man is an island, entire of itself; every man is a piece of the continent, a part of the main. If a clod be washed away by the sea, Europe is the less, as well as if a Surgeon General's Conference on Agricultural Safety and Health - 1991 67 Questions to Guide the National Agenda promontory were, as well as if a manor of they friend's or of thine own were: any man's death diminishes me, because I am involved in mankind, and therefore never send to know for whom the bell tolls; it tolls for thee. The public health sentiment is captured in the following line: Any man's death diminishes me, because I am involved in mankind. This is not a matter of epidemiology or the technology of public health, but rather a matter of the philosophy that motivates public health action. The antithesis of surveillance is captured in the following line: "Therefore, never send to know for whom the bell tolls." In earlier times, church bells were rung when people died. Currently we have a need for similar information to connect us to the burden of morbidity and mortality and to call forth public health practitioners so that deaths and morbid events can be in- vestigated and recurrences prevented. Surveillance in modern times is the equiva- lent of the tolling of the bells with the added commitment to investigation of the causation of morbidity and mortality and dissemination of data and analysis with the goal of prevention. Surveillance, as de- fined by Alexander Langmuir, the father of modern public health surveillance, and the founder of the Epidemic Intelligence Service of the Centers for Disease Control, "means the continued watchfulness over the distribution and trends of incidence through the systematic collection, consoli- dation, and evaluation of morbidity and mortality reports and other relevant data'13" for the purposes of prevention of disease or injury. It is worth lingering over some of the key words in this definition. "Continued watch- fulness" implies that the surveillance pro- cess continues over time, rather than being a one-time survey or epidemiologic study. Repeated surveys from which trends can be discerned are consistent with surveil- lance. "Collection, consolidation, and eval- uation" should differentiate surveillance as a process from the important, but different enterprise of registering cases in a disease register, such as a cancer registry, if this registry does not include analysis of the data and dissemination of the results. "Other relevant data" allows for collection of information on risk factors for disease, health or safety hazards, etc., or preventive interventions, such as immunization, rath- er than limiting surveillance to collection solely of data on disease. To differentiate surveillance from other useful collection of data, such as marketing surveys for a prod- uct, "for the purposes of prevention of injury and disease" should be added to Dr. Langmuir's definition. Surveillance should not be so definitively defined that in-depth investigation of indi- vidual or sentinel cases is excluded. A "sentinel health event" represents a failure of prevention, such as a maternal death or an industrial injury. THE ROLE OF SURVEILLANCE IN PUBLIC HEALTH PRACTICE The practice of public health can be de- fined as the logical application of methods of problem recognition, evaluation, and intervention for the purpose of prevention of disease and injury in populations. A working definition of epidemiology should reflect both the traditional broad notion that epidemiology is "the study of the distribution and determinants of disease 68 Papers and Proceedings frequency in man,"6 which encompasses In comparison to data purposefully collect- interest in epidemic and endemic diseases, ed for a research study, information from as well the inclusion of the supplemental death certificates on industry and occupa- views of theoretical epidemiology. tion and even cause of death will be col- Theoretical or modern epidemiology lected without quality control, by minimally focuses much more on the use of very trained observers, and will inevitably con- sophisticated analytic methodology for tain errors. However, surveillance data, understanding the relationship of risk fac- tor and disease, particularly of endemic often collected for administrative purposes and secondarily used for disease preven- disease, rather than on the description of epidemics.' tion, is inexpensive and readily available. Milham and colleagues found that farmers had a substantial excess in the proportion Surveillance in modern times is the equiv- of deaths due to electrocutions. When the alent of the tolling of the bells with the deaths were investigated, they found that added commitment to investigation of the many were due to contacting electric utility causation of morbidity and mortality and lines with portable aluminum irrigation dissemination of data and analysis with pipe. While the association of the goal of prevention. electrocution and aluminum piping must have been evident to the sphere of people `i involved with each incident, the problem was only brought to the attention of the A useful model that specifies the role of surveillance in the practice of public health public health community by the analysis of minimal information available from death has been developed by Greenwald,* and certificates, and the dissemination of further elaborated by Layde,9 and modified results for the purpose of prevention. here to describe the role of surveillance in the prevention of occupational injury and Data from the Annual Survey of the Bu- disease. reau of Labor Statistics" provide an exam- ple of tracking an occupational health o The first step in public health is the problem as its incidence changes. The recognition of a problem; a related goal is Annual Survey collects data from a sample tracking the trends of a problem as its of logs of injuries and illnesses kept by incidence increases. employers. Sam Milham provides an example from the These data demonstrate an upturn in the analysis of death certificates for industry numbers of cases of repeated trauma. Sur- and occupation.l' Usual industry and occu- veillance has done its job by disseminating pation is entered onto every death certifi- information on this apparent epidemic to cate; however, only in some states is it those with a need to know for the purpose coded in order to be machine readable. of prevention. The related role of From 1979 to 1987, about 2.9 million epidemiologic research necessary to deter- deaths were coded for industry and occu- mine the reality and etiology of this ap- pation in approximately 23 states. parent epidemic should be evident. Surveillance for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 69 Questions to Guide the National Agenda o The second step in the process of public health is the definition of the scope of a problem. Two examples reflect the value of ongoing collection of data in this en- deavor and the usefulness of periodic sur- veys . The first example concerns the surveillance of lead poisoning. In 16 states, laboratories report to the state health department if samples submitted for blood lead determination in adults are in excess of a state standard. This information provides a crude estimate for the burden of occupational lead poisoning for the United States, currently about 17,000 reports each year." A second example of the role of surveil- lance in providing an estimate of the scope of a problem comes from survey informa- tion periodically collected by the National Center for Health Statistics, Centers for Disease Contro1.13 From 1983 to 1987, successive periodic surveys provided infor- mation from approximately 2700 white, male farmers. Farmers report 2.7 cases of skin cancer per hundred farmers. Nonfarmers report less than one case of skin cancer per hundred people. Farmers have three-fold the amount of skin cancer than do nonfarmers. Thus, the periodic survey provides a crude estimate of the scope of the excess of skin cancer in farmers, in contrast to a research study that would likely include confirmation of each case, and which would estimate in substantially greater detail the exposure of the farmers, and would likely be designed to provide information on etiology or per- haps use of preventive measures. o The third step in the public health process is to conduct etiologic research to determine the cause of a disease. This step consists of an epidemiologic study, not surveillance. For example, an epidemiologic study might be conducted to determine the differential exposure of cases of eosinophilia-myalgia syndrome as compared to controls without the disease. It does not require the ongoing collection of information about cases; rather, it re- quires more detailed information about cases occurring during the research period. o Once an etiologic agent or exposure is identified, the fourth step in the public health process is the design of an inter- vention that will prevent transmission of the infectious agent, exposure to a chemical hazard, etc. Examples of inter- vention include immunization, withdrawal of a food contaminant, provision of a ven- tilation system, etc. This is not surveil- lance. o The fifth step involves a trial of the proposed intervention system in an experi- mental situation where a limited number of important factors are carefully con- trolled. This type of public health experi- ment does not involve surveillance. o Successful interventions in the controlled laboratory environment sometimes do not withstand the more rugged environment of the field test, the sixth step in the practice of public health. Surveillance can play a role in selection of field sites for testing. o The seventh step in the public health process is targeting scarce preventive re- sources in order to maximize their effec- tiveness. A classic example comes from the eradication of smallpox.`4 While the burden of smallpox was reduced by mass immunization, smallpox persisted because 70 Papers and Proceedings Surveillance for Agricultural Safety and Health, May 1, 1991 there were sufficient unimmunized to sus- tain transmission. A turning point in ef- forts to eradicate smallpox came with the use of intensive surveillance for cases and the targeting of immunization to the con- tacts of cases. CONCLUSION There are four goals for surveillance. These include: Similarly, greater success in cancer preven- tion might be obtained if screening pro- grams for breast cancer and cervical cancer were targeted to high-risk populations. Another example of the use of surveillance for targeting also comes from the surveil- lance of elevated blood lead based upon laboratory reports. Multiple elevated re- sults from a single worksite almost insure that the work environment is in need of ameli0ration.15 1. The identification of new occupational health problems. 2. The estimation of the scope or mag- nitude of the problem. 3. The delineation of the trend in in- cidence of the illness, disease, or hazard. 4. The targeting of opportunities for prevention. o The eighth step in the practice of public health is the evaluation of the effectiveness of the public health intervention. Tracking the trends of disease is one mechanism for evaluating the effectiveness of intervention. Surveillance is a powerful tool in many parts of the complex continuum of prac- tices that constitutes the public-health problem-solving process. For example, in 1958, Sweden instituted a law that any new tractor that was produced had to have rollover protection.16 In the years thereafter, surveillance data indicate a decline in rollover fatalities. In 1978 Sweden instituted another law that any tractor in use had to have rollover protec- tion, and the problem was eradicated. Epidemiologists have much to owe to the modern father of surveillance and field epidemiology, Alexander Langmuir, who in his wisdom commented, "Good surveillance does not necessarily ensure the making of the right decisions, but it reduces the chan- ces of wrong ones."3O REFERENCES 1. Institute of Medicine, The Future of Public Health. National Academy Press, Washington, 1988. 2. Public Health Service, U.S. Department of Health and Human Services, Healthy People 2000. National Health Promotion and Disease Prevention Objectives, Washington, D.C., 1991. 3. Langmuir A. The Surveillance of Communicable Diseases of National Importance. New EngIand Journal of Medicine. 268:182-191. 4. Langmuir, A. William Farr: Founder of Modern Concepts of Surveillance. International Journal of Epidemiology. 5: 13-18, 1976. Surgeon General's Conference on Agricultural Safety and Health - 1991 71 Questions to Guide the National Agenda 5. 6. 7. 8. 9. Rutstein, D., MulIan, R., Frazier, T., Halperin, W., Melius, J., Sestito, J.: The Sentinel Health Event (Occupational): A Framework for Occupational Health Surveillance and Education, JAPHA 73:1054- 1062, 1983. MacMahon Brian, Pugh Thomas. Epidemiology: Principles and Methodr. Little, Brown and Company, Boston, 1970. Miettinen OK Theoretical Epidemiology: Principles of Occurrence Reseanzh in Medicine. John Wiley and Sons, New York, 1985. Greenwald P, Cullen JW, McKenna JW. Cancer Prevention and Control: From Research through Applications. JNCI 79:389-400, 1978. Layde P. Beyond Surveillance: Methodologic Considerations in Analytic Studies of Agricultural Injuries. American Journal of Industrial Medicine. X3:193-200, 1990. 10. Helgerson, SD., Milham, S. Farm Workers Electrocuted When Irrigation Pipes Contact Powerlines. Public Health Reports. 1985 May-June; 100 (3):325-S. 11. Personal Communication. T. Frazier. NIOSH. Cincinnati, Ohio, 2/91. 12. Personal Communication. Paul Se&man. NIOSH. Cincinnati, Ohio, 2/91. 13. Brackbill, R., Behrens, V., Cameron, L. Prevalence of Conditions among Farmers 1983-1987. in press. 14. Foege, WH, Millar, JD, Lane, JM. Selective Epidemiologic Control in Smallpox Eradication. Am J Epidemiol 1971 Ott; 94(4):311-5. 15. Seligman, P., Halperin, W.: Targeting of Workplace Inspections for Lead. American Journal of Industrial Medicine 20:381-390, 1991. 16. Thelin, A. Epilogue: Agricultural Occupational and Environmental Health Policy Strategies for the Future. AJIM 18~523-526, 1990. 72 Papers and Proceedings Surgeon General's Conference on Agricultural SaWy and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute tbr Occupational Safety and Heatth April 30 - May 3, 1991, Des Moines, Iowa RESEARCH FOR AGRICULTURAL SAFETY AND HEALTH James A. Merchant, M.D., Dr.P.H. Professor, Preventive and Internal Medicine Director, Institute of Agricultural Medicine and Occupational Health The University of Iowa Mr. Mark Timm: Our next speaker is Dr. James A. Merchant, Director of Agricultural Medicine and Occupational Health at the University of Iowa. Dr. Merchant received his B.S. from Iowa State University, his M.D. from the University of Iowa, and his Doctor of Public Health in epidemiology from the University of North Carolina. In 1988, he became an Epidemic Intelligence Officer at the Centers for Disease Control with an assignment to the North Carolina Board of Health. After this assignment, he served as Assistant Professor in Medicine at the University of North Carolina. In 1975, Dr. Mer- chant became Director of the Division of Respiratory Disease Studies at NIOSH. In 1981, he became and currently is Professor of Preventive and Internal Medicine at the University of Iowa. Dr. Merchant has published broadly in pulmonary medicine and epidemiology. His early work was in associating cotton dust exposure with byssinosis. He has published broadly on different lung diseases, which include problems with vegetable dusts and other organic dusts in agriculture, farmers' lung, and asthma.' Dr. Merchant is active in professional organizations and in chairing and serving on expert committees at both the national and the international levels. Allow me to introduce to you Dr. James Merchant to speak on Research for Agricultural Safefy and Health. Dr. Merchant: ABSTRACT In identifying research priorities for agricultural health and safety, one must first define the populations at risk. In agriculture, those at risk greatly exceed the number of farmers who report sole or primary employment from agriculture. Agricultural production is now changing dynamically, resulting in a substantial increase in farmers with non-farm jobs, greater involvement of women and seasonal workers, and involvement of children and recreational farmers in agricultural operations. All are exposed to some degree to multiple farm hazards-farm machinery, livestock, chemicals, organic dusts, and a wide variety of biological hazards. Priorities for research in agricultural safety and health include disease and injury surveillance; epidemiological investigations of morbidity, mortality and risk factors; studies of toxicological effects and mechanisms of disease; and the opportunity for meaningful intervention for disease and injury prevention. Those engaged in this research must also recognize the influence of poverty, limited access to health care, and limited in- surance coverage among many living and working in rural areas. As the result of the national initiative in agricultural and environmental health, federal, state and foundation funding is now available to address these research priorities. The challenge is to maintain and cultivate these research opportunities through targeted research designed to advance our understanding and prevention of diseases and injuries among those with agricultural exposures. THE POPULATION AT RISK ry employment in farming; 3.1 million reported some farm income; there were The population at risk to farming expo- 2.7 million hired to do farm labor; and sures is not known with precision, In 1980, there were an additional 6 million farm- some 2 million Americans reported prima- family members, some of whom did farm Surgeon General's Conference on Agricultural Safety and Health - 1991 73 Questions to Guide the National Agenda work. But the number of full-time farmers is being reduced as agriculture moves dynamically to larger numbers of corporate farming operations, with greater numbers of part-time farmers and farmers with off- farm jobs, and more farm wives employed in both farm and off-farm jobs, while sig- nificant farm work is contributed by chil- dren under the age of 18. A state-wide survey of Kentucky farms found 26 percent of farm men had off-farm jobs, 15 percent of farm women had off- farm jobs, and 23 percent with both farm men and women holding off-farm jobs.' Women's role in agricultural production has been largely ignored in the occupation- al literature, yet the proportion of women participating in the agricultural workforce has risen steadily from 11 percent in 1940 to 46 percent in 1980.' In the University of Iowa Farm Family Survey of 1988 that included Iowa, Wash- ington and New York states, 25-40 percent of women (depending on the state) were employed full-time in farming, and 45-55 percent were employed part-time in farm- ing. Only 11-30 percent reported doing no farm work.' In addition, 3549 percent of the farm women surveyed were employed in off-farm work. Thus, many farm men face two work exposures (farm and off- farm job) while many farm women face three (farm, off-farm job, and home). In addition to the occupational risks posed by the off-farm jobs, there is a significant additional risk of travel to and from the off-farm job on rural road-ways, often under poor driving conditions. As 64 per- cent of the nation's 48,700 motor vehicle deaths in 1988 occurred in rural areas, travel to and from work poses an addition- al occupational risk, which has often been ignored in occupational health and safety research.4 There is even less information on the num- bers of children at risk to agricultural operations. In the University of Iowa Farm Family Survey, the proportion of farms reporting children regularly doing farm work ranged from 18 percent (New York) to 23 percent (Iowa).3 It is recog- nized, however, that the number of children at risk to agricultural operations is much larger, as they are often exposed to farm machinery, buildings, and livestock while not engaged in routine farm work. Migrant farmers are the most fluid popula- tion at risk in agriculture. The numbers at risk are not adequately defined, but it is known that migrant farmers assume some of the highest risks from exposure to agricultural chemicals, long hours, and some exposure to agricultural machinery, in addition to poor living conditions, limited-if any-insurance or health care, and often an additional risk of extensive travel over the harvest season. Migrant farmers are especially challenging to study, as they are highly mobile, have variable exposures, and are a difficult population on which to obtain valid data because of language and legal barriers. Migrant farmers are, nevertheless, a very high priority for research because of their extensive exposures and other risks to health. An additional population at risk in agricul- ture is the weekend or recreational farmer who typically farms a few acres using older farm machinery, often has some livestock, and often uses the same farm chemicals as full-time farmers. The number of weekend farmers is not known, but is increasing as 74 Papers and Proceedings urban areas encroach on adjacent farm factors and the multiple risks they face land. in agricultural work are. Thus, the total population at risk to agri- These questions will be high priorities for cultural exposures is large, but the number the NIOSH Farm Family Health and Haz- is unclear-while the number of full-time farm workers appears to be decreasing, the ard Survey and should also be priorities for others engaged in health and injury surveil- total population at risk to agricultural lance and epidemiological studies of agri- operations may not be, given the diversity cultural workers. of multiple work roles of farm men, wom- en, children, and migrant workers. Cur- RESEARCH METHODS rently, there is no uniformity in classifica- tion of farm men, women, and children in Research approaches to agricultural safety regard to farm work and off-farm work. and health may be divided into five broad Clearly, development of such a classifica- research methodologies: tion would be useful for assessment of agriculture - related diseases and injuries 1. Basic Research (Toxicology and Mecha- among those living in rural America. nisms). Therefore, four research priorities are: 2. Disease and Injury Surveillance (Infor- mation Systems). 1. To determine the distribution of farm men, women, and children and the total 3. Epidemiological Studies. population at risk in agriculture. 4. Demonstration and Education Research 2. To develop the best standard classifica- (Intervention Studies). tion of farm men, women, and children, by on-farm and off-farm employment, 5. Health Services Research. that will provide the most relevant clas- sification for health surveillance and Basic Research epidemiological assessment. Basic research is essential for adequate 3. To assess what additional occupational development of prevention strategies for morbidity and mortality is attributable agricultural safety and health. While this to off-farm work and to travel to and is less true for injuries, there is still a great from off-farm work, and what the inter- need for basic research on the toxicology active effects of these multiple risks on and mechanisms by which various agricul- disease and injury incidence are. tural exposures cause adverse health ef- fects. 4. To determine, especially among migrant farm workers, what non-farming mor- b One clear need for greater basic bidity and mortality is attributable to research is in the area of toxicological living conditions, limited availability of testing of agricultural chemicals, especially health care delivery, and extended trav- el and what the interactions of these older pesticides that have not yet been tested for acute and chronic toxicity. This Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 75 Questions to Guide the National Agenda is a subset of a larger testing issue faced by the National Toxicology Program. o At a National Institute of Environmental Health Sciences Conference on Agricultur- al Chemical Utilization and Human Health, the need for further chemical testing to address organ function, perinatal toxicity, immunotoxicity, and chronic and delayed effects including cancer and de- layed nervous system manifestations (and testing of combinations of chemicals) was strongly recommended. b A second area where basic research needs to play an important role is in the emerging area of agricultural biotechnology. Genetically engineered microorganisms promise substantial benefits for food production throughout the world. Potential benefits include new crop varieties that will benefit the grower through lower input costs and increased productivity, the food processor through production of higher-quality and consistent products, and ultimately the consumer through production of more appealing and nutritious foods. Use of biotechnology in agriculture has potentially significant implications for agricultural safety and health. Two potentially lowered risks that may accrue through use of agricultural biotech- nology include: 1. Reduced use or replacement of agricultural chemicals now known to be harmful to human health. 