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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 that poses significant unknowns and uncertain- ties, it is time to begin discussing the agricultural worker-health ramifications of biotechnology. The organizers of this conference, is placing this talk on its agen- da, recognized this need. I hope that this presentation will provoke a wide-ranging consideration and evaluation of the poten- tial impacts of biotechnology on farm worker health. The experiences that we have to draw on to initiate this discussion come from genetic engineering research laboratories, the pharmaceutical industry where genetically engineered organisms have been used for some time, and industries and agriculture based on traditionally developed microorganisms, plants, and animals. A complete discussion of risP would re- quire consideration of both hazards and exposure. This talk is limited to an at- tempt to identify potential farm worker health hazards that may develop from a large commercial agricultural biotech- nology industry. I have not attempted to describe exposure beyond general statements indicating that more farm workers are likely to be exposed to increased numbers of living or- ganisms-both genetically engineered and conventionally bred ones-and their products. The list of potential hazards I offer may be incomplete; I welcome suggestions. Some are more speculative than others. As the hazards are evaluated by experts, some will be judged as more problematic than others. Some concerns are the same that one would expect with non-engineered organisms. POTENTIAL BIOLOGICAL Opportunistic Pathogens6 HAZARDS Several factors point to the potential for increased problems for genetically en- gineered organisms that are opportunistic human pathogens. Developers may en- gineer microorganisms whose opportunism is unknown. Scientists may unknowingly engineer an opportunistic pathogen for one of two reasons. b First, they are working with organisms about which little, including opportunism, is known. Splicing genes into an organism requires little or no information about the organism's ecological or pathogenicity traits. b Second, engineers may have some infor- mation on the organism's ecological characteristics but, because of isolation between scientific disciplines, the scientists may not know that the same organism has been classified as opportunistic (or even frank pathogens) by human health experts.' The organism may, in fact, have different taxonomic designations in two different disciplines. Surgeon General's Conference on Agricultural Safety and Health - 1991 137 Issues That Affect the National Agenda 1. 2. Farmers and farm workers, as a population engaged in one of the nation's two most hazardous jobs (the other is mining), may often be unheal- thy and highly stressed as a result of their occupation"-and more susceptible than the population at large to oppor- tunistic infection. In addition to their occupational stress, the farm worker population is likely to show an increase in the number of immunosuppressed or compromised persons as a result of the epidemic of acquired immune deficiency syndrome (AIDS) and related diseases. Persons with suppressed or compromised im- mune systems are generally more sus- ceptible to infection by opportunistic pathogens. One example of an opportunistic pathogen that already is the subject of biotechnology research and development is the vaccinia virus-the virus originally used to immunize the human population against smallpox. The vaccinia virus has long been known to cause, though rarely, disease and death, including encephalitis,' in im- munocompromised/suppressed persons. Recently, three persons infected with AIDS reportedly died after being inocu- lated with a vaccinia viru~.`~ Work is underway to genetically engineer vaccinia virus to make vaccines against a number of animal diseases, including rabies and rinderpest. To create these vaccines, one or a few genes is taken from the rabies or rinderpest virus and spliced into the vaccinia virus. The genetically en- gineered vaccinia virus then is used to inoculate animals to prevent rabies or rinderpest from developing. FRANK PATHOGENS" Generally, we expect that companies will not use and regulators will not permit the use of genetically engineered human pathogens in agriculture. However, a problem arises because of the potential for splicing genes into poorly characterized or- ganisms, some of which may be human pathogens. As noted above, scientists may engineer organisms about which they know little in terms of ecological or pathogenicity traits. Another question that may arise is whether genetic engineering could transform a non- pathogen into an opportunistic or frank pathogen. Because pathogenicity is generally a complex trait controlled by many genes, it is not likely that splicing in one or a few genes could create a pathogen. On the other hand, there are instances where engineering an organism that is closely related to a pathogen, i.e., already possesses most of the characteris- tics of a pathogen, might change that or- ganism into a pathogen.12 ENDOTOXINS3 Greater use of gram-negative bacteria (e.g., pseudomonads and rhizobia) in biotechnology applications may increase the incidence of respiratory problems among farm workers. Some scientists have hypothesized that the endotoxin portion of the gram-negative cell wall may be respon- sible for the respiratory disorders as- sociated with a number of agricultural industries: grain and silage handling, pork and poultry production in confined facilities, composting, and poultry proces- sing.`" 738 Papers and Proceedings ALLERGENS" Allergens, which incite a hypersensitive reaction, include substances produced by plants, animals, and microbes. If biotech- nology achieves even a portion of the suc- cess promised by its proponents, there will be an increase in the agricultural use of living and novel organisms-and their products. Consequently, we may see an increased incidence of hypersensitivity-due to greater exposures to living organisms, in general, and due specifically perhaps to changes caused by genetic engineering. Genetic engineering may introduce new allergens, for example, by producing ex- pected secondary metabolites in microor- ganisms. Foreign genes in crops may produce new allergens in the plants and their pollen. ANTIBIOTIC RESISTANCE Many novel organisms are genetically en- gineered to resist one or more antibiotics. This is a trait added, not to improve the organism, but to confirm that gene splicing has been successful. Splicing in antibiotic resistance is part of standard genetic en- gineering methodology. The worker health issue that arises is the extent to which the unintentional ingestion of antibiotic- resistant microbes could result in the sub- sequent transfer of antibiotic resistance to gut microflora and eventually to pathogens.16 Transfer of antibiotic resistance to path- ogens could make them resistant to therapeutic control by the drugs to which they are resistant. Thus far, most drug resistances used in genetic engineering in this country are antibiotics not widely used clinically. Biotechnology and Agriculture, May 2, 1991 UNEXPECTED/UNKNOWN HAZARDS This is a category of hazards whose definition will only be known in retrospect. Generally, what I am proposing is that there may be unexpected and as yet unknown hazards associated with this high- ly artificial technology-perhaps a new illness or an old one unexpectedly as- sociated with genetically engineered or- ganisms. Already genetic engineering has produced unexpected effects. Three examples are: 1. 2. 3. Naked DNA from human cancer cells can unexpectedly trigger tumors when the DNA is applied to abraded skin. It was previously thought that DNA had to be transported into target cells by a carrier." Human or bovine growth hormone genes spliced into pigs gave the ex- pected result-leaner pigs. However, the genetically engineered pigs also displayed unexpected deleterious ef- fects: arthritis, gastric ulcers, weak muscles, and lethargy.l* Experiments with petunias, genetically engineered to alter pigment production in flowers, showed "results . . . completely different form those the scientists expected."" Not only was the actual frequency of nonpigmented flowers ten times greater than expected, but the flower pigmentation responses to environmental conditions were total- ly unexpected. POTENTIAL CHEMICAL HAZARDS One of first agricultural biotechnology products to reach the market will be crops engineered to resist herbicides, that is, Surgeon General's Conference on Agricultural Safety and Health - 1991 139 Issues That Affect the Natlonal Agenda crops created so farmers can apply more of certain herbicides to obtain weed control and not harm plants. Some of the her- bicides for which plants are being en- gineered for resistance are 2, 4-D, bromoxynil, glufosinate, glyphosate, and sulfonylurea. Increased use of certain herbicides, particularly those like 2, 4-D and bromoxynil, which are known or suspected to be human health hazards, poses risks to workers who apply them or are otherwise exposed." On the other hand, a potential improve- ment in farm worker safety may come from genetic engineering for pest resis- tance, such as splicing insect toxin genes into plants. Pest-resistant crops may provide at least a short-term decrease in the use of dangerous insecticides and fun- gicides. WHAT SHOULD BE DONE TO ENSURE WORKER SAFETY IN AGRICULTURAL BIOTECHNOLOGY? Four actions will go a long way toward enduring the safety of farm workers ex- posed to agricultural biotechnology products. 1. Evaluate risks. Public and occupational health experts should begin to evaluate the risks that a growing agricultural biotechnology industry poses to farmers and farm workers. 2. Use only no- or low-risk organisms, ones that are well-characterized and thoroughly evaluated, for potential human health hazards. Only these should be approved for agricultural use. 3. Reduce exposure to biotechnology products. Standard approaches, such as worker protection equipment, procedure, and training, should be adopted to reduce worker exposure to biotechnology products. 4. Initiate and maintain medical surveil- lance. The case for surveillance is best made in a report from a Centers for Disease Control/National Institute for Occupational Safety and Health (CDC/NIOSH) Ad Hoc working group on medical surveillance for industrial applications of biotechnology?' Uncertainty provides the strongest ar- gument for maintaining medical surveil- lance over workers engaged in industrial applications of biotechnology. As is the case for any newly developed technology, there is a lack of information concerning the nature or severity of any acute or chronic health hazards, which might be associated with the industrial applications of this technology. The CDC/NIOSH working group is of the opinion that medi- cal surveillance of biotechnology workers constitutes prudent medical practice. Such surveillance should be aimed at the early detection of sentinel disease events. The detection of any occupational illness caused by recombinant organisms or their products will have important biological and public health consequences and should be actively sought.0 140 Papers and Proceedings Biotechnology and Agriculture, May 2, 1991 REFERENCES AND NOTES 1. 