2. Reduced field exposures to crop production, especially to farm machinery, which is known to be the single greatest risk in farming. Biotechnology is currently being regulated by EPA through the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA, 7 U.S.C. 136-136~) and regulation adopted in 1984 (49 Federal Register 40659), the Toxic Substances Control Act (TSCA, 5 U.S.C. 2601-2929), and by the USDA through provisions of the Plant Pest Act (7 U.S.C. lSOaa-jj) and regulations adopted in June of 1987 (CFR Part 330). o While regulation of this emerging tech- nology provides some assurance that ap- propriate testing will be done, from a pub- lic health perspective it is essential that necessary testing for adverse effects on plants and animals be conducted in the laboratory and in small field experiments. Experience to date suggests that the use of biotechnology in agriculture will not be associated with unpredictable exposures that cannot be addressed using appropriate work practices.' Disease and Injury Surveillance The development of disease and injury surveillance or information systems is a very high priority for the advancement of agricultural safety and health research. As surveillance is covered by another speaker, I will confine my comments to those infor- mation systems especially important to epidemiological research. These informa- tion systems fall in two categories-those dealing with health effects (injuries and diseases) and those dealing with exposures (cohorts with specific exposures or systems defining exposures to which human or animal populations may be linked). o Information systems that are especially useful in epidemiology are specific disease and injury registries. Often existing cancer registration data is available from state or 76 Papers and Proceedings hospital data. Use of these information and birth defect registries. Data on the systems is an inexpensive and powerful epidemiologic tool. sale of certain farm chemicals provide another type of exposure registry. Another Through the State Health Registry of Iowa type may be derived from widespread tes- ting of drinking water for nitrates and at the University of Iowa, we are now able pesticides. to register birth defect and cancer inci- dence. An Alzheimer's Disease Registry has also been developed for some counties, While these exposure registries usually provide evidence of exposure to certain and a Rural Injury Surveillance System is now under development. agricultural chemicals, epidemiological research requires much more detail in terms of the types and amounts of specific These health effect registries are especially chemical use, the time-frames of use, the useful as they allow systematic collection type of application, and the use (and non- of large numbers of specific types of birth use) of protective equipment. These types defects, cancers, or injuries that can then of data must almost always be collected be studied quantitatively through the use retrospectively, but could be collected of case control studies. This approach has prospectively in a small cohort or in a been used effectively in the assessment of sample of a larger cohort. risk factors for a variety of specific types of cancer. Collection of representative exposure data is also essential in cross-sectional studies of The same approach is now being applied injuries and health effects. These data are to birth defects, which have an added ad- necessary in order to derive exposure vantage of having a much shorter latency response relationships, which are essential (hence more accessible and valid data). In to the development of guidelines for re- the case of injuries, there is no latency and duction of exposures and the prevention of the circumstances of injury are usually diseases and injuries. clear. This will allow the injury registry to collect more data at the time of the event o There are very few trained industrial and thus reduce the time and cost of case hygienists specializing in agriculture. The control studies. need for these skills in the collection and interpretation of environmental data is Epidemiological Studies critical to advance agricultural health and safety research. o A significant problem in assessment of surveillance and epidemiological data is the lack of adequate exposure data. The development of exposure registries is, therefore, especially attractive, Demonstration and Education Research Closely related to epidemiological research is the area of demonstration and education For instance, large cohorts of pesticide applicators who must be licensed to do their work now provide an especially im- portant opportunity for epidemiological research through record linkage to cancer research that utilizes intervention studies. While epidemiological research may clear- ly show an excess in a certain type of can- cer, birth defect, respiratory disease or specific type of injury, a valid model for Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 77 Questions to Guide the National Agenda intervention may not be available or may be difficult to implement. The traditional intervention model in occu- pational safety and health is that of regula- tion, which has seen some significant suc- cesses, such as the reduction of respiratory disease through the regulation of coal mine dust and cotton dust. Occupational safety and health regulation has, however, been greatly diminished over the past decade, and agriculture has traditionally not been a regulated industry. If we cannot develop a U.S. model for a proven intervention on the single most important cause of agricultural mortality, how can we succeed in addressing less dramatic yet still important causes of agricultural diseases and injuries? As a result, more innovative intervention methods for disease and injury prevention are needed in agricultural safety and health. A good example of the need for such a model is the prevention of tractor roll-over deaths through the application of roll-over protective structures (ROPS) on both new and older tractors. The epidemiological evidence for the very significant risk posed by tractors without ROPS is clear. The data available from Sweden, which mandated such a program, makes it equally clear that ROPS can prevent almost all tractor roll-over deaths. o An important question for this confer- ence is whether an American intervention model can be developed that can produce a significant reduction of tractor roll-over deaths and injuries. A second question, with much broader ramifications, is, "If we 78 cannot develop a U.S. model for a proven intervention on the single most important cause of agricultural mortality, how can we succeed in addressing less dramatic yet still important causes of agricultural diseases and injuries?" Health Services Research An observation made by Dr. James A. Dosman in his summary of the research workshops prior to the conference, "Agri- cultural Occupational and Environmental Health: Policy Strategies for the Future," was the following: It is striking that the organized scientific documentation of specific health risks is occurring at a time when changing rural economic resources and family and rural community infrastructures are leaving few community resources to alter specific risk patterns. Thus, the assessment and pre- sentation of health and family-life deft- ciencies must be viewed in a climate of economic adjustment, rural population decline, and loss of personal, financial, and social control by individuals and families. However, one must realize that whereas all these changes are occurring simultaneously, unacceptable injury, death, and dysfunction are occurring on the farms and in rural areas. This co- nundrum describes a widening gap in diagnostic and preventive health services, and in family support services, between rural dwellers and city dwellers.." While this paper is not intended to address the very broad field of health services research, this quotation points out that there are significant differences between rural populations and their urban counter- parts, which must be taken into account in conducting epidemiological research. In nearly every parameter of health-disease Papers and Proceedings and injury incidence, availability of health agricultural mortality over the past ten care, and related social services years has shown relatively little -people living in rural areas have less improvement and remains higher than that favorable statistics than their urban coun- of mining and construction. terparts.' Especially vulnerable are migrant agricultural workers who are at NIOSH, through its National Traumatic triple jeopardy-poor, rural and uninsured. Occupational Fatalities (NTOF) database, reports 20.7 deaths per 100,000 agricultural o These social service and health-care workers, versus 7.9 deaths per 100,000 for delivery factors clearly influence the inci- the general private - sector workforce.' dence of rural injuries and diseases and Results of epidemiological studies and point up the importance of interaction and newly developed surveillance systems sug- collaboration between those engaged in gest these national estimates may sig- agricultural health and safety research with nificantly underestimate both deaths and rural sociologists and those engaged in farm-related injuries. rural health care delivery research. AGRICULTURAL DISEASE AND INJURY RESEARCH PRIORITIES The Iowa Department of Public Health farm injury surveillance program (SPRAINS) reported 83 deaths for 1990 based on voluntary reports from health- Injury Morbidity and Mortality care providers." As this was the initial year of reporting, it is thought that this Available data on the risk of injury and number is incomplete; yet this number of traumatic death consistently reflect a high- deaths is over 60 percent higher than er injury risk to those living in rural com- previous estimates of farm deaths in Iowa. pared to urban areas, with a mortality rate Epidemiological studies draw our attention for unintentional injuries twice that of to the importance of farm machinery in urban areas.* This excess is attributable to fatalities and severe injuries, to higher several factors, including increased mor- rates of injury among children and the tality from motor and non-motor vehicle aged, and to the substantial numbers of deaths arising from higher speeds on intentional deaths (suicides and homi- poorer roads, less seat belt use, more use cides)." of high-risk utility vehicles, and poorer access to trauma care. At particular risk While it is clear that traumatic injuries and to rural injury are farmers, their family deaths are epidemic on American farms, members, and hired and migrant laborers. we still lack national and state-based information systems (surveillance), a rea- In addition to the several factors that place sonable understanding of risk factors, and rural residents at increased risk are added an adequate characterization of hazards of the occupational risks of farming. The farming associated with injury morbidity National Safety Council estimated deaths and mortality. Therefore, three research among farm residents to be 56.2 per priorities in the area of traumatic injuries 100,000, 30.1 of which were motor-vehicle- are: related, 20.1 work-related (18.1 in farm work), 8.0 home-related, and 4.0 public 1. Development of national and state- non-motor vehicle deaths.4 The trend in based information systems, which will Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 79 Questions to Guide the National Agenda provide essential injury and injury mor- tality incidence data by type of injury (ICD-9 codes), cause of injury (E- codes), place of injury and demographic information on the injured party. 2. From surveillance data or large epide- miological studies, case control studies of specific farm injuries, which will allow much better understanding of risk factors associated with the injury. 3. A much better environmental assess- ment of farm machinery, farm buildings, livestock operations, on and off-road vehicles, agricultural chemical use and storage, and available prevention mea- sures. This assessment is essential to epidemiological surveys and case- control studies Respiratory Health Effects Farmers and other agricultural workers are exposed to a number of respiratory haz- ards, the most common of which is organic dust. Additional exposures, which are known to be important include several agricultural chemicals, toxic gases from livestock confinement facilities, toxic and immunogenic constituents of microorgan- isms, feed additives such as antibiotics, and infestations of insects, which may produce lung disease." l3 A common denominator in these exposures is a significant exposure to organic dust, which has been shown by many epidemio- logical studies to result in acute symptoms of airway inflammation, heightened airway reactivity and asthma, and acute changes in lung function. Pulmonary edema followed by bronchiolitis obliterans and hypersensi- tivity pneumonitis are relatively uncommon but well-known pulmonary conditions aris- ing from certain agricultural exposures. In some agricultural populations with long exposure to organic dust, fixed airway obstruction has been observed. Despite recent interest in this area, there are sig- nificant research gaps including the follow- ing: 1. There is little surveillance data and incomplete epidemiological data on respiratory diseases in several agricul- tural populations. Disease patterns and risk factors are still incompletely understood in the animal confinement and grain handling and processing in- dustries, and from exposures to agricultural chemicals such as anhydrous ammonia. 2. `&here is a very great need for the de- velopment of dose-response data for agricultural exposures in order to allow fuller development of prevention strate- gies. 3. There is a need to more fully explore certain environmental factors, such as exposure to storage mites and the toxic products of certain microorganisms, in both the laboratory and through field studies. Cancer Epidemiological studies reported a decade ago initially raised questions about an association between soft-tissue sarcoma and lymphoma and exposure to acetic acid herbicides and chlorophenols. Since then, over 20 additional cohort and case-control studies have addressed this issue. The results of these studies are not consistent, but excess deaths from non-Hodgkin's lymphoma, multiple myeloma and leuke- mia have shown more consistent positive associations. 80 Papers and Proceedings In addition, excesses of lung, stomach and Assessment of adverse reproductive effects prostate cancer have been observed in has a significant methodological advantage cohort studies of manufactures and appli- over assessment of cancer incidence in that cators.14 Other potential risk factors for cancer incidence include viruses, and the latency from the time of exposure to the time of the reproductive effect is much dietary and other factors as possible shorter than that for cancer, which is gen- contributors to cancer incidence among agricultural workers." A number of erally 20 or more years. The lack of birth methodological issues pose difficulties in defect information systems has greatly hampered evaluation of birth defects in interpreting these findings and indicate association with environmental exposures. priorities for research in this area: Priorities for research in this area fall in two areas: 1. There is a uniform need for better environmental characterization of agri- 1. Additional systematic toxicological test- cultural chemical exposures through the ing of agricultural chemicals and com- development of valid and inexpensive monly used combinations of chemicals environmental exposure protocols. for adverse reproductive effects. 2. Use of exposure registries linked with 2. Further development of birth defect cancer registries promises to provide registries and linkage of these infor- important additional data on cancer risk mation systems with exposure registries, among agricultural workers. and through the development of case- control studies with adequate exposure 3. Improved epidemiological methods to data. assess and validate previous agricultural and other exposures are needed for Neurological Health Effects adequate analysis and evaluation of cancer data. Recent reviews of the neurotoxic effects of pesticide exposure have focused on chronic Reproductive Health Effects neuropsychological sequelae from expo- sures to organophosphate pesticides.19'" Concern about possible adverse While the early (immediate and delayed) reproductive health effects arises from neurotoxic effects are well-described for toxicological testing showing some agricul- organophosphate intoxication, until tural chemicals to be teratogenic, from recently little attention had been given to widespread use of some of these chemicals, evaluation of possible chronic effects. and from some case reports suggesting as- sociations between certain adverse repro- However, as the result of several case ductive effects and agricultural expo- studies and clusters of adverse behavioral sures.16' " The reports on dibromochloro- and neurological findings, the World propane (DBCP) on male reproductive Health Organization (WHO) and the function have provided an important exam- ple of the toxic effects of this pesticide, an United Nations Development Programme (UNDP) are coordinating a ten-country exposure, which now continues in some developing countries." European, prospective epidemiological study on the neurotoxic effects of low-level exposure to organophosphorus pesticides. Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 81 Questions to Guide the National Agenda This study includes both pesticide for- mulators and agricultural workers. Ad- ditional studies of three types are needed: 1. A replicate of the European study through the use of recently developed and standardized tests of neuro- psychological function and extensive characterization of exposures to organo- phosphate pesticides; 2. Well-controlled follow-up studies of workers who have documented cases of acute organophosphate intoxication for possible chronic neuropsychological effects; and 3. Greater attention to neurotoxic effects of agricultural chemicals through toxico- logical testing. Repetitive Trauma Trauma research in agricultural populations has focused almost entirely on acute traumatic injury and death. Yet repetitive trauma is known to be a much more significant problem than acute trau- ma in most industries. There is reason to suspect that significant repetitive trauma may occur as the result of vibration and repetitive tasks in the use of farm machinery and other farming oper- ations. A recent case-control study of hip joint arthrosis among Swedish farmers found a relative risk for this condition between 2.1 and 3.2, varying by length of time in farming.2' There is also reason to believe that long hours of work on agricultural machinery may induce significant muscle fatigue, which may, in turn, contribute to the risk to acute injury. Repetitive trauma has not been systematically studied among farming populations, but should be a research pri- ority: 1. Surveys of farming populations to assess acute injuries or other health effects should also include assessment of repet- itive trauma conditions, especially those involving the back, hip and knee. 2. Collaboration between agricultural engineers and biomechanical engineers should focus on ergonomic factors that may contribute to repetitive injuries and how these factors may be mitigated. Dermatitis Dermatitis is a condition endemic in farm- ing. Data from the Bureau of Labor Statistics (BLS) indicate a five-fold greater incidence of dermatitis among farm workers compared to workers in general industry. Because of the limitations in BLS data for agricultural workers, these findings may represent a significant underestimation of dermatitis in this working population. A recent survey of California grape and tomato workers found a high cumulative incidence of dermatitis, suggesting that dermatitis is a frequent and recurrent problem among these farm workers." 1. There is a need for systematic dermato- logical surveys of Earm workers with attention given to criteria for classifica- tion of dermatological conditions, to the sensitivity and specificity of question- naires, and to the correlation between questionnaire and exam results. 2. There is a great need for environmental evaluation and measurement of derma- tological irritants and sensitizers. 82 Papers and Proceedings 3. Development and evaluation of inter- vention programs to prevent dermatitis among farm workers are further re- search needs. Noise-Induced Hearing Loss agricultural industries and foundations, to the interest and support of several state and federal agencies, to the efforts of the National Rural Health Association, to the work of many university faculty who par- ticipated in the conferences and briefings, and to the commitment of many members Several studies have now reuorted bilateral high-frequency hearing loss io be quite of the U.S. Congress and several state legislatures. prevalent among farmersp Of particular concern is the frequency with which this As a result, and for the first time, a abnormality is observed among farmers healthy dialogue has involved all parties to under the age of 30. This strongly suggests these important issues. Significant resourc- that noise is the cause of this injury. In- es are now available through federal ap- deed, farm machinery and chain saws are propriations and some state appropriations known to generate noise levels above to mount this national research and inter- recommended limits. A further finding has vention initiative. This research effort is been that relatively few farmers use just beginning. The challenge ahead is to hearing protection. Therefore, research maintain this momentum and build upon priorities here include: these gains. 1. Systematic industrial hygiene surveys to CONCLUSIONS characterize farming operations where noise levels exceed recommended lev- 1. The high risk of disease and injury els. arising from agricultural exposures has now been recognized and has now been 2. Development and evaluation of inter- placed on the national public health vention programs to provide adequate agenda. hearing protection to those engaged in these farming operations. 2. Adequate resources and incentives have been provided to address the multiple THE NATIONAL AGRICULTURAL AND research priorities. These resources ENVIRONMENTAL HEALTH INITIATIVE must be maintained and cultivated. Since the publication of Agn'cultire At 3. A healthy dialogue has promoted the Risk: A Report to the Nation, which sum- involvement of most parties. Greater marized the recommendations arising from efforts are needed to involve full the national public policy conference, "Ag- representation of children, women, ricultural Occupational and Environmental migrants, and the rural poor. Health: Policy Strategies for the Future," and the dissemination activities of the 4. The challenge ahead is to prioritize, NCASH, there is a new level of awareness implement, and publish research fin- of the magnitude and severity of disease dings and translate this research into and injury among American agricultural meaningful prevention and health deliv- workers. Significant credit for initiation of ery programs.0 and support for this effort is due to several Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 83 Questions to Guide the Natlonal Agenda REFERENCES 1. Coughenour CM and Swanson L. Work Statuses and Occupations of Men and Women in Farm Families and the Structure of Farms, Rural Sociology. 48(1):23-43, 1983. 2. Fassinger PAD and Schwarzseller HK. The Work of Farm Women: A Midwestern Study, Research in Rural Sociology and Development. (1):37-60, 1984. 3. Ungar RL. Farm Women at Risk: Work Roles and Agricultural Bposures. Thesis, Department of Preventive Medicine and Environmental Health, The University of Iowa, 1990. 4. National Safety Council. Accident Facts, 1988 Edition. National Safety Council, Chicago, Ill, 1988. 5. Glass DJ. Agricultural Biotechnology: Occupational Health and Regulatory Issues in Occupational Medicine: State of the Art Reviews. 6(2):301-309, 1991. 6. Dosman JA. Technical Workshop Report: Working Group I: Occupational Health and Safety Strategies for Agriculture, American Journal of Industrial Medicine. 18:353-356, 1990. 7. Summer L. Limited Access: Health Care for the Rural Poor. Center on Budget and Policy Priorities, Washington D.C., 1991. 8. Baker SP, O'Neill B. and Karpf R. The Injuly Fact Book. Lexington, Mass.: Lexington Books, 1984. 9. Myers JR. National Surveillance of Occupational Fatalities in Agriculture, American Journal of Industrial Medicine. 18(2):163-168, 1990. 10. Currier R. Iowa Department of Public Health, Personal Communication, 1991. 11. Stallones L. Surveillance of Fatal and Non-Fatal Farm Injuries in Kentucky, American Journal of Industrial Medicine. 18(2):223-234, 1990. 12. Merchant JA. Agricultural Respiratory Diseases, Seminars in Respiratory Medicine. Thieme, Inc., No.3, 7:211-224, New York, 1986. 13. Merchant JA. Agricultural Exposures of Organic Dusts. Occupational Medicine: State of the Art Reviews. 2(23) April-JuneXl9-425, 1987. 14. Blair A and Zahm SH. Herbicides and Cancer: A Review and Discussion of Methodologic Issues, Recent Results in Cancer Research. 120~132-145, 1991. 15. Pearce N and Reif JS. Epidemiologic Studies of Cancer in Agricultural Workers, American Journal of Industrial Medicine. 18(2):133-148, 1990. 16. Schwartz DA and LoGerfo JP. Limb Reduction Defects in the Agricultural Setting, American Journal of Public Health. 781654-659, 1988. 17. Gordon JE and Shy CM. Agricultural Chemical Use and Congenital Cleft Lip and/or Palate, Archives Environmental Health. 36(5):213-221, 1981. 18. Whorton D. Dibromochloropropane Health Effects, Chapter 48 in Environmental and Occupational Medicine. WN Rom (Ed). Little, Brown and Company, Boston, 1983. 84 Papers and Proceedings Research for Agricultural Safety and Health, May 1, 1991 19. Rosenstock L, Daniell W, Barnhart S., Schwartz D, and Demers PA. Chronic Neuropsychological Sequelae of Occupational Exposure to Organophosphate Insecticides, American Journal of Industrial Medicine. 18(2): 321-326, 1990. 20. Davies JE. Neurotoxic Concerns of Human Pesticide Exposures, American Journal of Industrial Medicine. 18(2):327-332, 1990. 21. Thelin A. Hip Joint Arthrosis: An Occupational Disorder Among Farmers, American Journal of Industrial Medicine. 18(2):339-344, 1990. 22. Schenker MB and McCurdy SA. Occupational Health Among Migrant and Seasonal Farmworkers: The Specific Case of Dermatitis, American Journal of Indusbial Medicine. 18(2):345-352, 1990. 23. May JJ, Marvel M, Regan M, MarveI LH, and Pratt DS. Noise-Induced Hearing Loss in Randomly Selected New York Dairy Farmers, American Journal of Industrial Medicine. 18(2):333-338, 1990. Surgeon General's Conference on Agricultural Safety and Health - 1991 85 Surgeon General's Confemnce on Agricultural Satkty and Health FCWMSAFE 2000 . A National Coalition for Local Action Convened by the National institute rbr Occupational Satrsty and Health April 30 - May 3, 1991, Des Moines, iowa INTERVENTION FOR AGRICULTURAL SAFETY AND HEALTH Myron D. Johnsn.@ Ph.D. Administrator, Extension Service' United States Department of Agriculture Mr. Mark Timm: From Washington, D.C., our next speaker is Dr. Myron Johnsrud, Administrator of the USDA Extension Service. Dr. Johnsrud holds a master's and doctor's degree in administration from the University of Wisconsin and farmed for a number of years in North Dakota. He directed the North Dakota State University Cooperative Extension Service for 12 years. He served as chairman of the Great Plains Agricultural Council, and served on the Board of Directors of the Prairie Public Television Corporation and on the Board of Trustees of the National 4-H Council. Since 1986, Dr. Johnsrud has directed the US. Department of Agriculture's Extension Service. In thls position, he is responsible for a $15 million program and $370 million of federal allocations to the land grant univer- sities for cooperative extension service programs. He is responsible for a major program for redirecting the Extension Service, in partnership with the Cooperative Extension Service, a national network in the 50 states and territories, and more than 3,100 countries. The redirection focuses on current and critical issues of the nation. Dr. Myron Johnsrud will speak to us this morning on the critical issue of lnrervenrion for Agricultural Safety and Health. Dr. Johnsrud: INTRODUCTION are in protecting agricultural workers and "The health of the people is real& the foundation upon which all their happi- ness and all their powers AS a state de- pend ," Benjamin Disraeli, prime minister of Brit- ain, made that statement in a speech over 100 years ago, and it is still right to the point today. Safety, too, which we link closely with health, has long been essential to civilization. Salus populi suprema lex ("The people's safety is the highest law") was a legal and political maxim of ancient Rome. The need for surveillance and research to guide injury control efforts in agricultural safety and health presents many challenges that have been identified by the previous speakers. However, we must ask ourselves how society will judge our success in solv- ing the problems of agricultural injuries. I believe that society will judge our success by how effective our intervention methods 86 helping create the change in their behavior necessary for their success. Intervention countermeasures will rely upon the knowledge gained from research and sur- veillance programs to implement effective solutions to agricultural health and safety problems. What makes agricultural production one of the most hazardous occupations in the United States? As we attempt to prevent and reduce the incidence of fatal and serious accidents and chronic illness on our farms and ranches, do we know what areas to focus on for the most success? How do we keep agricultural safety and health from being overlooked when ad- dressing other issues that confront agricul- ture, such as the environment, animal wel- fare, or energy? How wide is our scope+loes it stop at the farm gate or timber mill? Or, does it include many segments of food, feed, and fiber processing? Papers and Proceedings These are just a few of the questions con- occupational injuries experienced by agri- fronting us today in the important issue of agricultural safety and health. This mom- culture over the past 50 years is due to the accomplishments of these professionals ing I want first to present a brief history working cooperatively through or- and the current status of intervention ef- ganizations such as the National Institute forts. Second, I will pose questions to for Farm Safety and the safety committees guide the concurrent session on developing and standards committees of the American intervention strategies for various targeted Society of Agricultural Engineers (ASAE). audiences, approaches to intervention, and the need for collaboration. Third, I will We cannot ignore the fact, however, that suggest some areas that I see as the pres- the rate of decline in agricultural fatalities sure points, injuries, and fatalities of high- and injuries is much slower than that expe- est priority and the places where we have rienced by mining and construction, the the best chance to intervene successfully. other two most hazardous industries in this nation. Except for this fact, we would not CURRENT STATUS OF INTERVENTION be here today. Because of it and the ef- forts of such organizations as NCASH, the Voluntary safety efforts have had much Congress has recognized the need to com- success. Agriculture has the most exten- mit additional resources to research, sur- sive community of voluntary safety profes- veillance, education, and intervention pro- sionals of any industry in the United grams. States. What was probably the first farm safety effort began in 1933, when the Sixth Most of the new programs are being ad- Annual Rock River Valley Safety Confer- ministered by NIOSH. In administering ence meeting at Fort Atkinson, Wisconsin these programs, NIOSH has recognized the organized a farm safety section. value of supporting existing programs. Au example of this is NIOSH's intervention In 1937 the National Safety Council held a program Agricultural Safety and Health meeting of an agricultural section. Its first Promotion Systems, which is providing farm conference took place in 1947. An funding to enhance educational safety organized professional effort to prevent programs through the Cooperative Exten- farm accidents began in the Cooperative sion System in 15 states. Extension system early in the 1940's with appointment of a full-time Extension farm Two new NIOSH programs crucial to de- safety specialist by the University of Wis- veloping intervention include establishing consin. two new centers in Iowa and California for agricultural research and education and A coalition of farm safety professionals supporting occupational health and safety representing agricultural equipment nurses in agricultural communities. These manufacturers, the Farm Bureau, insurance programs exemplify, too, the key questions companies, and the Cooperative Extension we must ask ourselves in developing System chartered the National Institute for strategies for intervention programs. Farm Safety in 1961 to provide a forum for the exchange of research results, surveil- 1. How do we implement promising and lance data, and effective intervention met- innovative new programs such as nur- hods. Much of the success in reducing the sing services in agricultural communities Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 87 Questions to Guide the National Agenda so that they complement existing inter- vention programs? 2. How do we foster programs that utilize the existing infrastructure of or- ganizations, such as the Cooperative Extension System and the National Safety Council, to enhance our ability to make the most effective use of resourc- es available for intervention programs? What is the current status of safety features on farm equipment? New farm equipment being sold today has the latest state-of-the-art safety technology. When machines are used and maintained proper- ly, injuries and deaths from machinery- related accidents can drop dramatically. ROPS for tractors and tractor seat-belt use could prevent the majority of tractor-relat- ed deaths. Virtually all new tractors sold in the United States have ROPS. Because of the relatively long life of trac- tors, most agricultural tractors in use do not have ROPS in place. Nearly half of the approximately 400 tractor-related deaths that occur each year in this nation involve rollovers. How do we ensure that the older tractors and machines without these modern safety features get retrofitted with modern safety features when feasible or get taken out of use? The issue of how such updating and retrofitting is practical presents a significant challenge. I encourage us not to focus solely on trac- tor fatalities, though they have become a focus of considerable media attention. They account for only a small percentage of nonfatal injuries on farms, compared with traumatic injuries from other causes and chronic occupational illnesses. Engi- neering and safety standards have long been the primary method of injury control. Many manufacturers of agricultural equip- ment rely heavily upon the voluntary stan- dards of ASAE in equipment design when no mandated standards exist. The devel- opment and issuance of technical standards by ASAE has contributed strongly to inter- vention for many years. New standards and updates related to safety are constantly needed. What inter- vention programs do we need to ensure that the vast array of small manufacturers of farm equipment are aware of and comply with both mandatory and voluntary standards? Unlike the situation in many other in- dustries, the autonomy of the agricultural workplace can render many safety stan- dards useless as safety features are discard- ed or overridden. How will this problem be overcome? DEVELOPING INTERVENTION STRATEGIES Characteristics of Target Audiences How wide a net do we cast for our targets? Do we include forestry and logging? Food, feed, and fiber processing? Textile mills? Workers at fast-food chains? Food safety in general, which means all of us who eat? As a first level of how wide we cast our net, let us focus on the 3.32 million per- sons who work on the nation's farms and ranches. Nearly half of these people are self-employed farm operators. The bal- ance are unpaid workers (family), agricul- tural service employees, and workers hired directly by farm operators. What methods would work best for reaching farmers ? A recent study in New York State found that farmers and farm- 88 Papers and Proceedings workers, while acknowledging the need for health and safety, did not have time to may be possible if children do not ride on tractors. attend meetings. Radio, general farm magazines, and con- Studies of the cognitive versations with others are prime informa- physical tion sources. The Cooperative Extension limitations of children at various stages up Service received a very high rating as a through 15 years of age indicate that they source of health and safety information. are being put at risk through farm ac- tivities that they are asked to perform. A sizable share of the farm population is children. Accidents are the primary cause of death among children less than 15 years I have yet to see a farm safety awareness old in the United States as a whole and in or education program that did not stress farming. About 23,000 farm children are the danger of extra riders on tractors. This injured on farms each year. Why are these poses some important questions that need injuries occurring? to be applied to all agricultural safety and health problems. Partly, it is the generally risky nature of the farm environment and the fact that it Why are our safety warnings going un- is both home and office for farmers and heeded? Are we reaching and involving for their spouses and children. Often, the our targeted audiences sufficiently to economic realities of farming create a develop effective education and awareness dependence on children for labor. Fre- programs that change behavior? What will quently, either there is no adequate child be the most effective combination of en- care for them off the farm or it is too gineering controls, awareness, education, costly for farm families. These problems regulation, and enforcement to find exist for both the farm-operator family and solutions to each problem? the migrant-labor family. Studies of the cognitive physical limitations In a recent national survey, farmers of children at various stages up through 15 reported that they allowed their young years of age indicate that they are being children (aged 6-9 years) to ride on a trac- put at risk through farm activities that they tor, and as many as 29 percent of 7-9 year- are asked to perform. Their parents do olds were driving the tractor. Between not understand that risk potential. How ages 7 and 15, farm children were per- do we direct our educational efforts at forming a wide range of farm operations these target populations? Helping farmers with tractors. understand the developmental limitations of their children could significantly reduce When asked about risks of such behavior, child accidents and deaths on farms. farm parents surveyed saw a low accident- risk level for their children when they were Another target population is the estimated riding on a tractor the parent was operat- 3 million migrant and seasonal farmwork- ing or when the children were operating ers from many different ethnic groups. the tractor. As great as a 40 percent Children are about one-third of this popu- reduction in the farm fatalities to children lation. Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 89 Questions to Guide the National Agenda No comprehensive baseline health data exist for them. Some of their health problems and hazards are well documented. Others require much more investigation and research. Their need for a wide variety of education and social services is enormous. What are the unique demographic, cultural, and language prob- lems that must be overcome to provide effective intervention programs for this targeted audience? The average age of U.S. farm operators is 52, with 21 percent of farm operators 65 or older. Farm workers aged 65 and over have two to three times the injury rate of other age groups. Older workers are more vulnerable to injury due to decreases in sensory capabilities (hearing, vision, smell). They also may be suffering from several chronic occupational illnesses that have high incidence rates among farmers. This target audience offers unique challenges for effective intervention programs that reduce their risk of traumatic injury and prevent increasing the severity of existing health problems. What intervention programs are needed by audiences who have experienced an injury? Approximately 600,000 farmers have a disability that impedes their ability to per- form essential farming tasks. This group is also at high risk to further injury. Expanding upon several pilot programs, USDA's Extension Service, in cooperation with the National Easter Seal Society and other nonprofit disability organizations, recently launched an innovative program to help farmers with disabilities continue farming. such services as identification and referral of farmers with disabilities, on-the-farm technical assistance for modification of the workplace, and, agriculture-based educa- tion to prevent further injury and disability. Accident victims can be a powerful influ- ence in creating behavioral change. How can we more effectively involve these in- dividuals and the grassroots organizations they have created, such as Farm Safety for Just Kids? Should we target groups that are not em- ployed in agriculture or live on farms but may become victims of farm injuries? What are the risks to individuals that visit or provide services to farms? Approximately 40 percent of the fatalities that occur in confined-space agricultural accidents are attempted rescuers of farm accident victims. The Cooperative Exten- sion System has trained more than 17,000 professionals in farm accident extrication procedure and nonprofessionals in first-on- the-scene emergency response procedures. These programs are crucial to reducing the risk of injury to the rescuer, reducing the severity of the injury to the victim, and emphasizing the value of injury prevention. Approaches to Intervention Various approaches to intervention have been applied to agriculture. What do we know about the effectiveness of injury control strategies in the agricultural workplace? What new method emanating from the public health approach and hu- man factors engineering will be required to solve these problems. 3 How do we educate to achieve behavioral changes toward bet- ter agricultural safety and health? Many educational programs are in place. Extension agents, disability experts, rural professionals, and volunteers will offer 90 Papers and Proceedings We have our own, ranging from training of national strategy could rest on the belief persons who will be using restricted-use that the most effective preventive efforts pesticides to courses that instruct youth will emerge from a process that emphasiz- (14-15 years old) in operating tractors safe- es identifying and characterizing problem ly. Of the more than 23,000 Nebraska areas and populations at risk. youth that have completed the tractor certification training program conducted by The collaborative efforts of engineers, the Universitv of Nebraska Cooperative Extension Se&ice, only two havg died in ergonomists, safety professionals, industrial hygienists, and experts in biomechanics and tractor-related accidents. the behavioral sciences are needed to address the most compelling problem areas by studying what makes up workplace A national strategy could rest on the systems and the process, tasks, and tools belief that the most effective preventive involved. They must identify potential efforts will emerge from a process that causal mechanisms, opportunities for inter- emphasizes identifying and characterizing vention, and possible prevention strategies. problem areas and populations at risk. How will automatic ("passive") protection be used more in agriculture? Passive pro- How do we educate people to change tection is generally more effective than "active" measures requiring effort by each accident-causing or otherwise risQ worker. behavior? Simple identification of a public problem such as agricultural safety and health is not enough to allow the design Engineering controls are available for and development of successful remedial many known hazards but have not been systematically applied and evaluated. programs. "Passive" measures of prevention could Building meaningful people-involvement involve worker protective-system ventures into the realm of intelligent microenviron- into problem identification, program ments that feature sensors, microproces- development, and program delivery is essential. Failure to involve the real sors, adaptive protective mechanisms, and stakeholders (the farmers and display and imaging technology to protect, inform, and warn workers for hazardous farmworkers) dooms even the most out- conditions at their onset. standing programs to failure. The era of unshared decisionmaking is generally be- How do we ensure that the safety and hind us. health of the agricultural worker is not sacrificed for the sake of other issues? In Need for Collaboration considering common issues, such as selec- tive harvesting versus clearcutting in the What is required. 