2. 3. 4. 5. 6. 7. a. 9. "Out Front in Biotech," Monsanto Magazine, Fall 1986. "L-Tryptophan Puzzle Takes New Twist," Science, August 31, 1990, page 988. See The Gene Exchange, Volumes 1 and 2, National Wildlife Federation, Washington, DC, 1990- 1991, for additional information on many of these organisms and products. In the 1970's the major risk associated with the new genetic engineering technologies was the potential for disease among laboratory researchers and the public. Conferences were held and experiments were conducted to evaluate the human health risks (see for example, Risk Assessment of recombinant DNA Experimentation with Escherichia coli K12, Proceedings from a Workshop at Falmouth, MA, published in The Journal of Infectious Diseases, Volume 137, Number 5, May 1978). Since that time, in the absence of epidemics attributable to recombinant DNA, the fears have largely dissipated. However, as far as we know, there have been no extensive, systematic studies monitoring the health of recombinant DNA researchers-recent disturbing report may cause a reconsideration of the safety of some aspects of genetic engineering research. See, for examples, "Some DNA Lab Work Raises Cancer Risks," BioWorZd Today, October 12, 1990, page 1; "Cancer Deaths Probed at Pasteur Institute," Science, June 27, 1986, page 1597. To understand the complexities and limitations in fully describing the human health risks of some biotechnology products, see "The Toxicology of Genetically Engineered Microorganisms" by L.S. Katz and J.K. Marquis, pages 51-63 in Risk Assessment in Genetic Engineering, M. Levin and H. Strauss, eds., McGraw-Hill, New York, 1990. Pathogens that do not cause disease in healthy individuals but may do so in certain unhealthy or stressed persons. "Plant-associated bacteria as human pathogens: disciplinal insularity, ambilateral harmfulness, and epistemological primacy" by M.P. Starr, Annals of Internal Medicine 90: 708-710, 1979. See, for example, Agriculture at Risk: A Report to the Nation by the National Coalition for Agricul- tural Safety and Health, Institute of Agricultural Medicine and Occupational Health, Iowa City, IA, 1989. "Vaccine Technology: Developmental Strategies," Bio/Technology, Volume 5, page 1038-1040, October 1987; "Smallpox, Vaccinia, and Cowpox" by A.R. Rao, pages 1672-1686 in Medical Microbiology and Infectious Diseases, edited by A.I. Braunde. W.B. Saunders, Philadelphia, 1981. 10. "Deaths of 3 Patients Not Included in Report About AIDS Experiment," New York Times, April 14, 1991. 11. Outright pathogens; pathogens that cause disease in healthy persons. 12. See "Phenotypic Properties of Source Microorganisms and Their Genetically Modified Derivatives," pages 99-112 in National Research Council, Field Testing Genetically Modijied Organisms: Frameworkfor Decisions, National Academy Press, Washington, DC, 1989, for a discussion of the potential effects of genetic engineering on pathogenicity. l3. Components of the cell walls of gram-negative bacteria. Surgeon General's Conference on Agricultural Safety and Health - 1991 141 Issues That Affect the National Agenda 14. See discussion and references in "Inhaled Endotoxin and Decreased Spirometric Values" by R.M. Casteban, SAA. Olenchock, K.B. Kinsley, and J.L. Hankinson, The New Engknd Journal of Medicine 317: 6054510, 1987. 15. Substances which induce hypersensitivity/allergy. Hypersensitivity in humans is a specific and deleterious reaction to a substance that does not, in similar amounts, affect other persons. 16. See, for example, "Emergence of Antibiotic-Resistant Bacteria in the Intestinal Flora of Farm Inhabitants," by S.B. Levy, Journal of Infectious Diseases 137: 688690, 1978. 17. "Some DNA Lab Work Raises Cancer Risks," BioWorld Today, October l2, 1990, page 1. 18. "Gene-Watchers' Feast Served Up in Toronto: Putting Foreign Genes into Domestic Animals, Science October 7, 1988, pages 32-33. 19. "Jumping Genes Confound German Scientists" by D. MacKenzie, Nau Scientist, December 15, 1990, page 18. See also "The German Experience Gained with Field Testing of Genetically Modified Plants" by P. Lange, pages 161-164 in Biological Monitoring of Genetically Engineered Plants and Microbes, Proceedings of an International Symposium, Kiawah Island, 1990. 20. Biotechnology's Bitter Harvest: Herbicide-Tolerant Crops and the Threat to Sustainable AgricuIture by R. Goldburg, J. Rissler, H. Shand, and C. Hassebrook, 1990, Biotechnology Working Group, Washington, DC. 21. "Medical Surveillance of Biotechnology Workers: Report of the CDC/NIOSH Ad Hoc Working Group on Medical Surveihance for Industrial Applications of Biotechnology' by P.J. Landrigan, M.L. Cohen, W. Dowdel, L.J. Elliott, and W.E. HaIperin, Recombinant DNA Technical Bulletin 5133-138, 1982. 142 Papers and Proceedings Surgeon General's Cont&ence on Agricuttural Salty and Health FARMSAFE 2000 o A National Coalition lor Local Action Convened by the National Institute ti~or Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa SURVEILLANCE: A PHYSICIAN'S VIEWPOINT &y John J. May, M.D. Director, Bassett Farm Safety and Health Project New York Center for Agricultural Medicine and Health The title of my talk today is A Physician's Viewpoint, which is a nice title. For a while I thought maybe I would just talk about the Chicago Cubs. Then a couple of weeks ago, I thought perhaps I would ex- pound about the Internal Revenue Service for a while. Actually, what I will try to do today is present a physician's point of view-a practicing physician's point of view-regarding our role in the surveillance of agricultural health and safety problems. I will try to build upon Dr. Halperin's very excellent discussion of surveillance this morning, focusing in particular on the potential contribution of the rural physi- cian. Next, I will review some of the likely obstacles or roadblocks that, at least in my mind, might prevent effective physician surveillance. Finally, I will try to suggest some ways of using existing resources to enhance physician surveillance. I will try to define a couple of terms. The first term is surveillance, which refers to the collection, collation, analysis, and dis- semination of data for purposes of pro- gram planning, implementation, and evalu- ation. For my purposes, when I talk about physi- cians, I am referring not only to medical doctors and doctors of osteopathy but also to registered nurses, to nurse practitioners, to physician's assistants, to anyone who is involved in the delivery of primary care in a rural setting. By "health department," I am referring to any body that processes the information that is reported to it and who collects and analyzes surveillance data. By "farmer," I am referring to a broad group: anybody who does physical work in agriculture. How is it that the physician gets involved in this scheme of surveillance, which was so nicely outlined earlier this morning? Well, of the methods that were described earlier, you will recall that some are based upon examination of large, existing, data bases, looking for evidence of trends in morbidity and mortality. Some are based upon recognition of excess hazard, possibly using some of the data that has been col- lected over the years by NIOSH or by OSHA. SENTINEL HEALTH EVENTS Dr. Halperin also mentioned the recognition of individual cases or sentinel health events. This is where, in my view, the practicing physician can contribute to surveillance. The sentinel events are oc- currences that have been determined to be of public health significance. Dr. Halperin described many of the other characteristics of the ideal sentinel event. The recognition of a sentinel event is im- portant, both for the individual case and for others experiencing similar risk. An appropriate response to a sentinel event Surgeon General's Conference on Agricultural Safety and Health - 1991 743 Surveillance - Agriculture-Related Diseases, Injuries and Hazards may involve an intervention aimed at the index case, which, hopefully, can reverse the problem or at least prevent further morbidity. . ..the intervention should affect other workers by either addressing the hazar- dous exposure, by screening similarly exposed workers, or by insuring that at least adequate protection is provided to similarly exposed workers. Additionally, the 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. These events can be detected in several ways. Screening programs Screening of specific worker populations can occur in various settings. A lot of this is done by employers both under duress from OSHA and on their own. It can be done through an occupational health clinic. If such screening uncovers evidence of occupational disease in a worker, this event should trigger a careful analysis and possibly an intervention. Reporting programs Alternatively, sentinel cases may be picked up in reporting programs, which may re- quire reports from physicians or, in some cases, laboratories. Examples of this might include patients who turn up with clinical evidence of occupational asthma, or situa- tions in which blood samples are deter- mined to have elevated lead levels. In most states, such situations are reported to the department of health. Often this is a 144 legal requirement for the practitioner. The value of this kind of case identifica- tion was demonstrated very nicely in a number of Dr. Halperin's examples earlier today. PROBLEMS IN PHYSICIAN REPORTING OF OCCUPATIONAL SENTINEL EVENTS For the next few moments, I would like to review some of the potential problems associated with the surveillance of sentinel events, both in theory and in terms of applying it to the agricultural setting. It is widely acknowledged that this type of surveillance leads to the detection of only a significant minority of cases. This is most clearly seen in the infectious disease experience. Here is a study from Vermont that looks at the typical or passive mode of reporting and compares it to an active approach in which physicians were contacted on a weekly basis. You can see that with the customary model, the passive model, only about half as many cases of hepatitis, mea- sles, rubella, and Salmonella were reported when compared to the more active ap- proach. If we