3 The attention, effort, forests, we need to be aware that selective and cooperation of individuals and organi- zations at every level of society, from this harvesting may be better for the environ- conference to our offices at home. Should ment but that it places the logger at a there be a national coalition to plan and to greater risk of injury than occurs in clearc- coordinate intervention programs? A utting using modern equipment. Can we engineer machines that allow selective Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 91 Questions to Guide the National Agenda harvesting and that protect the workers using them? We must apply a systems approach that identifies the multiple benefits and feasibility of intervention methods. For example, closed-container mixing systems for pesticides not only protect the applica- tor from exposure to pesticides, but can also prevent ground water contamination and reduce the possibility of mixing errors. Communication of multiple benefits can be an effective means of creating a change in behavior. FUTURE FOCUS Let us look at success stories in agricul- tural safety and health. What data do we have on them? We know they exist. Prob- ably one of the greatest shortcomings of existing educational farm-safety programs is the lack of scientific evaluations of their effectiveness. We must conduct more comprehensive evaluations. We need more than simple, generalized descriptors- beyond age and sex of the victim, the time of year of accident, and its severity-for us to develop innovative engineering or educational countermeasures. Although more research and more data are needed to direct intervention, we know certain health and safety precautions work; ROPS work. Educational programs by the Extension System and others in health, hygiene, and pesticide use all have their successes in reaching our target audiences. Where do we need to go? We need to focus on injuries that often result in death or severe disability because of their impact on the family and the economic and social costs to society. We need to find workable solutions to tractor fatalities and to reduce and eliminate them, if possible. Tractor-related injuries are about one-third to one-half of all fatal farm injuries. This figure has changed little in 20 years. We also know that the youth and the aged were involved in a significant portion of total tractor injuries. We need to reach these target groups more effectively. Injuries that occur with high frequency and may be easily prevented should receive high priority, even if less severe in nature. For occupational illnesses, we can increase educational efforts in the use of common methods of worker protection from haz- ards and in the use of protective equip- ment and clothing. Some types of clothing and equipment, for example, can reduce exposure to many harmful agents. We need feasible engineering controls to re- duce vibrations, noise exposure, air con- taminants, and other harmful agents. We need to stop the decay of basic health services available in rural areas and to reverse this trend. I have raised many questions for your consideration both now and after you re- turn home. Your presence here today is testimony to the momentum building to address this issue. I think that we can find the answers to solving these problems through the collab- orative efforts of all of you. We can act on measures that we know work now and search for more effective intervention countermeasures. Safety and health are the right of every person involved in agri- culture. I wish us success in solving our agricultural health and safety problems.0 92 Papers and Proceedings Surgeon General's Confemnce on Agriculturel SaMy and Hem FAIWSAFE 2000 o A National Coalition kw Lout/ A&on Convened by the National Inst/tufe for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa RURAL HEALTH POLICY By Jefiey Human, M.A. Director, Office of Rural Health Policy U.S. Public Health Service Surgeon General's Conference on Agricultural Safety and Health - 1991 93 Has this not been a terrific conference so far? We have outstanding attendance. We have had one excellent speaker after another. The commitment to improve agricultural safety and health has also been striking in these presentations. Groups like the National Coalition for Agricultural Safety and Health and the Farm Foundation have been working extra hours to form consensus on the national agenda we need to develop. This is a time of hope. One of the most interesting things about several of the presentations so far was the emphasis on the movie Field of Dreams, and its use as a metaphor of hope. I asked a city dweller last evening what movies urbanites relate to these days. ~ "Well," he said, "I'd include Deathwish, T i, Mean t Streets, and Escape from New ork." I think there is more hope in the country. This morning's Des Moines Re ' ter ran a nice story on Dr. Novello's sp ," ech, which I thought was a high point of thb meeting. What an anachronism to call her the "Sur- geon General." Her message makes it clear that she is both the "Pediatrician Generat" and the "Family Medicine General." And that is what we need in rural health. ~ Yesterday, everybody had a different ra $ `ng for agri- culture as a dangerous occup ion. It was first, second, third, and fourth'within an hour. Chris Atchison, and this morning, Dr. Bill Halperin seemed to me to have the best idea. Let us set up and run farm health and safety surveillance systems in all states as they do in Iowa. Let us keep track of injuries and deaths and let us export this record-keeping to the other states, so we can keep track on a national basis and so that we can intervene for prevention. We also need to educate the nation's public on the nature and extent of the dangers of farm work to get the assistance we need. It is very fitting that this meeting should be in Des Moines. It was in this city, in 1984, that the Des Moines Register won the Pulit- zer Prize for a series of articles entitled "A Harvest of Harm." Those articles argued, persuasively, that agriculture has become our most dangerous occupation. It was in Des Moines and Iowa City, in 1988, that Jim Merchant and Kelley Donham held a conference on agricultural health and safety; the conference led to the publication of Agricultzue at Risk: A Report to the Nation, a report that has brought the issues we are talking about today to the nation and to the Congress. The 1988 conference also led to the Ixma- tion of the National Coalition for Ag. icul- tural Safety and Health-a coalition that is continuing to keep these issues in the fore- front of national efforts to improve rural health; a coalition that has now integrated its work with the National Rural FIealth Association; a coalition whose work at Medical Intervention Problems and Opportunities raising consciousness made this meeting possible. Iowa's leaders have been very influential in other rural health endeavors. In the mid- 1980's, the administrators of small rural hospitals detailed the problems they were experiencing to the Congress. Don Dunn and Art Spies (who is with us today) of the Iowa Hospital Association, were among the chief spokespersons of the movement. The Iowa Congressional Delegation has been as united as any in the country in rural health advocacy. Senators Harkin and Grassley helped build a Senate Rural Health Caucus of 65 of the 100 members of the Senate, and they have delivered better-funded programs and new programs through the Senate Appropriations Com- mittee, on which they serve. Former Iowa Congressman Tom Tauka was the first co- chairman of the House Rural Health Care Coalition, which now has 165 of the 435 members of the House, including all of Iowa's Congressmen. There is one other Iowa leader we should speak of, but he is our next speaker. I will get to him soon. I am supposed to say something about the Office of Rural Health Policy, which I direct. We act as a voice of the rural constituency in the Department of Health and Human Services and coordinate its rural activities. So I come to meetings like this as much to listen as to speak.. Our primary responsibility is policy, but we also run some programs. For example, this year we will be making around 38 grants to states to help them establish or enlarge state Offices of Rural Health. These offic- es work like our federal offices but at the state level. I think they can be very effective in repre- senting rural constituencies in the state capitals, in working with communities and their health providers to solve local prob- lems, and in working with the farm com- munity on health and safety issues. This year, we will be making anywhere from 60 to 200 grants for local innovative health services programs or programs that support health professionals through edu- cation, telecommunications, or similar means. We expect several agricultural health and safety proposals. We fund seven rural health research cen- ters nationwide. All of them have some involvement in agricultural health and safety and one center-the Marshfield Med- ical Foundation-has agricultural health and safety as its principal emphasis. We heard about one of their projects yes- terday from Secretary Sullivan. It illus- trates the practical applied research I ask for from each center. When we looked at the tractor-rollover problem with Marshfield, we decided that there was no need for further research on the problem. What we decided we needed was a way to help farmers who wanted to retrofit older tractors with roll bars or other rollover protective devices to find those "ROPS," as they are called. So we asked Marshfield to develop and publish a catalog of all American manufac- turers of "ROPS," all products they pro- duce and what make of tractor, model of tractor, and year of tractor they will build. Then Marshfield sent the catalog to all extension agents in the country, so it is available where it is needed. 94 Papers and Proceedings Producing that catalog is not the best step we could take as a society. As we have seen in the slide on the Swedish experi- ence, the best step we could take would be to require "ROPS." But as an Office, it was the best we could do. We fund a national information center on rural health. It is a part of the U.S. De- partment of Agriculture and is within their National Agriculture Library. So if you want some rural health information, call l- 800-633-7701. The nice thing is that you can also get agricultural information or rural economic development at this same number. Add $24.95 and postage, and we will include all the hits of Boxcar WiZZie. That is l-800- 633-7701. Offer is not valid in Mexico or Canada. My own office is also a sort of information clearinghouse. In my presentations, I try to share ideas on the things that are hap- pening in the states and communities and in Washington that affect rural health. Thus, I talk around the country about the problems of rural health and about the potential solutions. For example, I tell state officials that they should train more nurses because we have a national rural nurse shortage. If they ask where to get the money, I suggest they cut back on training so many lawyers at taxpayer ex- pense. If we are short of nurses, we are short of essential health services for our people. If we grow short of lawyers, however, what are we short of? Essential lawsuits? Certainly with a few less lawyers we might have fewer malpractice suits. Seriously, let us confront conventional approaches and Rural Health Pblicy, May 1, 1991 make new choices with limited funds, choices that help solve rural health prob- lems. I tell people in other states about the package of programs offered to local sub- scribers by the University of Iowa's Insti- tute of Agricultural Medicine and Agricul- tural Health. I do not have time to tell you the specifics today, but I will mention three features of the program, which is based on a Swedish model. 1. It is hospital based and contributes to the viability of rural hospitals. That is important because 10 percent of all of America's rural hospitals closed their doors during the 1980's. 2. The program includes continuing medi- cal education for physicians. A 1979 survey showed that 70 percent of all medical schools offered no instruction in agricultural medicine. The other 30 percent offered an average of four hours of instruction during four years of medical school. The young physician new to an agricultural community may be baffled by pulmonary and cardiac conditions caused by agricultural dusts or chemicals. Ellen Widess' stories yesterday play out over and over again, and many times with worse endings when we do not prepare our physicians properly. 3. The program trains farm families to be responsible for their own health and safety. For example, they are shown how to make animal confinement hous- es safe for themselves and the animals. For more information, see Jim Mer- chant or Kelley Donham or David Pratt, who know more about these and other similar programs than I do. Surgeon General's Conference on Agricultural Safety and Health - 1991 95 Medical Intervention Problems and Opportunities I want to tell you about one last program. It is called "Stress Country Style," and it is in Illinois. A network of health workers throughout the state are available to help farm families. Farmers call an 800 num- ber, and help comes to them. There is no stigma because the encounter is private at the farm. Counseling is offered. Referral to mental health or debt consolidation or one of 100 other programs is offered. Oklahoma and Iowa have similar pro- grams. Seriously, let us confront conventional approaches and make new choices with limited funds, choices that help solve rural health problems. I We need more innovative stress reduction programs like these. In Ontario between 1979 and 1982, 95 of the 273 farm deaths were suicides, and the farm suicide rate has been documented to be high in this country as well. Mental health must be an important part of our national strategy. Incidentally, we need to place a special emphasis on teenagers when we look at mental health in the farm community. A survey by the University of Minnesota's Extension Service and the Medical School indicated that 5 of every 100 rural adoles- cents surveyed has attempted suicide with- in the past month. Nationally, the figure was 2 of 1,000. This was in the early 1980's during the height of the farm crisis, but other studies have shown pervasive high levels of depression among rural adolescents. I should also mention that our office pro- vides staffing for the National Advisory Committee on Rural Health. I have left some brochures about our office at the registration desk. If there are none left, call l-800-633-7701, and they will have us send you one.0 96 Papers and Proceedings Surgeon General's Conference on Agricuttud Safety and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute tit' Occupational W&y and Health April 30 - May 3, 1991, Des Moines, Iowa MEDICAL INTERVENTION PROBLEMS AND OPPORTUNITIES IN RURAL AREAS By Governor Robert D. Ray Chairman, National Advisory Committee on Rural Health Policy Mr. Jeffrey Human: My last assigned task is to introduce our next speaker. My honest impression is that Bob Ray is a real enigma. This is a guy who was elected to five terms as Governor of Iowa, and then found a life after politics on his own. He did not lose an electior+he quit. There was no scandal. He just left the political life. He wanted to try something new. This is almost unprecedent- ed in American politics. Then Bob went out and got jobs on his own and made a mark. He ran a successful insurance company, and now he is president of Blue Cross and Blue Shield of Iowa, with a million subscribers. He is not some absentee figurehead president either. A top official of Blue Cross nationwide tells me he has personally turned the program around in this state. Secretary Sullivan tcld us yesterday that Bob Ray is one of his advisors. Well, he should be, because Bob is chairman of the National Advisory Committee on Rural Health. That committee has provided Secretary Sullivan and the Congress with a series of challenging recommendations on rural health that have led to changes. For example, the Outreach program I told you about is partially a result of a recommendation of the committee. There is a great revival of interest in national health reform. There are many competing proposals. One of the best and most influential, based on universal insurance coverage, is from the National Leadership Commission on Health Care. The Commission's members read like a Who's Who in American health policy. The chairman is, of course, Bob Ray. Bob Ray also was a U.S. Delegate to the United Nations and former chairman of the Indochinese Refugee Panel, providing leadership in efforts to resettle Vietnamese and Cambodian refugees. Bob is a graduate of Drake University's Law School, and he has a lot of honorary degrees and distinc- tions. Those of us who work with him and for him with the National Advisory Committee on Rural Health have discovered more important things about Bob. We have found him to be intelligent, funny, caring, realistic, charming, articulate, and an excellent leader. He is one of the best listeners I have ever met. He knows more about health care than most of us. It is a pleasure to introduce one of America's great leaders, Robert D. Ray: Jeff, thank you. Thank you very much. I just learned a great deal about Jeff Hu- man. I have always admired him and his talent and his ability and I have watched him in Washington, knowing that he is not just a bureaucrat. He is a person with tremendous compassion and understanding of people, their needs, and their problems. Jeff, what I did not know about you is how flexible you can be. You have talked to us about education; you have talked to us about tractors; you have talked to us about Federal programs; you have talked to us about Boxcar WiZZie; and you have talked to us about me. I am here to tell you that I am sure thankful I do not practice law anymore. I am not sure I should have been invited to speak to you today at all because I am not sure of my own commitments. There is probably no one who is working harder or who believes more that we should hold down health care costs than I. Earlier this year, I was in an automobile accident and was taken to the emergency room. I was laying there flat on the slab and looking up, and two white spotlights were shining down on me. It was very, very warm and very comfortable. Surgeon General's Conference on Agricultural Safety and Health - 1991 97 Medical Intervention Problems and Opportunities I felt pretty good about that, but then I looked kind of from one side to the other, and I saw these green things running around. There were doctors standing here and there. Once in awhile one would lean over and look at me, and I would look at him. The funny thing about it is that never one time did I look up and say, "How much is it going to cost, Doctor?" And so there are conflicts within all of us. We want the best health care system possi- ble. We do not always want to pay for it. We believe that there are ways in which we can cut and save-but not on the service that we get. So, it is very difficult when we talk about what is needed and what is doable. If at first blush you think it is just overwhelming and impossible, you would quit. Then when you realize that things do hap- pen-maybe slowly, but they do happen. There is always change going around. Maybe the change will inure to a system that we want to change. That is the reason it has been exciting to me to work with Jeff Human and the people in Washington and DHHS. Some of the business people and the major leaders of this country are trying to do something about health care. We have long learned that you can not do some- thing about cost alone because if you con- trol cost, you reduce access. You cannot do something about quality of care alone, even though that, by itself, might reduce health care costs 30 or 40 percent, because it costs money to do cer- t ain things. You cannot just provide more access for everybody without affecting costs and qual- ity. So we have to deal with all of those aspects of health care and the health care delivery system together. I think that it is awfully easy for us in the rural areas to be neglected because we do not have the votes they have in the big states: California, how many congressmen do they now have? New York? It has been very impressive, what has hap- pened in Congress over the last several years. Jeff already mentioned how many members belong to the House Coalition on Rural Health. So, a lot of good things have happened, and our advisory commit- tee, I think, has had some influence, some impact, and I am pleased to be associated with them. I am pleased that the Surgeon General decided that we should have this confer- ence and that our senators endorsed it, and Tom Harkin helped to get it here in the State of Iowa. There is no better place we could have a conference on rural health than right here in the State of Iowa. I think we ought to have one of these every 50 years. An awful lot has happened to change the landscape of American health care during this past 50 years. Advances in technology and the proliferation of medical specialties allow us to live longer and healthier lives. That is good. But unfortunately, farm families, farm workers, and rural farming communities do not share equally in all of this achievement with our neighbors in urban areas. This conference is very timely, and I am pleased that it is here in the State of Iowa. And I want to thank the Surgeon General for being here. 98 Papers and Proceedings Medical Intervention Problems and Opportunities in Rural Areas, May 1, 1991 There are so many people that I would like to acknowledge on the federal level, on the state level, and on the regional level-our Senators, Congressmen, Dr. Donham and Dr. Merchant, and the list goes on and on. I am going to save you-spare you-the time that it will take do that. to Let it suffice to say, I truly appreciate what you are doing because this is important- not just to those people who live on farms, but even those who live in small towns; it is important to every one of us. I will get back to that. The diverse groups of people like yourself who focus specifically on rural health at this conference give us a unique chance to build and strengthen active, vital, rural health networks. It offers the opportunity to develop links between the researchers and the health professionals, between health professionals and extension agents, between extension agents and surveillance experts, and between surveillance experts and researchers. The list goes on and on; you get the picture. We just finished a rather tasty meal. You have probably had better; you have un- doubtedly had worse, but by most stan- dards, let me tell you, there are people in this world who have never, ever had a meal that good. Let me give you some food for thought. Just stop and pause and reflect for a mo- ment with me about who produced that food. I am not talking about the culinary part, the chefs part, but about the people who provided the labor and the risk and the sacrifice that we enjoyed at noon: we are spoiled. We in this country try to decrease the calories that we eat, while the rest of the world measures growth and progress by the increase in calories their people eat. Our farmers only get a very small fraction of what we spend for food. They get 4 cents for the wheat that goes into a loaf of bread, which costs roughly a dollar and a quarter. They get 5 cents for the corn that goes into a 7-ounce box of corn flakes, which sells for a dollar and a quarter. We in this country spend a smaller percent of personal income on food than any other civilized country. You people pay, on the average, 11.9 percent of your personal income for food. It was 18 percent in 1959. It has been reduced. Yet, in other countries, like the European countries, they are paying around 17 per- cent; Japan, 19 percent; the Soviet Union, 28 percent; India, 54 percent; China, 48 percent. We have a bargain. Look at what is happening in the Soviet Union. During our lifetime we have grown up knowing about two superpowers-one the United States of America and the other the Soviet Union. Today the Soviet people stand in lines for hours. You see them on television. You can watch them-waiting for a little piece of bread that they cannot even afford. Add to that the fact that the suicide rate for farmers is now 30 to 40 percent above the national non-farm rate. L We are fortunate, yet we take it all for granted. Our farmers produced the food that the chef prepared for us today, but they did it accepting some risk: the possi- Surgeon General's Conference on Agricultural Safety and Health - 1991 99 Medical Intervention Problems and Opportunities bility of an untimely death or serious injury or acute or chronic illness-all of that-while they were growing the food and raising it. RURAL STATISTICS Earlier at this conference, if I understand correctly, you heard some alarming statis- tics. Let me briefly reiterate what I think some of them were. Although farmers and farmworkers com- prise only 3 percent of the work force, they suffered 14 percent of work-related deaths, according to National Safety Council fig- ures. Agriculture, as you heard just a moment ago, precedes mining now as the most hazardous occupation. Unlike mining, where the death rates have been decreasing, agriculture mortality rates have remained consistently high during this past decade. The fatality rate in farm work is five times the average for all U.S. industry-five times. Researchers have discovered that midwest- ern farmers have a higher-than-normal chance of dying of leukemia. The cause is uncertain. Some experts fear an unusual incidence of leukemia is linked to the use of modern pesticides in raising corn. A serious new hazard known as "hog lung" is also one of the by-products of the mod- ern system of raising hogs in confinement. In a half-dozen or more of our cities, water supplies contain greater than acceptable amounts of pesticides and other synthetic organic chemicals. Millions of rural poor people are risking health problems because of substantially substandard diets. That problem is attrib- uted to the pride of rural poor who are unwilling to accept food stamps and other assistance. These numbers do not even take into account all the children who die each year in farm-related activities. In addition to deaths, there are 130,000 to 170,000 disabling farm injuries every year. These injuries entail an enormous hospital rehabilitation cost, and nearly half of all survivors of serious farm trauma are per- manently impaired. Add to that the fact that the suicide rate for farmers is now 30 to 40 percent above the national non-farm rate. Jeff just gave you some other information about that fact. He mentioned that I had served as a representative to the United Nations. When I was there, I found myself frequently talking to those of other coun- tries, and especially Africans, who no lon- ger could produce enough food for their own people. They had joined a crowd of socialized countries, and soon learned that they just could not produce food like they used to. They liked talking to me because they knew that I came from the State of Iowa, one of the best farm states in the country, in the world. We spent hours talking about how our farmers could produce food better than anybody in the world. I believe that we could help them. We used to talk about how we might do that. One day I was telling them about how wonderful