look at occupational health, the news is not really any better. One example is physician-generated reports of occupational disease in Maryland from 1981 through 1983. There were 17 clinics in the Baltimore area that were doing a substantial amount of occupational health as part of their practice. There were 16 board-certified occupational physicians in Maryland, and there were at least 143 worksite clinics in operation in the state. Papers and Proceedings Surveillance: A Physician's Viewpoint, May 1, 1991 In 1982, 279 cases in total were reported. Twenty-three percent of these were report- ed by one physician, and 62 percent were reported by another physician. So, 85 percent of all the case reports in Maryland in 1982 came from two physicians. Obviously, there are some potential prob- lems with the reporting of sentinel events in that the afferent limb of the reflex here is certainly not flawless. There is another set of problems relating to the other side, the efferent part of the reflex. The public health body, which is the recipient of these notifications, must have the personnel, the interest, and the funding to provide an appropriate analysis and response to these notifications. But look at what we know about the effective- ness of this interaction. This is from a 1985 survey of the health departments of 50 states as well as the health department of New York City and Washington, D.C. You can see that about 60 percent of the departments mandated physician reporting of selected occupation- al illnesses. Lead poisoning was the most commonly required reportable condition, yet only five of these health departments had developed criteria for evaluating reports of lead poisoning. Eighteen departments indicated routine or periodic efforts to obtain ad- ditional details on reported cases. Only 10 departments used the case report, so only about one-third of those who mandated reporting used the case reporting in any of their interventional activities, only seven departments had ever published a sum- mary of information from case reports, and no department reported having evaluated its surveillance program to determine the rate of reporting. So, it is clear that the surveillance of occu- pational sentinel events is a complex activi- ty. It is not currently being done optimally by any of the participants. PROBLEMS IN PHYSICIAN REPORTING OF AGRICULTURAL SENTINEL EVENTS: Physical and Farmer Interaction Now, let us look at some of the potential challenges involved in applying this model to agricultural health and safety. The physician and farmer interaction is not always a many-splendored thing. First of all, some farmers feel that they do not have the funding or the time required to see their physicians on a regular basis. A second issue is the farmer's perception of the physician's expertise regarding agri- cultural health problems. If I tried to assure an audience of farmers that their physician could consistently recognize occupational hazards and could always advise them reliably on the proper treat- ment and prevention, my statements might be received by the farmers with an ele- ment of skepticism. Physician Recognition of Sentinel Events This leads us into the second aspect of the issue of reporting, and that has to do with physicians. My observations over the last 10 years are that physicians, in general, tend to have relatively limited sophistica- tion with regard to agricultural medicine. There are a variety of occupational prob- lems, which have been outlined by Dr. Novello and a number of other speakers, that can affect farmers. Surgeon General's Conference on Agricultural Safety and Health - 1991 145 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Some of these are clearly job-related, and others are probably job-related. Many physicians would have difficulty diagnosing some of these conditions and would sel- dom relate others to the farmer's oc- cupation. Physician Reporting of Sentinel Events If we assume that the farmer does come to see the physician and that the physician correctly diagnoses the problem, does it get reported ? This relates to the physici- an's awareness of the responsibility to re- port as well as their interest in doing the reporting. I cannot show you any data on the level of this interest. As a practicing physician, I can assure you that when things get relatively busy, the interest in reporting is limited. Public Health Response to Sentinel Events Now, a final challenge in the physician reporting of agricultural sentinel events, in my mind, has to do with the need for a mutually productive interaction between the reporting physician and the health department. Reliable reporting will con- tinue only if it is clearly beneficial to either the physician or to his patient. Yet these departments have limited resour- ces. Even if there is sufficient interest at the health department level, it is unlikely that most health departments have the expertise in agricultural medicine to mount an effective response to this kind of infor- mation. For the past 10 minutes I have outlined a series of problems and roadblocks involved in this issue that make it seem that the likelihood of effective physician surveil- 746 lance is somewhere between slim and none. I believe, however, this is an effec- tive activity that can be made to work, and there are resources available that can be applied to the task. RESOURCES The National Coalition for Agricultural Safety and Health (NCASH) was formed, following the meeting in Des Moines and Iowa City. This group has successfully worked to secure funding to begin some of the efforts that we are seeing today. NIOSH certainly had contributed to this field prior to the beginning of the NCASH endeavor. Since then, it has received fund- ing needed to begin a more organized attack on these problems. Now, through NIOSH, there is a wealth of experience with occupational problems, although not specifically with agricultural problems. The recently designated NIOSH centers should be able to provide consultation and educational support that is specifically aimed at agricultural issues. As you know, these are located in Iowa and California. Another NIOSH-initiated program is the Rural Nurse Sentinel Program, which I suspect Dr. Freund will expand upon to- morrow. Briefly, this is a program that proposes to locate specially trained occu- pational nurses in rural regions where they will interact with rural physicians and oth- ers to form a network for surveillance pur- poses. In addition to NIOSH-funded programs, there are a handful of other groups around the country that have a particular interest and expertise in agricultural medicine. In New York we have been working in this field for about 10 years. We were preced- ed in this by the group from Marshfield, Papers and Proceedings Wisconsin. In other places in the country, there certainly are a number of interested individuals who have considerable experi- ence working with farmers and farrnwork- ers. Certainly, a number of the land-grant uni- versities have developed expertise in engi- neering and safety issues, and, in some cases, this has expanded into the area of health and health education. An example of this would be Bill Field at Purdue, whose interest in rehabilitation of injured farmers has resulted in his acquiring a knowledge of rehabilitation medicine that makes most of us physicians envious. Some occupational medicine groups have become increasingly interested in this field and clearly have become resources. Our previous speaker and her program in Seattle are certainly an example of this. In general, however, I think that agricultural problems are not an area of expertise or even of particular interest for many oc- cupational physicians. POSSIBLE SOLUTIONS Let me see if I can spend a few minutes proposing ways in which some of these resources might be used to help us get around the various obstacles that I de- scribed a few minutes ago. Physician and Farmer Interactions The physician and farmer interaction is a difficult problem, and it certainly needs to be addressed. Currently physicians are not viewed as being particularly knowledgeable with regard to agricultural problems, nor are they affordable or convenient to the farmers. Surveillance: A Physician's Viewpoint, May 1, 1991 Some of these issues can be improved, certainly with aggressive efforts at con- tinuing medical education. As you heard at lunchtime? here in Iowa interested physicians w&in a community may some- times enter a program in which they re- ceive intensive training in agricultural health problems at the center. Such in- dividuals then become local resources. Educational efforts by physicians can go a long way towards building bridges between farmers and physicians. Jim Hartye has developed an innovative approach at his clinic in North Carolina. Periodic health screening events are scheduled for the farm community. When these people come in for free spirometry or free blood pressure checks or free cholesterol checks, these are coupled with discussions of safety practices, protective equipment, etc. Mary Lee Hill, from our group, will pres- ent a poster later this week demonstrating the effectiveness of a similar program. A proposal for this type of approach was recently discussed by the American Academy of Family Practice. The experience that we have had in New York is that educational programs are a very effective way to reach out to the farm community. For this reason, we never decline an invitation to speak to a farm group, whether it be large or small. We have an educational booth that spends a lot of time on the road going to various farm shows and programs. We design the programs that accompany this booth to be interactive in some way. Frequently, there is some sort of a come-on with free hearing testing or free respiratory testing. The main point is to Surgeon General's Conference on Agricultural Safety and Health - 1991 147 Surveillance - Agriculture-Related Diseases, Injuries and Hazards obtain a teachable moment with this group and spend some time educating. These kinds of contacts with farmers and their families have enabled us to learn a lot. It also, at the same time, has strength- ened our relations with the agricultural community in New York and has enabled us to gain some recognition with the com- munity as having some experience and expertise in agricultural health problems. Now the local practitioner is unlikely to have the time, interest, or expertise to approach farmer education in this way. However, if one were supported in this effort with teaching materials, with exam- ples of acceptable protective equipment, as well as a basic understanding of this mate- rial, these efforts might prove not only possible but actually productive, not only in terms of educating but in terms of