our farmers were and how well they could produce food. Then, the very next day, I picked up the New York Times and there on the front page was a dateline story from Spencer, Iowa; and this is a quote, "More suicides on Iowa farms." I just hoped that my friends I talked to the 700 Papers and Proceedings day before did not read that. But it was and it is a fact of life. It is a shocking fact related mortality. Some of these figures of life. reflect the corn prices of the 1980's. You probably are not surprised to hear that the number of farm foreclosures reached I have just given you a few statistics that I 650,000 between 1981 and 1987. think indicate the importance of your get- ting together today for this conference. You may not know that rural America also Let me turn our attention to the big issue of rural health care and rural health care lost over 500,000 manufacturing jobs at the delivery. same time. It is estimated that for every seven farms that have been lost, one rural business has closed. RURAL POVERTY The rural population increased in the Many of you are undoubtedly familiar with 1970's. The 1980's saw a dramatic shift. the agricultural, occupational, and environ- Growth was stagnant at best and some mental health conference that was held here in Des Moines a couple of years ago. midwestem communities lost population, Iowa being one of them. All of you know That conference report was called Agricul- we are going to lose a Congressman. We ture at Risk. do not want to lose that Congressman; we have no choice. It described the need for occupational health and safety services. It discussed the These economic and demographic trends challenges facing the rural health care together with changes in the delivery and system, challenges like failing rural hospi- financing of health care have taken a huge tals, pay disparities between urban and toll on the rural health care systems, espe- rural physicians, difficulties in retaining cially the rural hospitals. Ten percent of both rural health providers and patients, all U.S. rural hospitals closed during the and the need for a strong emergency medi- 1980's, and it was estimated that about 25 cal services system. Although the public's percent of those still serving patients were image of rural America is one of pictur- in serious trouble. esque countrysides and healthy lifestyles, this image belies the reality of life in much With greater rural poverty has also come a of rural America. These are hard times rise in uncompensated care provided at for many rural communities, the result of rural hospitals. Under Medicare's perspec- both economic and demographic trends. tive payment system, rural hospitals, since 1983, have been paid at a lower rate than For example, the rural poverty rate in- urban hospitals, as much as 25 percent creased steadily during the 1980's and for lower. This has been devastating to many the first time is now higher than the urban rural hospitals because Medicare patients rate. Rural residents are much more likely represent an exceptionally high percentage than urban residents to have no health of their patients. insurance coverage at all-public or private, Rural residents are plagued by chronic disease, higher rates of infant mortality, and dramatically higher rates of injury- One of the first recommendations that the National Advisory Committee on Rural Health made to Secretary Sullivan was to establish a single national standardized Medical Intervention Problems and Opportunities in Rural Areas, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 707 Medical Intervention Problems and Opportunities payment for Medicare hospital reimburse- ments. I am pleased to be able to say that Secretary Sullivan has been successful in seeking a higher annual update for rural hospitals. The Congress has now legislated a phase-out of the rural-urban differential in Medicare payments. In 1989, the Federal Government imple- mented the Rural Hospital Transition Grant Program to address rural hospital vitality. Under this program about 180 new grants were made to rural hospitals each year for the past two years. Hospitals can receive up to $50,000 a year to help them with strategic planning and imple- mentation of programs to help them with that change in rural health care needs and practices. Iowa has fared very well under this pro- gram. Twenty-three of these grants were awarded to Iowa hospitals in 1990. That totals $819,000 and represents 10 percent of all the federal funds awarded. The second program that the Federal Gov- ernment is implementing right now is the EACH/PEACH Program. EACH means Essential Access to Community Hospitals. PEACH means Primary Care Hospitals. The Congress authorized this program in 1989 to provide financial incentives for rural hospitals to downsize and to focus on providing primary care and limited inpa- tient services and emergency care. The program also encourages these prima- ry care hospitals to form networks an- chored by larger full-service, essential- access community hospitals. Seven states will receive funding this year to develop networks in primary care in essential-ac- cess community hospitals. RURAL HEALTH PERSONNEL Another rural health issue receiving a lot of attention is the shortage of rural health personnel. To maintain a rural health system, we have to have physicians, nurses, emergency medical service helpers, and other health personnel. Rural counties have only one-third as many physicians per capita as the nation at large. In these counties, 20 percent of physicians are over the age of 65 and, obviously, are going to retire very soon. Communities also have problems recruiting and retaining physicians. Right now 165 Iowa communities are looking for doctors. Rural communities particularly find it difficult to recruit and retain registered nurses, physical therapists, occupational therapists, x-ray technologists, and other health professionals critical to health care systems. Some recent federal efforts may help ad- dress a few of these problems. The Na- tional Health Service Corps was re-autho- rized last year. Its funding was increased. This program places physicians, nurse practitioners and physician assistants in the underserved areas. In recent years, about 70 percent of the placements have been in rural areas. A Medicare bonus was implemented two years ago for physicians practicing in rural underserved areas. The bonus was in- creased just recently to 10 percent. That represents just a very small incentive, but given the substantially lower rate that many rural physicians receive as compared to urban physicians, it is at least a step in the right direction. Both of these provi- 102 Papers and Proceedings sions, I might add, were recommended by 1980's caused incredible stress for rural the National Advisory Committee for individuals and families, but the accompa- Rural Health. nying drop in land values and tax bases made it increasingly difficult for rural com- Congress has also mandated a new Medi- munities to finance mental health services. care physician payment system. Under this payment system, primary care physicians As we look at ways to strengthen our rural are going to be reimbursed at higher levels health care system, we have to make sure than they currently receive, and that ought that mental health services are a part of to help. that system. Mental health personnel are also trained for rural practice. Iowa State At the same time, we should not overlook University, for example, has recently been the issue of rural emergency medical ser- awarded a $4.5 million grant to establish a vices. In Iowa there are more than 400 center for family research in rural mental ambulance services and approximately health. 10,000 trained personnel. Seventy percent of these people are unpaid volunteers, and Right now Iowa has about $24 million in most all of them are in the rural areas. rural health related federal grants, employ- The difficulties of recruiting and retaining ing a variety of programs. these dedicated individuals who have other jobs, spend long hours in training, and Mercy Hospital here in Des Moines, for donate their time free to an important example, has received $750,000 for a can- health service are, I think, rather obvious. cer screening and control program for farm families in 35 Iowa counties. Rural volunteer ambulance services also struggle to purchase equipment. An ambu- CONCLUSION lance, fully stocked, is going to cost $70,000 and rarely is there money from Well, what is the sum and substance of it government to pay for that. all? I think, notwithstanding the problems and all the difficulties, we can be some- So they have their chili suppers and their what encouraged by the recent progress in chicken barbecues just to raise the money both rural health and in agricultural health for an ambulance, That, actually, is where and safety. Make no doubt about it, we most of the money comes from. It seems have a long, long way to go. kind of strange to think that the emergency services upon which we depend so heavily, Public policy items all have their life span particularly in rural areas-services that on the national agenda. The challenge treat farm injuries, heart attacks, highway that we face is to keep rural health and traffic accidents-are actually provided by agricultural health and safety issues on that volunteers. agenda long enough so that we can make and see a very substantial difference. RURAL MENTAL HEALTH If we can do that, we are going to see that Now, the third and last rural health issue I the time and the effort and the money want to mention is rural mental health. As were all well spent to ensure a future for I said a moment ago, the farm crisis of the our rural areas. This conference is unique Surgeon General's Conference on Agricultural Safety and Health - 1991 703 Medical Intervention Problems and Opportunities in Rural Areas, May 1, 1991 Medical Intervention Problems and Opportunities because of the range of the players that it has brought together. I would suggest that we have a second conference; in fact, I already did before the Surgeon General left. I think I am not speaking out of school-she said she agrees. We really ought to have one. I think it would be nice if we had it before 50 years, because I would like to come back. I would like to see what we have done between now and next year or the next year or whatever time that conference is set for. The last Surgeon General's Occupational Health Conference resulted in something maybe very important, the elimination of mercurial poisoning in the hatting industry. We do not have much hatting industry anymore. In contrast, this conference has the potential to lead to dramatic decreases in agricultural deaths as well as advances in preventing and treating agriculturally related diseases and injuries. To wrap it up, I would like to just share a quotation from the newsletter of the Cen- ter of Rural Affairs, Walthill, Nebraska. It puts what you are doing here in a broader context of rural development and, in a sense, summarizes what I think this confer- ence is about. I am going to quote: "Good rural development conserves the best in people; the resources they live from, the values that nourish them, and the institutions that sustain them. We need not try to prevent change but to shape it in ways that conserve our future." I would add to that, the health and future of our rural farmers, farmworkers, and the farm community. If we succeed at doing that, every one of us will benefit. I appre- ciate so much you being here, because that is what you are here for, to do exactly what that quote says. Thank you very much.0 104 Papers and Proceedings Thank you. I want to add my welcome to Iowa to the welcomes you have already heard from others in Iowa. I should give you a little warning. Some people have come to Iowa and said what a nice state it is, what a pretty state it is. My warning is, I came here in the Commission Corps of the Public Health Service 26 years ago, on a two-year as- signment with no intention of staying, and I am still here. So, we do not want you to leave the conference early, but if you do not want to get trapped into staying here, maybe as soon as the conference is over, you will want to get out of the state. Chris Atchison talked the day before yesterday about some of the things that are going on in the Iowa Department of Public Health in relation to agricultural safety and health. So I will not repeat those things. But I would mention that when you go to the poster sessions this after- noon, if my counting is somewhere near correct, there are 101 posters there. Five are from the Iowa Department of Public Health about our activities. There 1Surgeon General's Confennce on Agricultural Salty and Health F~,v.!%IFE 2000 o A National Coalition ior Local Action Convened by the National institute kr Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa INTRODUCTORY REMARKS By Ronald D. Eckz$ M.D. Director, Division of Family and Community Health Iowa Department of Public Health Dr. Richard A. Lemen: To lead this panel this morning is Dr. Ronald Eckoff, a physician who is currently the Director of the Division of Family and Community Health with the Iowa Department of Public Health. Dr. Eckoff is a native of Michigan, having trained in both undergraduate and medical school at the University of Michigan. He holds a Master in Public Health degree from Harvard University. He has been active within the Iowa State Health Department, and I was looking at his resume and noticed that somewhat4ike locusts, I suppose-every 20 years he has been asked to be the Acting Director or Acting Commissioner of the Iowa Department of Public Health. He has a very good background in public health, and he will be leading the discussion today. I would like, at this time, to present to you Dr. Ronald Eckoff of the Iowa State Department of Public Health. Dr. Eckoff: are another 22 or 23 from other agencies and organizations in Iowa: Iowa State University, the University of Iowa, the Lung Association, the Easter Seal Society, county extension, and others. So I would certainly encourage you to view those sessions this afternoon. As I have listened to other people and as I have talked to people here, I have come to the conclusion that everybody at this con- ference either is currently engaged in far- ming, grew up on a farm, spent a lot of time visiting their grandparents' farm when they were kids, or at least liked to visit farms or go to the petting zoo section of the zoo. I did grow up on a farm, but I am here to tell you that I did not do any of those dangerous things that some of the other speakers have talked about. I did not drive a combine at a young age, or a grain truck, or anything like that. Of course the fact that I grew up on a fruit farm in Michigan, and we raised apples and pears and that sort of thing, not corn and soybeans, might have had something Surgeon General's Conference on Agricultural Safety and Health - 1991 105 Issues That Affect the National Agenda to do with that. I will not mention to you the kinds of things that I might have done that were dangerous. This morning's session we shift gears just a little bit and talk about some issues that affect agricultural health and safety. We have been talking more specifically about some of the dangers and the activities, and now we are going to talk about issues that affect agricultural safety and health. Our first two speakers will address the agricultural work force and the behavior of its members. Then the second two speakers will reveal changes in the agricul- tural work place as it is affected by new and different crops and by biotechnology. Biotechnology is certainly a word we hear used a great deal these days.0 106 Papers and Proceedings Surgeon General's ConWence on Agricuttura/ Safety and Health ,QRMSAFE 2000 o A National Coalition Ibr Local Action Convened by the National institute Ibr Occupational SaWy and Health April 30 - May 3, 1991, Des Moines, Iowa THE AGRICULTURAL WORK FORCE: PATTERNS AND TRENDS By Leslie A. Whitener, Ph.D. Economic Research Service U.S. Department of Agriculture Dr. Ronald D. Eckoff: Dr. Leslie Whitener is a sociologist and Head of the Agricultural Labor Section, Economic Research Service, U.S. Department of Agriculture. Dr. Whitener holds M.A. and Ph.D. degrees in Sociology from The American University in Washington, DC., with specializations in the sociology of work and advanced statistics. She has over 15 years of experience in farm labor research and has authored or co-authored more than 50 papers, monographs, book chapters, and journal articles relating to the agricultural and rural labor force. Specific studies have focused on the problems and needs of migrant farmworkers, the effects of Food Stamp and Federal employment programs on hired farmworkers, and labor market conditions facing farmers who seek off-farm jobs. Dr. Whitener's presentation focuses on patterns and trends in the U.S. agricultural work force and their implications for farm safety issues. Dr. Whitener: INTRODUCTION to have one of the highest "accident" rates Major changes have occurred in American agriculture during the last 40 years, which have affected the way we think about farms and the nation's farmworkers. Farms have become fewer and larger and agricultural production has become increasingly concentrated on the bigger farms. The greater availability of machinery, chemicals, water, improved seed and live- stock, and public financing have led to a greater substitution of capital for labor. As a result, the number of agricultural workers has declined by over 70 percent since 1950 and the activities and working conditions of US. farm workers have changed dramatically. Some of these changes have raised serious questions about the health and safety of agricultural workers. Agriculture continues of any major industry group-a fact you will undoubtedly hear repeated throughout this conference. According to the Bureau of Labor Statistics, for example, the incidence rate of workplace injuries and illnesses for agricultural production workers (12.2 in- juries per 100 full-time workers in 1989) is exceeded only by construction and some manufacturing industries.*l Other data sources show even higher injury and illness rates for agriculture. My com- ments today will help to provide a context for understanding some of the farm safety and health issues raised in this conference. To that end, my presentation focuses on the changing structure of American farms and on the demographic and employment characteristics of the people who work on those farms. I will concentrate on three major points that have important implications for cur- *The incidence rates for agricultural production workers do not include workers on farms with less than 11 employees. Surgeon General's Conference on Agricultural Safety and Health - 1991 107 Issues That Affect the National Agenda B 0 Increased up to 45 percent Declined up to 16.7 percent m Declined between 16.7 and 52.8 percent Source: 1987 ~OIU~U of Agriculture Figure 1. Change in Farm Numbers, 1982-87. Two-thirds of the Nation's counties lost farms; the heaviest losses were in the eastern half of the Nation. rent and future agricultural safety and health issues. b First, U.S. agriculture has changed dramatically over time; farming and the nature of farmwork are very different today than they were in the 1950's. b Second, the agricultural work force is a diverse group of workers who perform a wide variety of activities on the farm. This diversity complicates generalizations about farm safety problems and solutions. b Third, all is not what it seems, and many of our long-held tenets about farming and 708 farmworkers are no longer relevant or have been based on stereotypic images that were never true. These new ideas and patterns suggest caution when projecting farm labor trends to the future. CHANGES IN FARM STRUCTURE Perhaps the most notable change in agriculture over the last four decades has been the decrease in the number of farms. Farm numbers declined by over 3 million between 1950 and 1987, falling to about 2.1 million farms in 1987.2 Yet, these declines have not occurred consistently across the country (Figure 1). Papers and Proceedings The Agricultural Workforce, May 2, 1991 Between 1982 and 1987, for example, the largest declines in farm numbers occurred along the South Atlantic coast and the Mississippi Delta. During this period, the slow-growing economy of the rural South encouraged many poor, part-time farmers to leave farming for higher-paying non- farm jobs. Many small farms were con- solidated into larger operations. The Corn Belt, Lake States, and most of the Northeast also showed declines in farm numbers but at slower rates of loss. While the farm recession of the early 1980's un- doubtedly affected major farm production states, the effects appear to be less serious than expected. During 1982-87, the period immediately following the farm recession, much more change occurred in regions not usually associated with major agricultural produc- tion. Figure 1 shows little shading in the midwest, and there is little indication of severe decline in these states.' The reces- sion apparently resulted more in financial restructuring than in farm loss in these areas. In contrast to these patterns of decline, farm numbers increased in many parts of the United States, particularly in the Western States and in southern Florida. The increase in farms may be a reflection of rapid population and employment growth in these areas during the mid-to late 1980's. Farm increases, particularly in the West, were also due to division of farms into smaller units as partnerships dissolved or as older operators retired and divided their farms among heirs. Farm numbers will continue to decline in the 1990's, but at a slower rate than was experienced during much of the post- World War II period. By the year 2000, the number is expected to drop by about 6 percent-substantially below the 11 percent decline seen during the 1980's. Thousands of Farms Acres 6000 1 I 600 \ Average Size o] , , , , F,,mNymbyrs, lo 1950 1987 Year Source: Census of Agruculture, selected years. Figure 2. Change in Farm Numbers and Size, 1950-87. As the number of farms decreased, average farrn size increased, forming what some have called the "Iron Cross of Agriculture" (Figure 2).5 Farm size averaged 216 acres in 1950 but increased FgSo;le' twice that, size (462 acres) by . ** There will be more large farms at the turn of the century than there are today, and by the year 2000 the largest 1 percent of farms is expected to account for half of all farm production.6 As the number of fams decreased, average fm size increased, forming what some have called the %-on Cross of Agriculture. " ** Note that the rates of increase in farm size have consistently declined since the 1950's, and the trend toward larger farm size may be stabilizing? Surgeon General's Conference on Agricultural Safety and Health - 1991 709 Issues That Affect the National Agenda The current trend toward fewer and larger farms is due to many factors, including technological development, economies of scale, tax laws, price instability, differences in operators' managerial ability, capital requirements, credit availability, foreign trade arrangements, and Government programs and regulations.' PATTERNS OF LABOR USE ON U.S. FARMS What do these structural changes mean for labor use on U.S. farms? Changing farm structure has transformed labor re- quirements on U.S. farms. Capital substitutions of machinery, chemicals, water, and fertilizer for labor resulted in a substantial drop in the need for the num- ber of workers in agriculture. In 1989, the number of hours of labor required in agriculture was about one-third of its 1950 level.' Feed, seed, and livestock purchases increased over 80 percent since 1950. The use of agricultural chemicals, including fertilizer, lime, and pesticides, increased by over 500 percent. During the same period, farm output and worker productivity increased dramatically. In 1950, the average farmworker supplied farm products for about 16 people; by 1989, the number had risen to 98 people.' As a result, the agricultural work force, including both family and hired workers, declined by over 70 percent between 1950 and 1989 (Figure 3). Farm operators and their unpaid family members continue to provide the major portion of labor in agriculture. percent of annual average employment; by 1989, the proportion had increased to 35 percent. Millions of Workers 8- 7- 6- 5 - 4 '- 3- 2- ,---- ---\ .k-- l- Hired ---------__ o- 1945 1955 1965 1975 1985 Year Source: USDA, NASS Farm Survey. Figure 3. Farm Employment Trends, 1945-90. The amount and type of labor used on farms is related to the size of the farm operation, the commodities produced, and the geographic location of farms.9 Less than half (about 954,000) of the nation's 2 million farms employed hired or contract workers in 1987.' Small part-time farms, particularly those involved in grain or livestock production, are more likely to rely on family labor. Larger farms, especially those producing fruits and vegetables, tend to have labor needs in excess of the capacities of the families who farm them. A closer examination of farms by three size categories provides a useful perspective on patterns of farm labor use (Figure 4). Small Part-Time Farms However, hired workers have gradually Almost two-thirds of the nation's farms are replaced some family workers on farms. small, part-time operations with annual In 1950, hired workers comprised about 23 product sales of less than $25,000. For 110 Papers and Proceedings most of these farmers, farming is a secon- dary occupation, and off-farm income has become increasingly important to their economic survival. Large i Commercial Mid-Sized Commercial (21%) Source: 1987 Census of Agriculture. Figure 4. Farm Size Based on Cash Value of Sales, 1987. These farms are generally small, owner- operated farms, largely dependent on family members for labor supply. Over two-thirds did not use any hired or contract labor in 1987, and the remainder averaged less than $5,000 in labor expenses per farm.9 Most are involved in grain and livestock production and are dispropor- tionately located in the southern half of the United States. Between 1982 and 1987, these small part-time farms ac- counted for half of the national loss in farms. Mid-Size Commercial Farms About one-fifth of U.S. farms are mid-size commercial farms with annual product The Agricultural Workforce, May 2, 1991 sales of $25,000-99,999. Mid-size commer- cial farms are largely producers of cash grains, cotton, and cattle-agricultural products, which do not require large amounts of hired labor per farm. The 1982-87 loss in the number of farms was heavily concentrated among mid-size com- mercial farms. This group suffered the largest rate of decline all the farm size categories, losing 12.5 percent of its farms. Operators of mid-size farms are under considerable financial pressure to either enlarge their farming operations to a more viable com- mercial size or to scale back to a smaller part-time size of operation. Consolidation of mid-size farms into larger units has been a major source of the growth of large commercial farms over the two past decades. Large Commercial Farms Large commercial farms, those with annual sales over $100,000, have grown in number over time and comprised about 14 percent of all U.S. farms in 1987. Agricultural production and hired farm labor use are becoming increasingly concentrated on these larger farms. The largest 2 percent of commercial farms (with cash sales of $500,000 and over) accounted for over half (54 percent) of the total expenditures for hired labor in 1987. These farms tend to specialize in vegetables, melons, fruits, tree nuts, and specialty crops. The production and har- vest of these crops has not been widely mechanized and continues to require large amounts of hired labor during critical periods. These large farms are concentrated geographically. California, Texas, and Surgeon General's Conference on Agricultural Safety and Health - 1991 III Issues That Affect the National Agenda Florida, together with four other states (Washington, Wisconsin, North Carolina, and Pennsylvania) accounted for almost half of all hired labor expenditures in 1987. Hired farmworkers will become increasingly important to agricultural production as these labor-intensive farms continue to grow in number. Patterns of change by farm sales class suggest continued movement toward a bifurcated or dual structure of agriculture. One group represents a small number of large, capital and labor-intensive commer- cial farms that produce a growing share of the nation's food and fiber. Source: Agricultural Work Force Survey. Figure 5. Components of the Agricultural Work Force, 1987. The second component represents a large number of small, owner-operated farms that are largely dependent on off-farm income and use few hired workers. Al- though comprising the majority of farms, these small part-time farms account for only a small portion of total production, and many exist primarily as a means of preserving a rural lifestyle for operators and their families.' THE AGRICULTURAL WORK FORCE: A PORTRAIT OF DIVERSITY Who are the nation's farmworkers? Data from the U.S. Department of Agriculture's (USDA) Agricultural Work Force Survey indicate that almost 7.7 million persons 14 years of age and older were employed on U.S. farms as farm operators, hired farmworkers, and unpaid farmworkers in 1987." Over 1 million persons performed more than one of these three activities. For example, some farmers operated their own farm but also hired themselves out for wages to other farmers. To avoid double-counting individuals in more than one category, individuals were grouped by their major farmwork oc- cupation, the activity in which they spent the most time during the year. By this definition, there were approximately 2.7 million farm operators (35 percent), nearly 2.2 million hired farmworkers (28 percent), and almost 2.9 million unpaid farmworkers (37 percent) (Figure 5). These data help to define an agricultural work force that is subject to potential risk from farm accidents, illnesses, and injuries because they work on farms. However, several groups are excluded from this population at potential risk, including children working on farms. The Fair Labor Standards Act allows children to legally work on farms under certain con- ditions.* * * The Agricultural Work Force Survey did not collect information on the number of children under 14 who worked on the nation's farms. We do know, however, 772 Papers and Proceedings that about 1.2 million children under 14 years of age resided in farm operator households; it is likely that many of these children helped out with farm chores. Another 800,000 children lived in households headed by hired farmworkers; some may have worked along with their parents." There is no direct evidence from the survey to suggest how many of these children actually worked on farms. The Agricultural Work Force Survey also did not count two other groups of hired farmworkers-foreign workers who legally enter the United States to do temporary farmwork and undocumented foreign workers who enter this country illegally to do hired farmwork. These hired workers were probably not included in the survey data because they returned home before data collection in December or because they tended to avoid contact with Federal enumerators. These two groups are discussed in more detail later in this paper. A look at the numbers and characteristics of the different components of the agricul- tural work force reveals the considerable diversity among these workers and points up the difficulties of generalizing farm occupations. The Agricultural Workforce, May 2, 1991 Farm Operators About 2.8 million people operated a farm that they owned, rented, or leased at some time during 1987, according to USDA's Agricultural Work Force Survey.`" Two or more persons (such as a husband and wife or partners) could operate one farm, and both would be included as farm operators under this definition. Most of the farm operators were white (97 percent), male (77 percent) and middle- aged (median age of 47 years). Farm operators on average had relatively high levels of formal education. Eight out of ten operators had completed high school and three out of ten had some college education. Farm operators averaged 235 days oper- ating a farm in 1987. About 58 percent worked 250 days or more operating a farm, while only 11 percent worked fewer than 25 days. In addition, almost half did some non-farm work during the year and non- farm work provided an important source of income. Those who did non-farni work averaged 213 days of work in non-farm activities with average annual non-farm earnings of $15,882. Unpaid Workers Unpaid farmworkers are those who do any amount of farmwork without receiving cash ***The Fair Labor Standards Act limits the employment of minors in agriculture according to age and occupational activity. Children 14-15 years old may work on farms outside school hours in non-hazardous occupations in agriculture. Children aged 12-13 years may work outside school hours in any nonhazardous farm job with written parental consent or on the same farm where their parents are employed. Children lo-11 years of age may work outside school hours in any nonhazardous farm job, with written parental consent only on farms where none of the employees are legally entitled to the Federal minimum wage; a special waiver may be obtained from the U.S. Department of Labor. Children of farm owners or operators may be employed by their parents at any time and in any occupation on a farm owned or operated by their parents." Surgeon General's Conference on Agricultural Safety and Health - 1991 113 Issues That Affect the National Agenda wages or salary, or receive only a token cash allowance, or do farmwork for room and board or payment-in-kind. The largest component (46 percent) of the agricultural work force in 1987 was made up of the 3.6 million people who did unpaid farmwork. The majority of these workers were white (95 percent), male (66 percent), and young (median age of 31 years). They had relatively high levels of education; 77 per- cent had completed high school and 37 percent had some college." The largest component (46 percent) of the agricultural work force in 1987 was made up of the 3.6 million people who did unpaid farmwork. I Most of these unpaid workers did not reside in farm operator households. However, the 34 percent of unpaid workers who did live in farm operator households generally worked more days at their farm activities. They averaged 101 days of un- paid farmwork compared to only 30 days for those not living in farm operator households. Almost 70 percent of unpaid farmworkers did some non-farm work during the year. They averaged 211 days of non-farm work and 40 days of unpaid farmwork and earned an average of $13,900 from non- farm work during the year. Hired Workers The nation's hired farmworkers originate from three different sources of labor: domestic workers (including those hired directly and those employed through crew leaders or farm labor contractors), foreign nationals brought into the country under the H-2A Program, and undocumented foreign workers. 1. Domestic Hired Farmworkers The number of hired farmworkers has decreased by almost 40 percent, falling from a high of 4.2 million workers in 1950 to about 2.5 million in 1987." Most of these losses occurred in the 1950's and 1960's, largely as a result of the adoption of new production and marketing tech- nology on farms, including labor-reducing machines and higher-yielding crops and livestock. During the 1970's, however, hired worker displacement slowed considerably as large- scale mechanization and technological innovations with large labor displacement potential leveled off. Between 1970 and 1987, the number of hired farmworkers stabilized at 2.5 to 2.6 million annually, after years of continuous decline." On average, hired farmworkers are young and male, with relatively low levels of education. More than 40 percent of hired workers 25 years of age and over had not completed high school compared with only 15 percent of the U.S. labor force 25 years and over. The educational disadvantage was even more pronounced for minorities. Because of the seasonal nature of agri- culture, hired farmwork is frequently unstable, sporadic, and of short duration. In 1987, the average hired farmworker spent 112 days doing farmwork. However, there was considerable variation in days worked. More than half (55 percent) worked fewer than 75 days during the year. Only one-fifth were year-round workers who worked more than 250 days during the year (Figure 6). 114 Papers and Proceedings Percent - Herd sheep in Idaho. c25 25-74 75-149 150-249 250+ Days Worked Source: 1987 Agricultural Work Force Survey. Figure 6. Hired Farmworkers by Days of Farmwork, 1987. Hired farmworkers were paid an average of $4.87 per hour for farmwork in 1987. This low wage and the seasonal employment combined to make hired farmworker earnings among the lowest of all occupational groups in the United States. Hired farmworkers earned an average of $6,663 from both farm and non- farm jobs in 1987, accounting for only 41 percent of the $16,2501' earned by the average nonagricultural private sector workers. However, the nation's hired farmworkers are a diverse labor force, and a picture of the average farmworker can be misleading. Popular image depicts hired farmworkers as a large, undifferentiated group of low- income workers with little education and few skills, who harvest the nation's fruits and vegetables mostly in California and Florida. Yet hired farmwork comprises a wide range of activities performed all over the United States.12 For example, hired farmworkers: - Cut sugarcane in Florida. - Strip and bale tobacco in Kentucky. The Agricultural Workforce, May 2, 1991 - Operate a combine in Kansas. - Milk cows in Vermont. - Shear Christmas trees in Michigan. - Stock catfish ponds in Florida. - Serve as farm managers in Oregon. Hired farmworkers not only perform widely different activities, but they work for a variety of reasons. Hired farm- workers include household heads, who do hired farmwork on a regular or year-round basis and whose families depend on their farm earnings for economic support, as well as non-farm workers who do seasonal farmwork to supplement their non-farm earnings. Also included is a large group of students, housekeepers, and others not in the labor force most of the year, but who do a few days or weeks of farmwork during the year. Some of these workers are earning extra spending money while others contribute necessary earnings to the family income.16 2. Migrant Farmworkers Migrant farmworkers provide a necessary supplement to local labor when demand exceeds the supply of farmworkers living in a local areas. After almost 50 years of Congressional hearings, countless Federal task forces, poignant documentaries and books, and national media coverage of the socioeconomic problems of migrant farm- workers, we still wrestle not only with the question of how to help these workers, but also how to count them. Data collection is complicated by the wide variation in definitions and measurement procedures used by Federal agencies and others concerned with migrants, as well as with difficulties in counting a transient population. As a result, population counts Surgeon General's Conference on Agricultural Safety and Health - 1991 115 Issues That Affect the National Agenda range widely from a low of around 200,000 reported by USDA in the mid-1980's to as many as 1.6 million migrants and their dependents reported." Little statistical information is available on the travel patterns or routes followed by migrants as they harvest the Nation's crops. Common perception suggests the existence of three major migrant streams, one each on the east and west coasts, and one in mid-continent. However, the uniformity of migrant travel patterns has not been well-documented leading one farm labor expert to observe that: The maps of migratory streams-Atlantic, Pacific, and Mid-continent-which in the past were so prominent and still are to be seen now and again, embodied more jlows of imagination than of people." Figure 7 illustrates the commonly per- ceived image of three major migrant streams. Figure 8 shows the more likely patterns. In 1977, David Lillisand et al. conducted a survey for the Legal Services Corporation across the county to determine the state of origin, last state of employment, and next state of destination for migrants in various states." While the data do show three broad patterns of migratory travel consistent with the common image, they also indicate con- siderable deviation from three major streams. The study concluded that if pat- terns of migrant travel existed at all, they were much more complex than the commonly perceived image of three streams. 3. Foreign Workers Foreign workers leave their home countries to work in U.S. agriculture because there are more jobs and higher wages here. Lack of education, work ex- perience, or language fluency do not hinder foreign workers as much in agricul- ture as in many other types of jobs. As a result, many U.S. farm employers have come to rely on foreign workers as a ready source of labor. b Temporary Foreign Workers. Some foreign nationals are legally admitted to the United States to do hired farmwork under the H-2A Temporary Foreign Worker Certification Program. This program, administered by the U.S. Department of Labor, permits foreign workers to enter the United States to do farmwork when there are not enough available qualified domestic workers to the work and when the employment of do Figure 7. Travel Patterns of Domestic From Puerto Rico Seasonal Migratory Agricultural Workers. - Source: Migrant Health Program, U.S. Public Health Service. 176 Papers and Proceedings The Agricultural Workforce, May 2, 1991 foreign workers will not adversely affect the wages or working conditions of similar- ly employed U.S. farmworkers. About 26,000 farm jobs were certified for foreign workers under the H-2A program in 1989. Due to their small numbers, H-2A workers have little effect on the national farm labor market. However, they do account for a significant portion of the labor force in some production areas, particularly Florida sugarcane, and eastern and northeastern apples. Concern over the large number of un- authorized workers coming to the United States led to the passage of the Immigration Reform and Control Act (IRCA) of 1986. The Act was designed to reduce the flow of undocumented workers by imposing fines and jail terms on employers who hired them. At the same time, IRCA offered legal U.S. residence status to qualifying un- documented workers who had resided b Undocumented Foreign Workers. Illegal aliens have a much greater effect on the U.S. farm labor market because of their large numbers than do legally admitted foreign workers. There is little reliable statistical infor- mation on the numbers and characteristics of these workers. Deriving a reliable count is problematic because of the c migratory nature of this illegal work force and Figure 8. Farm Labor Migration Patterns." because many of these - Source: Lillisand et al. in a study prepared in 1977 for the Legal Services Corporation. workers will not participate in surveys for fear of revealing their illegal continuously in the United States since status. before January 1, 1982. Over 1.7 million persons were approved for resident status. Experienced observers of the farm labor market during the mid-1980's believed that Many of these people are experienced undocumented workers accounted for farmworkers and may choose to continue about lo-15 percent of all hired farm- to work in agriculture. IRCA also es- workers, with higher proportions in the tablished a Special Agricultural Worker labor-intensive fruit and vegetable sector.20 (SAW) program for producers of Farm labor experts now believe this figure perishable commodities. to be much higher. This program allows undocumented workers who previously worked in seasonal agricultural services to apply for legal Surgeon General's Conference on Agricultural Safety and Health - 1991 777 Issues That Affect the National Agenda resident status. About 1.3 million persons applied, and a high approval rate is ex- pected. IRCA could have important implications for the supply, demand, working con- ditions, and wage structure of both illegal and U.S. hired agricultural workers in the future. The absence of reliable statistical information on illegal aliens creates dif- ficulties for estimating the effect of im- migration reform on agriculture. . ..the hired component of the agricultural work force will continue to grow in impor- tance as hired workers increasingly replace family workers on farms and as the number of large, labor-intensive com- mercial farms continues to increase. However, it is likely that many of the farms affected by immigration reform will be those that hire large numbers of seasonal farmworkers. Vegetable, melon, fruit and tree nut, and horticultural specialty farms are generally the least mechanized and require a large number of workers for short periods of time. These farms are generally concentrated on the Pacific Coast, in the Southwest, the Nor- theast, in Florida, and around the Great Lakes.`, 21 OUTLOOK FOR THE FUTURE Patterns of farm labor use have changed dramatically over the past four decades and definite employment trends emerged in the seventies and eighties. What do these trends suggest for farm labor re- quirements in the future? It is likely that the trend toward fewer and larger farms will continue in the near future, although the rate of change is ex- pected to be slower than during the 1970's and 1980's. Also, the hired component of the agricultural work force will continue to grow in importance as hired workers increasingly replace family workers on farms and as the number of large, labor- intensive commercial farms continues to increase. If current trends in farm inputs persist, we will see increased use of agricultural pes- ticides, fertilizers, and pesticides. Mechanization of the harvest of some fruits and vegetables is possible in the near future, but labor reductions are not likely to be as great as those of the 1950's or 1960's. For tree fruits and nuts, extensive replan- ting of trees is often required for machine harvesting, and costs for replanting and lost productive years are often difficult to justify. For some fruits and vegetables, such as strawberries and asparagus, the technology needed to machine harvest efficiently with minimal product damage has not yet been developed.16 The 1990 Food, Agriculture, Conser- vation, and Trade Act of 1990 directs the Secretary of Commerce to include ques- tions relating to agricultural accidents and farm safety in the 1992 Census of Agriculture. Several factors will help determine pat- terns of farm labor use in the future, including technology development, inter- national trade, farm programs, immigration policy, and relative prices of major farm 178 Papers and Proceedings The Agricultural Workforce, May 2, 1991 inputs. Recently enacted immigration reform legislation has not yet been em- pirically evaluated and could have impor- tant effects on farm labor supply, demand, and wages. Also, negotiations are currently underway between Mexico and the United States concerning removal of trade barriers bet- ween the two countries. A Mexican free trade agreement has the potential to affect movement of jobs and workers across the border. SUMMARY AND IMPLICATIONS My comments today point to three major conclusions: b First, changes in the structure of farming have dramatically affected the numbers, activities, and working conditions of the agricultural labor force. Farming and the nature of farms are very different today. The trend toward fewer and larger farms has reduced the number of family workers but increased the average farm's hired labor requirement. Operators and hired workers must have a varietv of skills to nerform farm tasks. ranging from hea equipment operator to chemical applicator.2 Length and intensity of farm work days exhibit high variation, - and the number of hours worked per day is often dictated by weather conditions. The use of agricultural chemicals on the farm has increased dramatically since the 1950's, and technological developments have placed a wide variety of complex machinery on U.S. farms. The changing nature of agricultural work has led to increased concern about the health and safety of agricultural workers. . Second, the agricultural work force is comprised of diverse workers with dif- ferent demographic characteristics, skills, and experience, who work on a variety of farms in a multiplicity of farm activities throughout the country. Components of the agricultural work force include farm operators, unpaid workers, domestic hired farmworkers, legal and illegal foreign workers, migrants, and children. This diversity complicates generalizations about farm safety problems and solutions. F Third, many of our long-held beliefs about farming and farmworkers are no longer relevant or have been based on stereotypic images that were never true: 1. 2. 3. 4. 