alter- ing the relationship that currently exists between physicians and farmers. In the waiting room of a rural clinic in Sweden that is run by a physician, with a particular interest in agricultural medicine, prominently displayed are various types of protective equipment as well as instruc- tions. He provided fairly sophisticated discussions of ergonomics for his patients. I think these kinds of effort go a long way to building bridges with the farm com- munity. Physician Recognition of Sentinel Events The problems in physician recognition relate to the level of sophistication that the physician has regarding occupational and specifically agricultural health problems. The potentially large number of events, many not clinically certain or absolutely related to work, clearly poses a problem for these physicians. Here again, aggres- 148 sive, continuing medical education is part of the answer. In addition, I think the number of report- able events must be limited to a few. These should be defined for epidemiologic rather than clinical purposes. For exam- ple, if we agree that farmer's lung is an appropriate target for surveillance, we would not require that a case demonstrate repeated recurrences, antibody positivity, and a predominance of lymphocytes in the bronchoalveolar lavage fluid. Rather, we would want to hear about any febrile reactions with myalgias or cough that occur following dusty work. The determination of whether this is farmer's lung, or organic dust toxicity, or simply pneumonia would be made later on by a different part of that reflex loop. A form that we use in the Occupational Health Network in New York allows for a sub- stantial amount of uncertainty regarding the clinical diagnosis. Nevertheless, these people get on the re- cords and it is possible at a later date to sort out how certain we were and how good the evidence was that this was a bona fide case. So I think that although physi- cians have a need to be quite certain, epidemiologists are more comfortable with less certainty. Physicians have to be edu- cated to this difference, if they are going to report these cases. Physician Reporting of Sentinel Events Physician interest in reporting agricultural or any illness is going to be affected by the level of antipathy felt towards the local health department. In my home state of New York, this is considerable, and the easiest way to infuriate a New York physi- cian is to send him a letter that says, "Dear Provider, The New York State Department Papers and Proceedings of Health now requires that you do the following." There is no way to enforce these kinds of laws, and so I do not think it is a productive way to approach the physicians. Interest in reporting is further moderated by the amount of time and effort needed to do so as well as by the natural reluc-, tance to get wrapped up in what is some- times a quagmire of workmen's compensa- tion. If the health department hopes to receive reports, the system must be readily accessible, user friendly, and perceived as beneficial either to the physician or to her patient. A system like the Poison Control Center Network, which provides consulta- tion and support to the physician, will at- tract a lot more interest than simply another annoying letter from the health department. Active surveillance has repeatedly been shown to be more effective and well- received by physicians. Once again, I will use an example from the infectious disease literature. This is a study from Rochester, New York. They divided the physicians into three groups. Some received a weekly phone call, some received a weekly post card, and most just performed passive surveillance as is typical. Not surprisingly, there was substantially more response in the telephone group than in the post card group. There was better response in the post card group than in the passive group. So the message is that active surveillance is better, and I think NIOSH, recognizing this, has initiated the nurse surveillance program, which I men- tioned earlier. Surveillance: A Physician's Viewpoint, May 1, 1991 Public Health Response to Sentinel Events Now, the final series of roadblocks, as I see them, are at the level of the health department. We have already seen that health departments often have poor, if any, response to the cases of commonly report- ed occupational illness. The response to agricultural illness is likely to be worse, since it's unlikely that the department will have any experience, much less expertise, in the area. It is not likely that agricultural problems will be able to compete in a busy, urban- based, overworked, and underfunded health department. What is the solution to this particular set of problems? I would propose that the health department ought not to be directly in- volved in the feedback part of this loop. Ideally, this would best be done by a group, which is interested in and knowledgeable about agricultural problems-a group that could offer the "poison control center"-type of approach with support and consultation for the refer- ring physician. Ideally, industrial hygiene and agricultural engineering consultation would be offered to the physician's patient. Who can provide these kinds of services for the health department? In some cases, it might be a medical school. In general, however, I think most medical centers' lukewarm approach to occupational health, abysmal records in rural health, and lack of appreciation of agricultural medicine make it likely that we should look else- where for help. The resource, which I would favor, is the existing NIOSH program for Centers for Agricultural Research, Education, Disease Surgeon General's Conference on Agricultural Safety and Health - 1991 149 Surveillance - Agriculture-Related Diseases, Injuries and Hazards and Injury Prevention. Expansion of this program on a regional basis throughout the country would enable education of physicians so frequently mentioned in the last few minutes. These centers would interact to support the nurse sentinels, provide user friendly feedback and support to practicing physicians, and help bridge the gap between the farm community and the medical establishment. In summary, I believe that the practicing rural physician can definitely make a valu- able contribution to the detection of occu- pational sentinel events in farmers. There are particular problems, or potential problems, that are related to the ability of health departments to coordinate respons- es to these reports, related to the compe- tence of physicians in agricultural medi- cine, and related to the farmers' percep- tion of the physician relative to the farm workplace. I believe that there are potential solutions to these problems and that many of these might best be approached by the use of regional centers for agricultural health and safety, which could provide education, consultation, and support services to prac- ticing physicians and farmers.0 750 Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARMSME 2000 . A National Coalition for Local Action Convened by the National Institute for Occupational Sakty and Health April 30 - May 3, 1991, Des Moines, Iowa CHEMICAL HAZARDS By Lina!u Rosenstock, M.D. Director of Occupational Medicine University of Washington Dr. Henry A. Anderson: So, let me introduce Dr. Linda Rosenstock who is Director of Occupational Medicine at the University of Washington. She has done considerable research and has been very active dealing with chemicals-actually all occupatlonal exposures--and today is going to specifically address chemical exposures as they occur in the agricultural setting. Dr. Rosenstock: There are two things that I would like to highlight during this discussion about pesti- cide health effects. The first is to consider how surveillance can be used to prompt further investigation and research, particu- larly looking at the interface between sur- veillance and research. The second is to use this opportunity to talk specifically about a class of pesti- cides-the organophosphate pesti- cides-because of their significant acute toxicity and because of their potential for chronic toxicity. As we try to break new ground and broad- en our concern for farmers and farmwork- ers to include community effects of expo- sures, we will need to investigate the whole spectrum of the dose-response curve. I will provide evidence of long-term neuro- logic consequences of the highest levels of exposures, which are those that follow serious acute poisoning. I want to raise for consideration the poten- tial for long-term, chronic neurologic ef- fects from lower levels of exposures to pesticides in the unpoisoned worker. This could happen by directly applying or han- dling the pesticides and even, perhaps, in the indirect exposures seen in the com- munity setting. SURVEILLANCE My colleagues and I at the University of Washington first became involved in pesti- cide health-effects research in clinical evaluation of patients. Our primary goal at the Occupational Medicine Clinic is to attempt to define a patient's medical con- dition and then to try to determine wheth- er or not it is work-related. One such patient was a farmworker who had spent all of his adult life in farm labor He was living east of the mountains near some of our largest apple orchards. He was referred because of concerns by his physician, who had known him well for a number of years. Following an episode two years before we saw him, he devel- oped a number of new, now chronic, health problems. At the time we saw him, the patient com- plained of persistent headache, memory loss, confusion, and generalized fatigue. These symptoms followed soon after a significant pesticide poisoning two years earlier. He had been involved in a full day of working behind a chemical sprayer, sus- taining significant skin absorption of an organophosphate pesticide, and was over- Surgeon General's Conference on Agricultural Safety and Health - 1991 757 Surveillance - Agriculture-Related Diseases, Injuries and Hazards come and soon hospitalized with what was a moderately severe pesticide poisoning. He never successfully returned to work after that episode. He tried to go to work one week later and just could not. It was at this time that his family and his physician documented a sig- nificant change in his general mental status. The patient had one previous significant pesticide poisoning five years before this latter episode, from which he recovered well except for some continuing complaints of new, mild headaches. On physical examination, we found evi- dence of disorientations and problems with memory. Clinically, he looked similar to elderly patients who present with dement- ing disorders such as Alzheimer's disease. Full neuropsychological tests documented in a more objective fashion significant abnormalities in