5. Despite long-term declining trends in farm numbers, some areas of the country, particularly the West, are ex- periencing increases in the number of farms. The majority of U.S. farmers are part- time farmers and have a principal oc- cupation other than farming. For whatever reason, farming is a second job, and many work only a few days in farm activities. Employment of hired farm workers is highly concentrated on the large com- mercial farms, and 2 percent of the biggest farms accounted for over half of all labor expenditures. While the number of hired farmworkers has declined over the last 40 years, most of the decrease was in the early 1950's and 1960's. During the 1970's and 1980's, the number of workers stabilized. While many hired farmworkers are involved in the harvest of fruits and Surgeon General's Conference on Agricultural Safety and Health - 1991 179 Issues That Affect the National Agenda vegetables, farmworkers also do such diverse activities as shearing sheep, pruning Christmas trees, stocking cat- fish ponds, and baling tobacco. These findings suggest that we should not become complacent about long-term pat- terns and trends in farm employment. However, continued monitoring of farm labor conditions is dependent on adequate data collection on all components of the agricultural work force. While we collect comprehensive infor- mation on agricultural production levels, value of sales, and costs of production, little data are available on the characteris- tics, wages, and working conditions of agricultural workers. More detailed farm labor information at the local level is needed to help assess the impact of farm labor policies and programs, including those related to agricultural safety and health, on the employment and working conditions of the nation's farmworkers. Passage of the most recent Farm Bill may help to improve our data collection efforts in this area. The 1990 Food, Agriculture, Conservation, and Trade Act of 1990 directs the Secretary of Commerce to include questions relating to agricultural accidents and farm safety in the 1992 Cen- sus of Agriculture. The Bureau of the Census is currently pre-testing a series of questions to collect these data in the next Census. At the same time, the Farm Bill also authorizes the Secretary of Agriculture to make grants for the establishment of farm safety education programs for farmworkers, timber harvesters, and farm families. These grants, coordinated with state offices of rural health and the U.S. Department of Health and Human Services, are to provide information on such topics as the reduction of occupational injury and death rates, exposure to farm chemicals, occupa- tional rehabilitation of farmers with physical disabilities, and farm accident rescue procedures. The changing nature of agricultural work has led to increased concern about the health and safety of agricultural workers. While funding for these grants has not yet been appropriated, the mechanism is in place to improve our farm safety educational efforts. These two legislative components of the 1990 Farm Act recog- nize growing National concern over agricultural safety and health issues and provide the potential to improve our data collection and expand our educational efforts to help reduce accidents, illnesses, and deaths on the nation's farms.0 720 Papers and Proceedings The Agricultural Work-force, May 2, 1991 REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. U.S. Department of Labor. Survey of Occupational Injuries and Illnesses, 1989. Summary 91-1. Washington, D.C.: Bureau of Labor Statistics. January, 1991. U.S. Department of Commerce, Bureau of the Census. 1987 Census of Agriculture. Volume 1, Geographic Area Series, United States Summary and State Data, 1989. Brooks, Nora L., Judith Z. KaIbacher, and DOM A. Reimund. Farm Structural Trends in the 1980's. AIB No. 605. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1990. Carlin, Thomas A. and DOM A. Reimund. Changes in Farm Structure. Paper presented at the Annual Agricultural Outlook Conference, Washington, D.C., 1990. Friedland, William H. The Labor Force in U.S. Agriculture, in Lawrence Busch and William B. Lacy, Food Security in the United States. Boulder, Co.: Westview Press, 1984, pp 143-181. Smith, Matthew G., Clark Edwards, and Neal Peterson. How Many Farms? Projecting U.S. Farm Numbers and Sizes, Rural Development Perspectives. Vol. 3, Issue 3. June, 1987. Schertz, Lyle P., et al. Another Revolution in U.S. Farming. 7 AER No. 441. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1979. U.S. Department of Agriculture. Production and Efficiency Statistics, 1989. Washington, D.C.: Economic Research Service, 1991. Oliveira, Victor J. Hired and Contract Labor in U.S. Agriculture, 1987: A Regional Assessment of Structure. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, forthcoming 1991. Runyan, Jack L. A Summary of FederaI Laws and Regulations Affecting Agricultural Employers. AIB No. 550. Washington D.C.: U.S. Department of Agriculture, Economic Research Service, 1989. Ohveira, Victor J. The Agricultural Work Force of 1987. AER No. 609. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1989. Oliveira, Victor J. and E. Jane Cox. Characteristics of Agricultural Work Force Households, 1987. AIB No. 612. Washington, DC.: U.S. Department of Agriculture, Economic Research Service, 1990. U.S. Department of Agriculture. The Agricultural Work Force Survey of 1987. Economic Research Service, 1987. Oliveira, Victor J. Trends in the Hired Farm Work Force, 1945-87. AIB No. 561. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1989. U.S. Department of Labor. Employment and Earnings. Washington, D.C.: Bureau of Labor Statistics. January, 1987. Whitener, Leslie A. and Rafrq Mtmir. Hired Farm Labor, pp 102-112 in Barse, Joseph R. (ed.), Sever1 Farm Input Industries. Agricultural Economic Report No. 635. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service. Washington, DC, 1990. Surgeon General's Conference on Agricultural Safety and Health - 1991 121 Issues That Affect the National Agenda 17. Whitener, Leslie A. Migrant Farmworkers: Characteristics and Trends, in Out of Sighi, Out of Mind: An Update on Migrant Farmworker Issues in Today's Agricultural Labor Market. National Governors' Association, 1985. 18. Holt, James, et al. Toward the Definition and Measurement of Farm Employment, in Proceedings of Workshop on Agricultural and RuraI Data. Jointly sponsored by the American Agricultural Economics Association and the U.S. Department of Agriculture, 1977. 19. Lillesand, David, Linda Kravitz, and Joan McClellan. An Estimate of the Number of Migrant and Seasonal Farmworkers in the United States and the Commonwealth of Puerto Rico. Washington, D.C.: Legal Services Corporation, 1977. 20. Coltrane, Robert. Immigration Reform and Agricultural Labor. AER No. 510. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1984. 21. Duffield, James, Mitchell J. Morehart, and Robert Coltrane. Labor *end&es Help Determine Farms Affected by Immigration Reform. AIB No. 557. Washington, D.C.: U.S. Department of Agriculture, Economic Research Service, 1989. 22. Daberkow, Stan G. and Conrad F. Fritsch. Agricultural Workplace Safety? A Perspective on Research Needs, American Journal of Agricultural Economics. 61 (4), 1979, pp 824-835. 722 Papers and Proceedings Surgeon General's Confemnce on Agrfcultural SaWy and Health FARMSAFE 2000 o A National Coalition Rx Local Action Convened by the National institute Ibr Occupational Safety and Health April 30 -May 3, 1991, Des Moines, Iowa ATTITUDES AND RISK BEHAVIOR By Pamekz D. Elki& Ph.D. Professor, Department of Sociology Eastern Washington University Dr. Ronald D. Eckoff: Our next presentation will be by Dr. Pamela Elkind on attitudes and risk behavior. Dr. Elkind has a bachelor's degree in sociology from Boston University, a master's degree in sociology from Boston University, and a Ph.D. in sociology from Northeastern University with joint course work at Tufts University. Her special areas of work have been environment and energy, social impact assessment, medical sociology, rural communities, and research methods. Dr. Elkind has held a variety of research and consulting positions and for the past ten years has been at Eastern Washington University in the Department of Sociology where she is a professor of medical sociology, environmental sociology, and a research specialist. Dr. Elkind will be presenting this morning in relation to Attitudes and Risk Behavior. Dr. Elkind: Thank you. Good morning. I have been asked to speak to you today about behavioral attitudes related to hazardous farm activities. To speak to this subject, three questions should be asked. b Firstly, why consider agricultural at- titudes? b Secondly, what are the relevant at- titudes? . Thirdly, how are these attitudes related to farm health and safety practices? These are the questions we will consider today. AGRICULTURAL ATTITUDES The first question I shall address is, Why consider agricultural attitudes? As in this extraordinary conference, farm health and safety is receiving attention in the early 90's. Coalitions of concerned citizens and organizations are becoming common. OSHA is developing regulations. NIOSH is funding large projects. Kellogg is initiating special innovation projects. Popular magazines are covering the risks of agriculture. Programs and projects that deal with the safety of farm populations are being conceptualized. Within the framework of the various projects, there appears to be an important assumption. This assumption, simply stated, is that to make agriculture safe for the farm families and workers, it is neces- sary to motivate them to protect themsel- ves from health and safety hazards. The assumption further suggests that the way to accomplish this is to educate them about the dangers and possible negative outcomes of hazards. It is assumed that armed with the statistics and the knowledge of the means of protection, the agriculturalist will change behaviors, ul- timately diminishing injuries and casualties. I shall attempt to demonstrate to you that these assumptions lack validity. Principal persons in 206 farm families were interviewed in the State of Washington, in 1988 and 1989. The data were gathered as one of four subgroups in an analysis of farm hazards sponsored by the University Surgeon General's Conference on Agricultural Safety and Health - 1991 123 Issues That Affect the National Agenda of Iowa, Institute of Agricultural Health and Occupational Medicine. Many of you have referred to this as the NCASH study. 1 This assumption, simply stated, is that to make agriculture safe for the farm families and workers, it is necessary to motivate them to protect themselves from health and safety hazards...1 shall attempt to demonstrate to you that these as- sumptions lack validity. There is a good deal of similarity between the four states, data sets, but today we will speak of Washington State. Respondents were asked to compare farming to other occupations in terms of occupational hazards, including health effects and in- juries. In our Washington State sample, 80 percent of those questioned believed that farming is at least as dangerous as other occupations, and there is no significant correlation between perceptions of farm safety and gender, occupational longevity, age, education, or outside occupational status. This leads us to conclude that there is a generalized agreement across all categories in the farm population that agriculture is hazardous. However, the knowledge that farming is dangerous does not necessarily affect the attitudes of the respondents (Figure 1). When asked if they were more concerned about farm safety and health than econ- omic issues, as, for example, farm product prices, only 21 percent were more con- cerned about health and safety. Furthermore, when later in the interview we asked if the health hazards in farming are great enough for them to discourage their children from farming, only 6 percent 124 of the sample replied yes (Figure 2). In fact, those who felt farming was most dangerous were more likely not to dis- courage their children from farming. Number of Resoonses Percent Yes 43 20.9 No 140 45.5 Equally Concerned 53 25.7 Figure 1. More Concerned About Health and Safety Than Farm Product Prices. There is the greatest likelihood that a farm family knows agriculture is dangerous in terms of health and injury, yet parents believe it is an appropriate occupation for their children and are more concerned over the economics of agriculture than anything else. Figure 2. The Health Hazards in Farming Are Great Enough That You Could Discourage Your Children from Farming. In an interview, it is difficult to evaluate behavior, since only reported behavior is measured. Yet, some elements may be scrutinized. Respondents were asked about the precautions they take when dealing with agri-chemicals, tractors, machinery, or with grains, feed, and bed- ding material. They were asked to choose from among lists of choices, which range from staying Papers and Proceedings downwind and washing one's hands to wearing protective devices and using machine or vehicle safety equipment. Though many of the safety approaches would appear to take little effort, 18 per- cent did none of these. Conversely, 82 percent of the sample take some safety precaution, and there is no significant difference in their behavior with respect to the degree they consider agricul- ture hazardous. Some families practice a good deal of safety. About 40 percent of the sample reported that they regularly practice 5 percent to 10 percent of the safety precautions. Again, there was no significant difference between these behaviors when correlated with diverse perceptions of farm hazards. This analysis suggests to us that: b First, based on the sample of Washington State farm families surveyed, there is a good deal of knowledge about farm hazards in the population. Farmers perceive agriculture as dangerous. b Second, we might conclude that the attitudes about the importance of those hazards with respect one's own life differ from the knowledge of the hazards. In fact, when weighed against the family's economic well-being or a child's future in agriculture, the hazards are overlooked. b Third, behaviors of taking precautions tend to be unrelated to the knowledge of hazards. Farmers who regularly take many safety precautions do not say that farming is any more or any less dangerous than those who do nothing to protect their families and workers. Thus, I will argue, based on the Washington State sample, that knowledge Attitudes and Risk Behavior, May 2, 1991 about farm-based safety and health hazards is unrelated to deep-seated values and attitudes about what is important in farm life, and it is ultimately unrelated to the behaviors found in farm families with respect to safety practices. I will further argue that if knowledge is, in fact, not related to the reported attitudes and behaviors, one cannot conclude that change in the knowledge about safety will yield change in safety precautionary behavior. There are, I might add, some number of intervening variables within the attitudinal structures of farm families that require understanding in order to discover in what way behavioral changes might take place to increase farm safety practices. RELEVANT ATTITUDES Next, we should discuss what the relevant attitudes are that we might consider. Research since the 1930's has demonstrated a consistent value orien- tation pervasive in rural farm regions. The value set is known as agrarianism. It ap- pears to partially emanate from Thomas Jefferson's anti-Federalist thinking as ap- propriated from Aristotle, Locke, and Montesquieu. The pattern is derived from farmers' back- grounds in the class struggles of the 18th century European estate system. o Agrarianism suggests that rural life is natural and healthy rather than ar- tificial or evil. o The ownership of land makes the farmer self-reliant and independent. o Agriculture is nationally important. o Thus, farming is a virtuous occupation. Surgeon General's Conference on Agricultural Safety and Health - 1991 125 Issues That Affect the National Agenda The sense of equality and independence in agriculture points to a positive benefit of democracy, and farmers tend to be fierce defenders of democracy. Sociologists defined rural life, early in the century, as having an habitual character and an even flow. Life rested upon deeply felt and emotional relationships rooted in the steady rhythms of uninterrupted habit. The intimate relations between persons were based upon their individuality and wholeness. The traditional lifestyle was comprised of friendship groups, neighbor- liness, and blood relations. The attitudes of persons involved in 20th century agricultural production result from a lifestyle structured around conflic- ting values; traditional agrarian and con- temporary market values clash. The social values and ideas had their points of reference within these social groups and organizations. Farm-based economic independence and social equality foster the sharing of problems and ac- tivities by collectives engaged in land-based living over time. However, the deepest problems of modern life derive from the claim of the individual to preserve the autonomy and individuality of existence in the face of overwhelming social forces, of historical heritage, of exis- tence, of external culture, and of the tech- nique and technology of life. Farmers ex- perience these problems more than other groups. Agrarian values stress autonomy and individuality, but agriculture neces- sitates a great deal of interaction within the economic and political institutions of the society. Agriculture is a scientific endeavor re- quiring a great deal of educational back- ground reinforced by practical experience. It involves a knowledge base in agronomy, economic projection, and fiscal management training, personnel management training, and a solid knowledge of both the marketplace and government regulatory policy. Farming today, at every level, is involved with local, state and federal governments in, for example, subsidies, tax adjustments, and regulations of both crop output and farm practices. Technological develop- ment necessitates a constantly changing body of regulation in agriculture. The agricultural lifestyles, attitudes, and behaviors today are the outcome of the opposing forces of traditional agrarianism against the economic realities of a highly technical, rapidly changing society. The attitudes of persons involved in 20th cen- tury agricultural production result from a lifestyle structured around conflicting values; traditional agrarian and contem- porary market values clash. The result is a shared pattern of living and thinking, which differs from both the old farm ways and the highly urbanized, post-industrial society. SAFETY AND HEALTH PRACTICE Finally, let us consider how these attitudes are related to farm health and safety prac- tices. There is a paucity of research on the question, but I shall use a few of the avail- able studies to suggest some answers. According to Warwick, everything we know about accidents leads us to the conclusion 726 Papers and Proceedings that faulty habits and attitudes are the prime accident producers.' Murphy, hypothesizing that those farmers who hold different attitudes about health and safety from other farmers would have different accident records, looked at the diversity of attitudes and accidents in Pennsylvania.' Using a semantic differen- tial procedure contrasting attitudes in about 500 farmers, he found no significant difference between the attitudes of persons working where accidents had occurred in the previous five years, and those of ac- cident-free farmers. In fact, no differences in safety attitudes or occurrences were found between farmers, when they were grouped by such demographic and struc- tural variables as farm size, number of workers, type of farm, level of education, or hours worked on the farm. He concludes that other factors are likely to be more related to farm accidents than safety attitudes. His suggestion is that the pressures exerted by society and the low value actually placed upon safety in the decision process is likely to cause more risk behavior and, ultimately, accidents. Napier, et al., conducted an extension- based analysis of farm risks in the state of Ohio.3 Their statistically based research also indicated that there were no sig- nificant demographic or structural variables that would account for the ac- cident rate differentials on farms in Ohio. Further, they considered a farmer's ac- cident background and decided that social learning or experience with hazards does not make a significant difference in ac- cident rates, since people may or may not repeat their mistakes. Farm family attitudes may be related to economic well-being, as the Washington Attitudes and Risk Behavior, May 2, 1991 study suggests. They may revolve around the problems of agricultural productivity and the various costs surrounding preven- tive measures; however, the attitudes and ultimately behaviors could also be con- nected to a range of risk-taking personality characteristics and coping mechanisms. They are also likely to be related to an occupational culture. An excellent example of occupational culture could be considered that of mine workers. Yount found very definite work culture charac- teristics in risk behavior associated with mine workers.4 The manner in which they treated hazards, the interaction with respect to fear, and discourse while in social settings all demonstrated risk-taking and hazard-- coping mechanisms shared by the work culture. These characteristics and attitudes are influenced by the environment of their daily work, and they influence their everyday behaviors. Similar feelings and findings are likely to be found in farmworkers. Other elements such as ethnic or gender culture may also be related to attitudes. For example, a NIOSH/OSHA safety training story comes to mind. An Hispanic male working with hazardous materials was ordered to wear protective clothing: shoes, mask, and gloves. He wore all of these items except the gloves. When ordered continuously to wear the gloves for his own protection, he finally responded that yellow gloves remind him of his mother washing dishes. As a strong male, he could not force himself to wear the gloves. When black gloves replaced the yellow ones, the problem was solved. In the case of this worker, there were personality characteristics associated with Surgeon General's Conference on Agricultural Safety and Health - 1991 727 Issues That Affect the National Agenda the cultural statement of masculinity that were outstanding. These stories are per- vasive in the occupational safety domain. What characteristics and attitudes are at play when engineers monitoring construc- tion sites or hazardous waste sites and educated not to enter sealed tunnels beyond four feet continuously take flash- lights and go into these areas? They have read the statistics, and they are well-educated persons. If asked, they respond that they have been doing it for years, or it is the only way to get the job done, or they shrug and laugh, according to one OSHA-trained supervisor. Do each of you use seat belts? I am sure you have read the studies. And how many of you smoke cigarettes despite warnings? Much as Murphy, Napier, et al., Aherin and others--many others-are suggesting, in order to reduce farm hazards, it will be necessary to undertake a good deal more investigation into the forces behind the for- mation of attitudinal behavior and far communities.U~ The various dimensions of risk-taking behavior and their attitudinal components tend to be at the very heart of this problem. Only through a thorough comprehension of these behavioral dynamics will policy-makers and change agents design successful interventions, which are likely to alter risk-taking in order to reduce farm injuries and health hazards.0 REFERENCES 1. 2. 3. 4. 5. Warwick, W. Safety Education: Man, His Machines and His Environment. New Jersey: Prentice Hall, 1975. Murphy, Dennis. Farm Safety Attitudes and Accident Involvement, Accident Analysis and Prevention. Vol. 13, No. 4:331-337. London: Permagon Press, 1981. Napier, T. L, W.R. Goe, and R.R. Pugh. Incidence and predictive factors associated with farm accidents in Ohio. Ohio Extension Service document, 1987. Yount, Kristen R. Work-emergent behaviors and traits: the segregation of energy workers in boom- towns. Differential Impacts of Rural Resource Development, Pamela D. Elkind (ed.) Boulder: Westview Press, 1986, pp 119-144. Aherin, Robert A. Understanding and Predicting the Safety Behavior of Farmers, Paper presented at the American Society of Agricultural Engineers Conference, Chicago, 1985. 