a wide array of neurologic functions consistent with an organic brain syndrome or chronic encephalopathy. On the basis of this information, we con- firmed that he had a significant dementia- type illness. Important questions still re- mained. What caused this illness? Was it related to work? There were certainly several features that made us think it was not traditional Alzheimer's disease. Not only was he a bit young to present this level of abnormality from the disease, but it had come on rath- er suddenly. Clearly, the temporal relation to the pesticide poisoning was remarkable. With that in mind, we decided to turn to the medical literature for assistance. Over the last few decades, there have been many suggestions of the potential for chro- nic neurologic problems to follow acute 752 poisonings. Little formal epidemiologic research has been done. ORGANOPHOSPHATE PESTICIDES Our lack of knowledge is perhaps surpris- ing given the extent of pesticide exposures and intoxications. Current estimates from the World Health Organization (WHO) are that around the world there are about three million severe pesticide poisonings a year. Organophosphate pesticides are the leading cause of intoxications in most ar- eas. Only about one-third of the poison- ings are occupational. Two-thirds of these are accidental, including suicide. It is estimated that the annual poisoning fatality rate on a global basis is about 220,000. People who get occupationally poisoned, as expected, have a lower fatali- ty-to-case ratio than those who sustain intentional and unintentional nonoccupa- tional poisoning. It is estimated that 99 percent of fatal poisonings occur in the developing world. It has also been estimated that about 5,000 to 10,000 serious poisonings occur each year in the United States. Much is known about the early effects that will follow acute organophosphate pesti- cide intoxication. In addition to the acute syndrome there are a few others, which may follow by days or perhaps weeks. The question, though, that I would like to address and give you some information about is whether or not high-level, acute, single doses of organophosphate exposure can lead to chronic central nervous system neurologic deficits. Papers and Proceedings Chemical Hazards, May 1, 1991 In order to look at this question, we had and reasonably well-validated pesticide an opportunity to perform a study in Leon, registry has been in place there for about 4 Nicaragua. Leon is the center of an agri- years. cultural region in Nicaragua. A very active Table I. Neuropsychological Performance of Poisoned and Comparison Charts. TEST Mean Test Score (SD)' Estimate of Poisoned Not Poisoned Difference of n = 36 n = 36 Means (95% Cl)' LANGUAGE WAIS-R Vocabulary 25.2 (12.1) ATTENTION Verbal WAIS-R Digit Span"' 4.6 (2.1) Visual Digit Vigilance (seconds) 305 (135) MEMORY Verbal RN Auditory Verbal Learning' 7.9 (2.9) Visual Benton Visual Retention Test++ 4.6 (2.4) VISUO-MOTOR Speed Digital Symbol" 19.2 (12.5) Sequencing Trail A (seconds) 81 .O (33.0) Problem Solving Block Design 7.7 (7.3) MOTOR Steadiness Pursuit Aiming II" 75.9 (33.6) Reaction Simple Reaction Time (milliseconds)' + 340 (Ill) Dexterity Santa Ana Dexterity Test (dominant hand)' + 31.7 (6.5) Speed Finger Tapping (dominant hand) 46.3 5.9 AFFECT/SYMPTOMS Brief Symptom Inventory3 20.6 (10.7) Questionnaire 16 7.2 (4.0) 28.7 (9.4) 6.3 (3.2) 1.7 256 (91) 60.3 8.8 (2.7) 6.1 (2.2) 25.4 (11.9) 6.1 63.3 (26.7) 20.6 14.7 (9.2) 6.9 94.4 (29.9) 18.4 308 (50) 32 35.6 (7.0) 4.2 47.3 (6.4) 1.1 18.8 (9.8) 1.8 4.7 (3.8) 2.5 3.4 (-1 .I ,8.0) 0.9 1.5 ;0.6,2.9)* (18.9,101.9)* (-0.2,2-O) (0.6,2.5)* (1.6,10.6)* (7.7,33.5)* (3.7,10.2)* (7.3,29.6)* (-2.0,66) (1.3, 7.0)* (-1.9,4.0) (-2.9,6.5) (1.0,4.1)* " = Test results represent raw scores (numbers of incorrect responses) unless other units are specified. + = Positive value for Estimate of Means (and 95% Cl) indicates worse performance by poisoned cohort relative to comparison cohort. Estimate is based on paired t-test. Estimate may differ from value obtained by subtracting sample means in instances where full paired data were not available. `+ = Component of WHO Neuropsychological Core Test Battery (11). 4 = ~~0.01 by paired t-test. ' Digit Span (total recalled: forward and backward). SD = standard deviation 2 Rey Auditory Verbal Learning (number correct after distraction, Trial VI). Cl = confidence interval 3 Brief Symptom Inventory (Positive Symptom Total). -Adapted from Rosenstock L et al. Chronic Nervous Effects of Acute Organophosphate Intoxication, The Lancet. 338: 223-227, 199 1. Surgeon General's Conference on Agricultural Safety and Health - 1991 753 Surveillance - Agriculture-Related Diseases, Injuries and Hazards For example, in one region over a several- month period in 1987, there were close to 300 reported cases. Most were occupation- al cases of poisoning and two-thirds of these were hospitalized. Some conditions of pesticide use in Nicaragua are worth noting by a look at some photographs. A common reason for occupational poisonings is malfunction of backpack sprayers. These are made of plastic and there often are not replacement parts available. Skin absorption is has- tened in the hot climate. A breakdown of equipment in league with skin absorption can lead rapidly to serious overexposures. Another photo shows a warning label on a container; the label that gives a warning is in English. This is not very helpful in a Spanish-speaking country where only about half the population in the rural area is even literate. I will now review briefly how we undertook the study and what our main results have been. We were able to identify 36 men who had been hospitalized in the main hospital in this region with moderate to severe organophosphate pesticide poison- ing. We studied them, on average, about two years after the poisoning episode. A community comparison group was com- posed by matching to each poisoned indi- vidual someone of the same age and sex who was either a close friend or a sibling and who worked in the same community. By doing this kind of design, which is a retrospective, cohort, matched-pair design, we had a comparison group that was signif- icantly exposed to pesticides. What was different was that this group had never been medically treated for a poisoning. Neuropsychological functioning was as- sessed by a test battery, which evaluated a 754 wide array of neurological functions includ- ing motor testing, visual perception and processing, testing of memory and lan- guage abilities, and affect. Table I shows the characteristics of these populations. There was good matching of otn community (never poisoned) and our poisoned group. Table II. Characteristics of Poisoned and Comparison Cohorts. Not Poisoned Poisoned (N = 36) (N = 36) Mean age in years (2S.D.) 27.6 (29.5) 27.8 (k9.3) Number with no formal education 17 (47%) 12 (34%) Number who consumed any ethanol in past month 13 (36%) 16 (44%) Number with heavy ethanol consumption past month* 5 (14%) 6 (17%) * Defined as drinking more than 70 bolt/es of beer or 70 one-ha/f bottles (500 cc) of rum in past month. - Adapted from Rosenstock L et al. Chronic Nervous Efiects of Acute Organophosphate Intoxication, The Lancet. 338: 223-227, 1991. They are almost identical in age. About 70 percent of the comparison cohort has also worked with pesticides. A large num- ber also gave complaints that were consis- tent with pesticide poisoning, but they had not been hospitalized for these episodes. The poisoned group performed worse than the non-poisoned comparison group for all outcomes studied (Table 11). Papers and Proceedings Chemical Hazards, May 1, 1991 In one set of tests, which is a World Health Organization (WHO) standardized, neuropsychological battery, the poisoned group had statistically significant worse performance on five out of six subtests. We also did some additional tests. The same pattern holds. On the basis of this study and the ac- cumulating evidence in the medical literature, we feel that even episodes of acute organophosphate poisoning can cause permanent neurologic dysfunction. We cannot in this study tease out as much precision as we would like to compare the contribution of cumulative pesticide expo- sure to the overall effect. Any analysis we did, looking at why the poisoned group did worse, suggested that it was the actual QUESTIONS episode of acute poisoning that contributed as the main factor to these differences in performance rather than other measures of pesticide exposure. On the basis of this study and the accumulating evidence in the medical literature, we feel that even epi- sodes of acute organophosphate poisoning can cause permanent neurologic dysfunc- tion. Although we concluded that it was likely that the patient first presented in this dis- cussion had sustained a work-related or- ganic brain syndrome, much remains un- known about organophosphates and chron- ic neurologic sequelae. Further study is needed to try to replicate our findings and explore the effects of specific chemicals within the organophosphate group, the role of other factors interacting with these chemicals, and the clinical significance of the observed neuropsychologic disturb- ances.tl Dr. James A. Dosman: Linda, thanks a lot. I really enjoyed your talk. As scientists we never pay attention to one case, but, as you know, clinical observation is the first step in epidemiology. About two years ago a man came to me who said that he was perfectly healthy until one afternoon when he was spraying with (inaudible); it is a carbamate. When he went out in the morning, the wind was still. Then the wind came up and it blew over him. When he got in at noon he felt so weak that he could not get to the house. Eventually he did. He lay there for two or three days; he seemed to recover. Since that time, he has been unable to do anything. He has felt depressed. He cannot make decisions. He cannot be effective. I would like to ask you, do you think, on the basis of the work that you have carried out, that this kind of mental reaction is possible following one overdose? Dr. Linda Rosenstock: I think it is a good question. Using the word "possible" makes it a little easier to answer. If I were asked, again using this legal standard, if there is a greater than 50 percent likelihood, I would have more trouble saying yes. I think the case reports in the medical literature suggest that there may be significant anxiety and depression following exposures. The question is how much exposure and what the mechanism is. Unfortunately, I think the conventional wisdom has been to say people just get traumatized and we are looking only at a psycholog- ical reaction. They are anxious and it has nothing to do with the effects, directly, of the chemicals. Surgeon General's Conference on Agricultural