128 Papers and Proceedings Surgeon General's Conference on Agticultural Sakty and Health FARM&FE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa INDUSTRIAL CROPS OF THE FUTURE By Daniel E. Bugler, Ph.D. Director, Office of Agricultural Materials U.S. Department of Agriculture Dr. Ronald D. Eckoff: We shift gears a little bit again now. instead of talking so much about the workers, we're going to talk about some other things that are happening that relate. Our next presentation will be by Dr. Daniel Kugier, regarding industrial crops of the future. Dr. Kugler has a Ph.D. in Agricultural Economics from Michigan State University and works for the United States Department of Agriculture. He led economic and policy studies for soil and water conservation programs with special emphasis on the economic impacts of variable cost sharing and soil depletion on the adoption of conservation practices. In 1986, he joined the Cooperative State Research Service in Washington, D.C., to start up and manage the Department's Kenaf Development Program, a program designed to remove barriers preventing the commercialization of this non-wood fiber plant for manufacture of newsprint. in 1989, he was appointed director for the Office of Agricultural Materials, where he oversees research, development and commercialization of a number of crops, which provide new raw materials and chemical feedstocks to industry. Dr. Kugler will speak, this morning, on the topic, industrial Crops of the Future. Dr. Kugler: First, I want to thank the organizers for the opportunity to come here to Iowa and I thought that the best way to illustrate this address this important conference in the area would be to provide you seven area of issues, which affect the national examples of industrial crops of the future. agenda. It is always important to keep in- They have a variety of potentials. Some of them are commercializable now; some next formed of changes that will affect the agricultural industry, which is so important week; some of them may require the remainder of this decade before they can to our country. come to the marketplace. Specifically, I want to offer to you a You will find that a number of them are glimpse of an area of agriculture that many surprisingly common. Others, as I have of you know nothing about or, at most, may not think about on a day-to-day basis. mentioned before, you may have never seen or heard of before. It is an area that we refer to as industrial crops or agricultural materials-these being ASPEN, SOUTHERN PINE crops or materials, which provide non-food, non-feed materials to industry for use in processing and product manufac- The first crop is the very beautiful aspen ture and marketing. These materials tree. Many of you may be familiar with it. This tree is an excellent source of wood generally do not enter the food chain either for human consumption or as fibers and is harvested mainly from the northern United States and from forest animal feeds, although there are some plantations in Canada. notable exceptions in pharmaceuticals and in the area of some by-product meals that are used for animal feeds. The fiber from this tree is very well suited for the manufacture of dry-formed compos- ites. Aspen, in a dry, refined form-very Surgeon General's Conference on Agricultural Safety and Health - 1991 129 Issues That Affect the National Agenda coarsely refined- resembles shredded wheat. When you take it and blend it with syn- thetic fibers such as glass or polyester and add thermal-setting resins, you can create an air-laid, non-woven mat. This par- ticular kind of mat can then be put into a heated compression mold to make a variety of shapes of various angles and depths that can be used in a wide variety of products with which you are very familiar. Common applications include interior car door panels, dashboards, and the head liner that is over the top of you when you sit in your automobile. So, the next time you're rolling down the window in your car, underneath that vinyl or leather panel there may be an aspen tree. CORN, WHEAT, RICE, OR POTATO STARCH The second example is pretty familiar to you folks here in Iowa. Corn is very abun- dant and well known as a food source in our diets. However, there is more to do with corn than to just eat it. Corn is a principal source of starch, which is being extensively explored by government, universities, and industry to make degradable thermoplastics or starch polymers. Here in the United States alone we manufacture, on an annual basis, some 60 billion pounds of plastics from petrochemical sources. There are technologies available right now that can put up to 40 percent starch-and it can be from wheat, potato or other sour- ces-into various kinds of plastic film such as grocery bags and trash can liners. There are other technologies that are in development that will put 85 percent to 95 percent starch into these kinds of plastic materials and use it to make a variety of molded products. There is one effort that we believe is very significant-the Department of Agriculture and Department of Defense have joined hands with several universities and a major private company to produce degradable starch products, which will satisfy the Marine Plastic Pollution and Research Control Act of 1987. That particular act of Congress requires the Navy to cease the disposing of plastics at sea by the end of 1992, unless they are fully degradable in the marine environment. This is a very, very busy project. It is a very challenging and, we believe, achievable opportunity. INDUSTRIAL RAPESEED AND CRAMBE For the next industrial material, you will see a very beautiful slide of a crop in the state of Idaho. It is industrial rape seed. Many of you may know a cousin of this crop, called canola. The canola variety vegetable oil is sold in your supermarket under the Puritan label, from Proctor and Gamble. The industrial variety of rape seed, however, retains a high content of erucic acid, and that erucic acid can be used to manufacture a number of functional fluids, plastics, and nylons. I have several examples of things we are doing with high erucic acid rape seed. We have been working with some com- panies and universities to produce an automatic transmission fluid supplement, which is made from the derivatives of rape seed oil. Tests have shown at this point, when compared to standard factory-fill 130 Papers and Proceedings fluids, that with this particular kind of supplement, wear is reduced 50 percent, oxidative breakdown is reduced 24 percent, and that pentane insolubles are reduced some 60 percent. In another product, we are producing cut- ting fluids from rape seed oil. The cutting fluids show longer use. They show ex- tended tool life. In addition to that, there are no halogenated fluids produced, which require hazardous waste disposal. One other very significant product, which has been made from crambe oil, another crop source of erucic acid, is nylon 1313. Crambe, indeed, is a crop of the future and nylon 1313 is a product of the future because it is very lightweight, has very low water absorption characteristics and shows exceptional dimensional stability. We expect in the near future that nylon 1313 will be used in a variety of aircraft and marine applications. GUAYULE My fourth example is another very interes- ting crop. Guayule is native to the south- western United States and northern Mexico. It is a perennial shrub that reaches maturity at about three to five years of age. We extract natural rubber and resins and a variety of other chemical feedstocks from the plant's steno, branches, and roots. The advanced varieties of this particular plant have about 10 percent high molec- ular weight rubber, which is very similar to and comparable in performance with the Hevea rubber, which we import mainly from Malaysia, Thailand, and Indonesia. We are currently 100 percent import dependent for our nation's rubber supply, Industrial Crops of the Future, May 2, 1991 and it costs us a billion dollars a year in export dollars. Right now we are manufacturing tires made from guayule natural rubber, which will go on the Navy's F18 and A4 aircraft at a Goodyear plant in Virginia. We are also manufacturing light truck tires, which will be used for testing by the Army at a Firestone facility in Illinois. These are very important strides forward in developing a domestic rubber industry. In addition to the natural rubber in this particular plant, there are some very interesting resins. The most notable one can be used to produce a strippable coating for preservation of machine parts and mothballing aircraft. We are currently seeking work with the Air Force to test out this particular coating. KENAF The fifth example is another industrial crop that many of you may know if you have an ornamental hibiscus plant in your yard at home. This is a hibiscus grown for its industrial fibers, called kenaf. It is an annual plant of tropical and semitropical origin, native to east central Africa. In the cotton belt of the United States, this crop will grow 12 to 20 feet tall and produce six to ten tons of dry matter per acre. The fibers of this particular plant are very interesting. There are two fibers in the plant: a bark and an inside core. They make a very natural mixture for manufacture of newsprint. The outer fibers are long and tough and strong. The inner fibers are short and flat and make good filler and surfaces. When you take the entire plant and thermo- mechanically pulp it, you make a very high Surgeon General's Conference on Agricultural Safety and Health - 1991 737 Issues That Affect the National Agenda quality pulp that makes a very high quality newsprint, which has been accepted by the newsprint industry as a real commodity. Currently in the state of Texas, there are plans to build a $50 million newsprint mill based on kenaf. We hope to see those plans activated this year and to see news- print in production by the end of 1992 or early 1993. In addition to newsprint, there are a variety of other products made from kenaf fibers, which show premier. These are composites, packaging, poultry litter, high- grade specialty papers, absorbants and soil amendments. PACIFIC YEW TREE The next example of an industrial crop is the Taxus plant, an ornamental yew used as a landscaping shrub all over the country. Bark of the Pacific yew tree and needles and twigs of ornamental Taxus shrubs yield a complex natural chemical called taxol. According to the National Cancer Institute, taxol is the most important anticancer drug in 15 years and is in the last stage of can- cer. The Department of Agriculture has organized an effort to establish immediate, medium and long-term supplies of the tree bark and shrub clippings for extraction of the drug. Agriculture will help provide the renewable raw material for this life-saving drug. SOY BEAN The last example, like corn, is another very familiar agricultural plant. But also like corn, there is more to do with soybeans than eat or feed it. Printer's ink using soybean oil has been under development since the early 1980's and inks with 30 percent soybean oil are in use. Notably, The Gazette in Cedar Rapids, Iowa, under the leadership of Joe Hladky, Publisher and Chair of the American Newspaper Publishers As- sociation Technical Committee for Inks, is the pioneer in daily commercial use. In March 1991, the Department of Agricul- ture announced a 100 percent soybean oil ink that is completely compatible with newspaper presses. This formulation removes all the petroleum from the ink and shows low rub-off, lower cost, and more environmentally soundness in terms of degradation and recycling of old newsprint. If all newspaper ink were made with soybean oil, it would require 40 mil- lion bushels. RENEWABLE MATERIALS We are talking about renewable materials from agriculture, and I stress the word "materials." We are looking to make polymers, functional fluids, composites, structural materials, natural fiber products, and pharmaceuticals-all of which are extremely important to the health of our business and industry in this country. Why do we do this ? There is a variety of reasons. There are some very obvious balance-of-trade implications here, where we can reduce the imports of certain com- modities, in particular petroleum and rub- ber. There are opportunities to turn around and export things that we currently import. There are very obvious areas in which we can improve the competitiveness of our country by utilizing the excess productive capacities of our farmland to produce new 732 Papers and Proceedings crops or to use some of the crops that we are currently producing in excess. All of this, of course, is designed to spur rural economic development, increase our domestic production and add value to our agricultural materials at home, send them to the international market place. In addition to that, we are trying to alter the image, to some extent, of agriculture, and to let this country and the world know that agriculture, indeed, is a very high-tech business. In the area of leadership, one of the things we would like to be able to do in this country is to be a leader in technology development. One thing we have done an excellent job on in this country, for years and years, is research. We are the pre-eminent research country in the world, but the honest truth is, we have not done a very good job of taking those research results and moving them into the marketplace by doing value-added work. Many other countries come here, take our research discoveries and inven- tions home with them, make the products and then deliver them back to us. There is no need for that. We can do much of that here in our own country. Industrial Crops of the Future, May 2, 1991 How are we going at this? The Office of Agricultural Materials is a very small of- fice. We are working very closely with industry, very closely with academia, and very closely with state and federal gov- ernment to do something that Washington calls `precompetitive generic technology development." We are trying to enable commercialization, that is, to bridge the gap that currently exists between the research bench and the marketplace. In addition to that, we are trying to alter the image, to some extent, of agriculture, and to let this country and the world know that agriculture, indeed, is a very high-tech business. We are every bit as sophisticated as and have scientific talent on a par with those that are conducting research on supercomputers, high-performance ceramics, etc. To close, let us look at this slide that shows the official seal of the United States Department of Agriculture. It has an animal-drawn plow in the front and some shocks of corn in the back. Focus your attention at the statement at the very bot- tom, where it says: Agriculture is the foundation of business and commerce. Industrial crops and many other crops can be and are strengthening and enhancing that foundation.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 733 Surgeon General's Conference on Agricultural SatWy and Health FARM&FE 2000 o A National Coalition tir Local Action Convened by the National Institute kw Occupational Sidety and Health April 30 - May 3, 1991, Des Moines, Iowa BIOTECHNOLOGY AND AGRICULTURE By Jane Rider, Ph.D. Biotechnology Specialist National Wildlife Federation Dr. Ronald D. Eckoff: Our final presenter this morning is Dr. Jane Rissler, who will be speaking about biotechnology and agriculture. Dr. Rissler received her Ph.D. degree in plant pathology from Cornell University and conducted postdoctoral research in fungal physiology at the Boyce-Thompson institute for Plant Research. She has taught and conducted research in the university setting for a number of years. Since 1983, Dr. Rissler has been engaged in biotechnology science and regulatory policy work. From 1983 to 1988, she was at the Environmental Protection Agency where she was involved in the formulation and implementation of biotechnology policies. She served as a science advisor for and a project manager of the Pile Technology Project that operated under the Toxic Substances Control Act and was a special assistant in biotechnology to the EPA Assistant Administrator for Pesticides and Toxic Substances. In those position, she helped to develop EPA biotechnology regulatory policy and coordinated EPA's activities in the development of the Federal regulatory framework for biotechnology. She currently is a biotechnology specialist with The National Wildlife Federation. As part of her work in the National Wildlife Federation's National Biotechnology Policy Center, she has recently authored or co-authored several documents: Biotechnology's Bitter Harvest, Herbicide Tolerant Crops and the Threat to Sustainable Agriculture, Natural Resources and Environment, Biotechnology and Pest Control: Quick Fix Versus Sustainable Agriculture published in the Global Pesticide Monitor. She is the co-editor of the Gene Orchange a National Wildlife Federation Newsletter that provides a public voice on genetic engineering. This morning, Dr. Rissier will discuss Biotechnology and Agricul- ture. Dr. Rissier: INTRODUCTION I was asked to come here today to talk with you about potential farm worker health issues raised by the use of biotech- nology products in agriculture. In fulfilling that request, I will briefly explain the tech- nology, where it is likely to be heading in the next decade, and some concerns for worker safety that may arise from the tech- nology. I appreciate the opportunity to provoke discussion of biotechnology and agricultural worker health issues and hope that worker safety experts will consider and evaluate these issues as the technology is developing and before its widespread use. Before I begin, however, I would like to tell you of my biases that are relevant to 734 this talk. I represent a major environmen- tal group, the National Wildlife Federation, the country's largest conser- vation, education, and environmental ad- vocacy organization, with over 5.8 million members and supporters and 50 affiliated state groups. Four years ago the Federation established the National Biotechnology Center, to try to prevent the environmental and human health consequences associated with other technologies, such as the synthetic chemical, fossil fuel, and nuclear tech- nologies. The Center's objectives are to minimize the risks of this new technology and to ensure that the public has a role in the regulation and development of the technology. Papers and Proceedings I am here, not as a proponent of agricul- tural biotechnology, but as a skeptic-a skeptic who fears that the technology poses significant risk and uncertainty. Further- more, from a vantage point of studying the industry for nearly eight years, I seriously question whether biotechnology should or can assume a major role in answering the environmental, human health, and produc- tivity problems facing U.S. agriculture. WHAT IS BIOTECHNOLOGY? Broadly speaking, biotechnology refers to the use of living organisms as products or processes for humanity. People have used organisms for food and drink (e.g., yogurt, bread, wine, cheese) for millennia. From early agriculturalists to 20th century plant and animal breeders, humans have manipulated living organisms to improve food and fiber production. 1 I am here, not as a proponent of agricul- tural biotechnology, but as a skeptic-a skeptic who fears that the technology poses significant risk and uncertainty. Advances in molecular biology in the last three decades allow human beings to manipulate organisms in dramatically dif- ferent ways than are possible with traditional breeding methods. Many of these methods have been developed out of basic research in the 1960's and 1970's and have been adapted in the last 15-20 years to produce commercial products. These methods, along with the products and processes developed using them, constitute modern biotechnology. The terms are not used precisely or consis- tently. Sometimes the term biotechnology Biotechnology and Agriculture, May 2, 1991 is used to characterize a small subset of techniques, that is, genetic engineering, gene splicing, or recombinant DNA techni- ques. Other times it is used in varying degrees to include other techniques. A Powerful Technqlogy This is a powerful technology-a technology in its infancy. As an illustration, I use the words from a promotional piece from Monsanto, a company that made a huge investment in biotechnology: A new science destined to take [hulmankind into technology as a scien- tific milestone comparable to the realization of atomic energy or the development of semiconductors and powe#ul computers. ' The power of the genetic en- gineering-gene splicing-techniques comes from the capacity to combine genes from a wide array of organisms: mouse genes in tobacco plants, human genes in bacteria, or chicken genes in potatoes. Traditional breeding techniques are dramatically more limited in the range of possible gene com- binations. Only closely related organisms can be interbred by traditional means. By combining genes from widely disparate or- ganisms, genetic engineers will create a variety of genetically novel organisms im- possible by traditional means. Expected Products Using genetic engineering techniques, cell and tissue cultures, and other modern techniques, the industry promises transfor- mations in the way food and fiber are produced and processed in this country. Among the products already on the market and that we can expect to see in the near Surgeon General's Conference on Agricultural Safety and Health - 1991 135 Issues That Affect the National Agenda future or within a decade or two are the following: 1. 2. 3. 4. Genetically engineered food (grain, fruit, vegetables, oil) and fiber crops-for example, genes from insects, chickens, mice, fish, bacteria, viruses, and unrelated plants have already been splices into crops; these crops have been field tested in the last two years. Food and food supplements from genetically engineered microor- ganisms-cheese, yogurt, alcoholic beverages-for examples, a cheese en- zyme produced by bacteria containing a cow gene is already in wide commercial use and tryptophan, a food supplement derived from genetically engineered bacteria, was on the market; it was removed because nearly 30 people died and hundreds more became ill with eosinophilia myalgia syndrome as a result of consuming the product; whether the genetic engineering contributed to the toxicity is not yet known2 Genetically engineered food animals-cows, pigs, chickens, fish-carp with a trout growth hormone gene are being tested in ponds in Alabama; pigs and cows containing human genes have been produced. Genetically engineered hormones, an- tibiotics, vaccines-among the products thus far developed, bovine growth hor- mone, derived from genetically en- gineered microorganisms, is being used to enhance milk production; a recom- binant vaccine against pseudorabies is already on the market; a recombinant rabies vaccine is being tested in wild animals in Virginia and Pennsylvania. 136 Papers and Proceedings 5. Genetically engineered microorganisms to control plant diseases and enhance crop growth--several recombinant microbes have already been field tested. 6. New uses of crops and animals to produce commercially valuable chemicals-cows producing drugs in milk; tobacco plants producing anti- cancer proteins. While this list is incomplete,' it gives an idea of the power of a technology still in its infancy. BIOTECHNOLOGY COMPANIES The following are companies that are farthest along-as measured by their progress in field testing genetically en- gineered plants and microorganisms-in developing novel organisms for use in agriculture: . Monsanto . Ciba-Geigy = DuPont . Sandoz . Calgene = BioTechnica a Upjohn . Pioneer HiBred . Crop Genetics International . Northrup King * Rohm and Haas * Agrigenetics Advanced Sciences . Agracetus * Canners Seed . Amoco Technology . Boyce Thompson Institute . Wistar Institute H Rogers NK Seed = Dekalb Plant Genetics = Frito-Lay * Campbell Institute for Research and Technology. WHAT FARM WORKER HEALTH ISSUES ARE RAISED BY AGRICULTURAL BIOTECHNOLOGY? Based on industry predictions about the nature and pace of agricultural biotech- nology, it is obvious that farm workers will Biotechnology and Agriculture, May 2, 1991 be exposed to genetically engineered or- ganisms: micro-organisms, viruses, plants, animals. 1 I hope that this presentation will provoke a wide-ranging consideration and evaluation of the potential impacts of biotechnology on farm worker health. Keeping in mind that this is a new tech- nology, one based on a highly artificial manipulation of living things, one tha