Safety and Health - 1991 755 Surveillance - Agriculture-Related Diseases, Injuries and Hazards In our study, we were actually surprised. We expected to find differences in psychiatric performance. In other words, there is increased anxiety and depression in the previously poisoned group, which I went over quickly. In our study, we found no such differences. That made it easier for us to say everything else was real. If we found differences, then a lot of critics would say, "Well, you are or@ measuringproblems with memory because people are depressed; if you are depressed you do not concentrate as well because you are distracted." It made it easier for us to defend our results. But I still think, despite our negative findings in that regard, that the medical literature suggests that results like this can happen. I think they are worthy of further investigation. It is too easy to write off all of these people who have these complaints and say that they, all of a sudden, got a little crazy when they were not crazy before. Dr. Henry Anderson: I think we all want to keep in mind that we are going to be hearing examples. What we are challenged with is, what data systems or what surveillance currently exists that can assist in the identification of the cases so that it can interface with follow-up research? We have one of the key chemical exposures. I think we are all aware that there are multiple chemical exposures that go on in the agricultural setting. One of the key ones is the organophosphate poisoning. We think in terms of the continuum that Bill presented. We have laboratory testing to measure effect. Whether it is an adverse effect is still being argued. We have exposure assessment techniques. We have disease outcomes ranging from fatality to acute poisonings. The challenge is, "How can surveillance assist in a better understanding of the other parameters that relate to these types of exposures?" 756 Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 o A National &m/it/on ti.w Local Actjon Convened by the National institute for Occupational Salty and Heatth April 30 - May 3, 1991, Des Moines, Iowa RESPIRATORY DISEASES By James A. Dosman, M.D. Director, Center or Agricultural Medicine University of Saskatchewan SUMMARY The structuring of health surveillance pro- grams for widely dispersed agricultural populations is difficult because of the mul- tiplicity of exposures and health effects. There is also the difficulty with reaching and communicating with widely dispersed populations. In order to accomplish this objective, a co- operative approach between government, industry, the community, and individuals is necessary. In order to achieve successful "rural family life enhancement," a high degree of local ownership and leadership in the program is essential. The problems of structuring health surveil- lance programs for widely dispersed popu- lations that do not fit traditional labor- management structures for industry are numerous. Nonetheless, the significant issues relating to health and well- being-involving high rates of death, dis- ability, and accidents; respiratory difficul- ties as the result of dust, microbe, and chemical exposure; possible enhanced can- cer risks as a result of environmental ex- posures; hearing loss as a result of unquan- tified and uncontrolled noise levels; skin problems as a result of exposure to dusts, chemicals, microbes, and other substances; and stress and psychiatric problems as a result of isolation, economic difficulties, and inter-generational family problems-all demand a coordinated occupational health program. On the organizational level, structuring such programs is difficult as farmers and other agricultural workers are widely dis- persed, do not belong to single organiza- tions or companies, and are thus difficult to reach for health surveillance, early iden- tification, and an educational-preventive perspective. THE TOOLS OF HEALTH SURVEILLANCE In this model, no one organization may be responsible for, or effectively deal with, occupational health and well-being ques- tions. In order to achieve success, cooper- ation is required between government, industry, the community, and individuals. This paper describes certain approaches at each of these four levels. 1 . ..we recommend the establishment of health and safety committees at the local level, organized by target populations, for the purpose of identifying issues, facilitating programming, and achieving results. GOVERNMENT Governmental agencies can exercise con- siderable influence on health surveillance by moral leadership, regulatory approach- es, and information retrieval and distribu- tion. In Canada, for example, Labour Surgeon General's Conference on Agricultural Safety and Health - 1991 157 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Canada, a regulatory agency for workers that is involved in the cereal grain indus- try, requires that dust levels be maintained at no greater than 10 mg/m3 time-weighted over an &hour day, and that workers be given the opportunity for questionnaire assessment and pulmonary function testing every 3 years. As part of this program, Labour Canada requires receipt of dust level and medical information. The latter requirement has contributed to compliance and interest in the program on the part of industry and labor. It has provided scientific information that is being utilized to estimate longitudinal effects of grain dust exposures on human health. Thus, the regulatory process ap- pears to be accomplishing a number of goals: 1. Reduction and regulation of environ- mental dust levels. 2. Compliance of industry and workers in providing for, and being involved in, a periodic human health assessment pro- gram. 3. The utilization of information from this program in scientific research, that in Table I. Number or Dust Samples Obtained in Elevator Facilities. turn may assist in level regulations. re-evaluating dust In some ways, this program may be consid- ered a model of the manner by which government may stimulate action at several levels. INDUSTRY Where concentrations of agricultural work- ers exist, as in the grain transport and storage industry, industry may play a lead- ing role in promoting good health amongst its workers. Utilizing the Canadian grain industry as an example, compliance among companies in initiating dust removal equip- ment in grain facilities has been relatively good. Table I indicates that out of a total of 2,048 dust samples obtained in grain facilities in Canada in the early 1980's, only 19.8 percent of the samples obtained by Labour Canada, and 17.2 percent of the samples obtained by the companies them- selves, exceeded the recommended maxi- mum dust exposure limit of 10 mg/m'. An additional dimension to the provision of health surveillance services for these workers is taking place in Canada in the Province of Saskatchewan. In this prov- ince, all grain companies have gone be- Canadian Grain ~5 mg/m3 >5 mg/m3 > 10 mg/m3 n % -2L -2L Labour Canada* 341 64.8 -ik 35.2 %i 19.8 Companies'* 1008 66.2 514 33.8 261 17.2 Samples Collected: o 1980-1984, n = 526 H 1978-1986, n = 1.552 Total = 2,078 - Reprinted from: McDufie HH, Pahwa P, Dosman Jk Respiratory Health Status of 3,098 Canadian Grain Workers Studied Longitudinally, American Journal Industrial Hygiene. (in press) 1991. yon6 the legal requirements of Labour Canada and are providing sufficient resources for a more comprehensive approach to health surveil- lance that goes beyond the minimum respiratory re- quirements of the regulatory agency. 158 Such additional services include, in addition to respiratory testing, one-to- one nurse counselling invol- ving lifestyle management Papers and Proceedings (smoking and other issues), use of personal protective devices, back care, stress, and a variety of other occupational health ques- tions. In our experience, the workers have responded positively to this initiative. COMMUNITY The provision of health surveillance to widely dispersed farmers and their families must, by necessity, involve the community. In Saskatchewan, in the model being uti- lized, a widely dispersed approach is taken to occupational safety and health through the Agricultural Health and Safety Net- work of the University of Saskatchewan. In this approach, individual rural municipalities, the local unit of self-govern- ment, enroll their resident farm families in the Agricultural Health and Safety Net- work for the promotion of better health and farming practice. Since its commence- ment three years ago, 10 percent of the rural municipalities in the province have enrolled their farm families in this net- work, comprising about 7,000 persons. Once enrolled in the network, individual farm families receive preventive materials on various topics relating to good healthy farm practice annually. In addition, health surveillance services, such as respiratory testing and seminars on safe dust management, the use of personal protective devices, and other issues, are provided. Recently, as part of this pro- gram, seminars on safe chemical management have been offered, and a hearing conservation survey took place in one municipality. This program is financed by individual subscriptions from the municipalities, amo- unting to l/lOth of one mill of taxation per year. The relation between the Center for Respiratory Diseases, May 1, 1991 Agricultural Medicine, which promotes the program, and individual farm families is through elected rural Municipal Councils. While it is too early to determine the ef- fectiveness of this approach to health sur- veillance, it appears to offer potential. THE INDIVIDUAL The most successful approach to good work, health, and lifestyle practice is through an educated and motivated indi- vidual. Farm families are scattered widely geographically. With farm work practices being ingrained over many years, the pro- cess of education remains the most impor- tant and useful means of making gains. The basis of the approach through the Agricultural Health and Safety Network is to achieve an educated and motivated individual. Yearly provision of materials, the provision of stickers for farm imple- ments identifying individuals as members of the Agricultural Health and Safety Net- work, and tailored educational sessions are important in this process. In addition, information and material developed within the geographic area in question that is useful to, and identified with, the type of farm practice, social issues,' and family life of the region, are important. RURAL FAMILY LIFE ENHANCEMENT The goal of health surveillance in the agri- cultural industry should be a broadly based approach to a multiplicity of issues that go beyond the workplace per se arid result in an enhanced quality of life for persons who live in rural areas, the majority of whom are involved in agriculture and its related industries. In order to accomplish these goals, a combined, coordinated approach between government, industry, community organizations, and individuals is essential. Surgeon General's Conference on Agricultural Safety and Health - 1991 159 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Underlying this cooperative approach is lishment of health and safety committees the necessity of local ownership of and at the local level, organized by target pop- leadership for programs that are undertak- ulations, for the purpose of identifying en. Specifically, we recommend the estab- issues, facilitating programming, and achieving resu1ts.O 160 Papers and Proceedings Surgeon General's Conference on Agticultwal Safety and Health FARMSAFE 2000 o A National Coalition kr Local Action Convened by the National Institute For Occupational &My and Health April 30 - May 3, 1991, Des Moines, Iowa SURVElLLANCE OF INJURIES IN AGRICULTURE By Susan Goodwin Gerberich, Ph.D. Division of Environmental and Occupational Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota Robert W: Gibson, PhD. Division of Environmental and Occupational Health, School of Public Health, University of Minnesota, Minneapolis, Minnesota, and Department of Behavioral Sciences, School of Medicine, University of Minnesota, Duluth, Minnesota Paul D. Gundemon, Ph.D. National Farm Medicine Center, Marshfield Medical Pesearch Foundation, Marshfield, Wisoconsin L. Joseph Melton III, M.D., M.P.H. Department of Medical Statistics and Epidemiology, Mayo Clinic/Mayo Medical School, Rochester, Minnesota L. Ronald French, Ph.D. Chronic Disease and Environmental Epidemiology Section Minnesota Department of Health, Minneapo!is, Minnesota Colleen M. Renier, B.S. Department of Behavioral Sciences, School of Medicine, University of Minnesota, Duluth, Minnesota John A. True, MS. Department of Agricultural Engineering, University of Minnesota, Minneapolis, Minnesota W Peter Cam, M.P.H. Division of Environmental and Occupational Health, School of Public Health University of Minnesota, Minneapolis, Minnesota ABSTRACT There has been no comprehensive data system to identify the magnitude of the injury problem in the rural farming community or the potential risk factors that may be associated with this problem. Serious discrepancies among the existing data sources, pertinent to occupational morbidity and mortality, limit identification of the true magnitude of the problem. Based on a recent National Academy of Sciences report, it has been documented that fatal as well as non- fatal occupationally related injuries have been greatly undercounted. In part, these discrepancies in mortality and morbidity data are due to variations in definitions, the worker populations included, methods of case ascertainment, and the data sources utilized. Fatality rates identified for agriculture have ranked among the highest for many years. However, given the overall discrepancies among the data systems and the reporting limitations for agriculture, these would appear to be extremely conservative estimates. 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 Surgeon General's Conference on Agricultural Safety and Health - 1991 767 Surveillance - Agriculture-Related Diseases, Injuries and Hazards due to the lack of analytical studies. This paper includes an historical perspective of surveillance and its importance to the problem of injuries in the agricultural community. Special emphasis is placed upon the data sources and methodological approaches that have been used in agricultural surveillance, including advantages and limitations. Among the agricultural injury surveillance efforts that will be discussed are two major population-based efforts, conducted by a multi-disciplinary team, using a methodology that can also serve as a model for long-term surveillance efforts at the state, regional and national levels. These efforts are the Ohnsted Agricultural Trauma Study (OATS) and the Regional Rural Injury Study (RRIS): 1. The overall purpose of OATS was to identify the magnitude and characteristics of the injury problem among all farms in Olmsted County, Minnesota, using a telephone interview methodology, validated through medical records. Data pertinent to the household members, characteristics of the farm operation, and injury events (farming and non-farming related; intentional and unintentional) were collected. In concert with this effort, a case-control study to facilitate identification of risk factors, an inter- and intra-rater reliability study of E-coding, and a follow-up pilot investigation of machinery-related injury events were also conducted. Specific findings, including injury rates, characteristics of the injuries and injury events, and risk factors, are presented with regard to implications for surveillance. 2. OATS provided the basis for the Regional Rural Injury Study (RRIS), currently being conducted in a five-state region: Minnesota, Wisconsin, North Dakota, South Dakota, and Nebraska. Data collection covers a twelve-month period of time for over 4000 rural households, utilizing computer-assisted telephone interviews (CATI). This effort will enable the identification of injury rates for each state and the region as well as multiple analytic substudies, including tractor-rollovers 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 Stratepy Workshop. INTRODUCTION There has been no comprehensive data system to identify the magnitude of the injury problem in the rural farming com- munity or the potential risk factors that may be associated with this problem that can enable progress in the prevention of agricultural injuries. Serious discrepancies among existing data sources limit identifi- cation of the true magnitude of occupa- tional morbidity and mortality. For exam- ple, the fatality rates identified for agricul- ture have ranked among the highest for many years, but a recent National Acade- my of Sciences report,' documented that fatal as well as non-fatal occupationally- related injuries have been greatly under- counted. Another major barrier to progress in the prevention of agricultural injuries has been a deficiency in knowledge about specific causes or risk factors due to the lack of analytical studies. This paper includes an historical perspective of surveillance and its importance to the problem of injuries in the agricultural community. Special em- phasis is placed upon the data sources and methodological approaches that have been used in agricultural surveillance, including advantages and limitations. 162 Papers and Proceedings SURVEILLANCE: AN HISTORICAL PERSPECTIVE Surveillance is a French word originally meaning, "keeping a close watch over an individual or group of individuals in order to detect any subversive tendencies."2 Cur- rent dictionary definitions, e.g., "vigilant supervision, " "spylike watching," or "watch or observation kept over a person, especially one under suspicion or a prisoner,`" continue this negative con- notation. This historical perspective provides a basis for the negative percep- tion of "surveillance" in the general population that can seriously affect data collection efforts. Surveillance of disease evolved in the 17th century when fear of plague epidemics resulted in efforts to document the impact of morbidity and mortality. Subsequently, surveillance efforts have been utilized to monitor acute disease outbreaks and to ascertain potential relationships between working environments and certain health conditions in Europe.2 However, it was not until the 19th century that surveillance had evolved as a "means of collection and interpretation of data related to environ- mental and health monitoring processes for the definition of appropriate action, for prevention and health care."2 A surveillance effort comparable to those that were developed in Europe and fo- cused on disease entities did not emerge in the United States until 1900; full national mortality coverage was not attained until 1933. INJURY SURVEILLANCE Of great importance is the fact that, al- though injuries have been identified as a persistent problem over time, there have Surveillance of Injuries in Agriculture, May 1, 1991 been no adequate comprehensive surveil- lance systems established.' In particular, occupational injuries, which constitute an important part of the injury problem in the United States, have not received attention commensurate with the magnitude of the problem. Agriculturally related injuries have received even less attention since about 95 percent of all farming operations, by virtue of their size, do not fall under the jurisdiction of the Occupational Safety and Health Administration's, or other agencies' recording and reporting require- ments." ' Occupational Injury Surveillance Serious discrepancies among the existing data sources pertinent to occupational morbidity and mortality limit identification of the true magnitude of the problem. In 1989, the National Safety Council esti- mated that there were 10,400 occupa- tionally related fatalities.' The Bureau of Labor Statistics: (BLS) reported 3,300 for the same year.' A third source of occupa- tional fatality data is the National Trau- matic Occupational Fatality (NTOF) data base at NIOSH, based on death certificates specifically coded with the "injury-at-work' designation. Through this source, it was estimated that approximately 7,000 work- related fatalities occurred each year during the period between 1980 and 1985. Similar discrepancies are identified for non-fatal occupational injuries. In 1989, the National Safety Council estimated that there were 1.7 million disabling injuries. During the same year, the Bureau of Labor Statistics estimated that ap- proximately 6.2 million work-related inju- ries occurred, with 2.9 million of those involving lost work days? Another source of data is based on a sample of ap- proximately 66 emergency rooms from the Surgeon General's Conference on Agricultural Safety and Health - 1991 763 Sweillance - Agriculture-Related Dlseases, Injuries and Hazards United States Consumer Products Safety Commission's (CPSC) National Electronic Injury Surveillance System (NEISS). From an unpublished NIOSH report based on these data, it was estimated that over 3.8 million occupational injuries of varying severity and outcome are treated every year in all U.S. emergency departments. In part, these discrepancies in morbidity as well as mortality data are due to variations in definitions, the worker populations that have been included, different methods of case ascertainment, and the various data sources that have been utilized." and interpretation, epidemiologic surveil- lance (Figure 1) enables the identification of the magnitude of the morbidity and mortality problem, injury epidemics, new injury problems, and potential risk factors. CQEVENTIW AND CWTWL JTRATBZYIPRXIW ItAA4ENTATIOH PLAta4Iffi INTEWRETATION Agricultural Injury Surveillance Fatality rates identified for agriculture have ranked among the highest across all occupations for many years. Based on National Safety Council data for 1989, agriculture accounted for a rate of 40 deaths per 100,000 workers, compared with 9 deaths per 100,000 workers for all occu- pations. National morbidity rates in agri- culture have been elusive due to the lack of adequate population-based data for non-fatal events. Figure 1. Surveillance of Injuries in Agriculture. However, the data suggest a major prob- lem among farm residents.s'"-15 In 1989, an estimated 120,000 disabling injuries oc- curred in agricultural work, with 70,000 of these involving farm residents.' Given the discrepancies among the various data sys- tems and the reporting limitations for agriculture, the estimates identified would appear to be extremely conservative. Of particular importance is that it can provide a scientific basis for analytic re- search to identify specific risk factors that are critical to the development of interven- tion strategies for the prevention and con- trol of agricultural injuries. The integrity of a surveillance system is reliant upon regular evaluation and modification, as ap- propriate, with specific attention to validity and reliability measures. Finally, the sur- veillance system provides for ongoing eval- uation of specific prevention and control activities so that alterations can be imple- mented, if necessary, along the way. ELEMENTS OF SURVEILLANCE A major barrier to progress in the preven- tion of agricultural injuries has been not only a lack of knowledge about the magni- tude of the problem but also a deficiency in knowledge about the specific causes or risk factors due to the lack of analytical studies.`s*`6 Through ongoing, systematic data collection, with consequent analysis Meaningful injury surveillance requires data that will allow the calculation of pop- ulation-based morbidity and mortality rates. This requires complete numerator and denominator data for the population from which the data are drawn. 164 Papers and Proceedings Surveillance of Injuries in Agriculture, May 1, 1991 A serious deficiency in many of the surveil- lance efforts that have been initiated is the inabili data. Y to identify adequate denominator 4 1 ) 17-19 Not only is it essential to iden- tify the total numbers of people at risk but also the various demographic characteris- tics of that population (e.g., age, gender, education, socioeconomic status, length and types of exposures, experience, and behavioral characteristics). Of further importance is the collection of exposure data that address the farming operation, including the sizes and types of operations, the animals involved, and the machinery, equipment, and chemicals that are in use. Basic to the numerator is a clearly established definition of injury that may be very broad or may focus on specif- ic types and severity of injuries, sources and locations of injuries that occur to the entire population or, perhaps, to certain subpopulations, and whether the injuries are intentional or unintentional.`9 These elements are all integral to an injury definition. Utilization of an active versus passive system of reporting will enhance the likelihood of identifying complete nu- merator data."* u Of further importance is consideration of the specific time period for which the data are to be collected, the relevant data analysis to be conducted, and dissemination and utilization of the results."' 22 Based on recommendations published from a National Academy of Sciences Commit- tee,4' p there are essential data elements for injury surveillance (Table I). These include time of the event; place of occur- rence; demographic characteristics of the injured person; characteristics of the injury, including the body part affected, type and severity; the agent causing the event, as well as the source and mechanism of the event, and the circumstances surrounding the injury event; medical care provided; Table I. Essential Data Elements for injury Surveillance. INJURY CASE ELEMENTS . TIME OF EVENT . PLACE OF OCCURRENCE o DEMOGRAPHIC CHARACTERISTICS OF THE INJURED PERSON (e.g., age, gender, education, socioeconomic status, occupation) o CHARACTERISTIC OF THE INJURY (including body location affected, type of injury, severity) o ' AGENT CAUSING THE EVENT (e.g., mechanical, chemical, electrical energy) o * SOURCE OF THE EVENT (e.g., machinery, tractor, gun, animal) o * MECHANISM OF THE EVENT (e.g., fall, struck by/against) 9' CIRCUMSTANCESSURROUNDINGTHEINJURY EVENT (actively involved, equipmentfailure, weather, surface, or other environmental conditions) o MEDICAL/HEALTH CARE PROVIDED TO THE INJURED PERSON o HEALTH OUTCOME OF THE EVENT (e.g., complete recovery, persistent disability involving limitation of activities) o Necessary to facilitate International Classification of Diseases (ICD) External Cause Coding (E-coding). Adapted from Ing, 198.5; Committee on Trauma Research, Commission on Life Sciences, Natural Research Council and the National Institute of Medicine, 198.5. Surgeon General's Conference on Agricultural Safety and Health - 1991 765 Surveillance - Agriculture-Related Diseases, Injuries and Hazards and overall health outcome. Inclusion of appropriately coded severity levels is par- ticularly important in determining the overall magnitude.a*25 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. Identification of the agent, source and mechanism of the injury event, together with the circumstances surrounding the event, is crucial to External Cause Coding, or E-coding, using the International Classi- fication of Diseases (ICD) codes and modifications specific to agricultural inju- ries.", 26 The use of E-codes provides the critical link between the source and the nature of an injury, which enables targeting for more comprehensive analytic studies to identify specific risk factors and, subse- quently, to develop relevant prevention and control programs; it also facilitates comparisons across data sets. The fact that intervention at the source of the injury event has been the most successful in the prevention and control of injuries high- lights this element as integral.% The items that have been identified pro- vide only the very basic elements of a surveillance system. More comprehensive systems can be implemented with the rec- ognition that as more items are included, the system becomes more expensive and it is more difficult to ensure consistency and quality of the data.19 766 SURVEILLANCE OF AGRICULTURALLY RELATED INJURIES Advantages and Limitations of Surveillance Efforts A v&e@ of efforts in the surveillance of agriculturally related injuries have been undertaken to ascertain the magnitude of the problem, with varying degrees of suc- cess. The data sources for these efforts are presented in Table II (at the end of this paper), with elaboration on the ad- vantages and limitations of each of these sources. For example, death certificates, which are utilized in agricultural fatality surveillance, are easily accessible. Yet there are many limitations, including the persistent lack of attention by those who complete these certificates to indicating that the event occurred at work. As a single source for surveillance, fatalities account for an extremely small proportion of the total problem.15 The Occupational Safety and Health Ad- ministration (OSHA) is extremely limited as a data source, given that about 95 per- cent of farms are not covered by this sys- tem; Federal appropriations do not enable enforcement of OSHA regulations among farms employing ten people or less. For a variety of reasons, there has also been underreporting of both morbidity and mor- tality data through the BLS.' Workers' Compensation data also are limited by virtue of a small proportion of farmers covered by this system. Another very large national system, the Fatal Accident Reporting System (FARS), which is operated by the National Highway Traffic Safety Administration (NHTSA), enables identification of non-truck farm vehicle fatalities that occur on roadways.z7 However, it is not possible to identify the Papers and Proceedings specific type of vehicles involved through this system. Newspaper clipping services have been used by several investigatorsS*12 in various efforts and, while this source has serious limitations, it can facilitate recognition of emerging as well as persistent injury problems. To a limited degree, it can also detect fatal events that are not readily accessed through death certificate data. While hospital records may enable iden- tification of specific diagnoses and treat- ments, there are also many limitations in using these records for surveillance. These include the problem of confidentiality, as well as inadequate information on the cir- cumstances surrounding the event and the long-term consequences, together with a bias toward the more severe injuries." Of particular importance is the fact that only a small proportion of injuries related to farm operations result in hospitalizations and, with extremely rare exceptions, the hospital record sources are not population- basedls. The records from emergency departments, outpatient facilities, and from primary care practitioners have even greater limitations, including accessibility, unless they are linked into a major data base. Operation of such data bases is extremely difficult and, consequently, very rare. The denominator is a major problem for these data sources, as well. While there are a few success stories, linking multiple data sources is extremely complex and not recommended.19 Data from a combination of some of the above sources have also been used with varying success.`9*2830 In Minnesota, a feasibility effort in establishing injury sur- veillance was initiated to link multiple Surveillance of Injuries in Agriculture, May 1, 1991 existing data sets, ranging from hospital- based data to agency-based data, including highway crash events.19 Many limitations were identified. These included: 1. Issues of confidentiality, which prevented access to personal identifiers in some cases, preventing detection of duplication of cases. 2. Quality and quantity of data elements, affected by varying injury definitions, data elements included, methodologies and a combination of active and passive reporting. 3. The inability to calculate rates other than for mortality, which accounted for only 0.3 percent of the total injury problem. Finally, there is the potential for ongoing surveillance using in-person and telephone- based interviews or mailed questionnaires, each with advantages and limitations. In general, the quality of data do not vary greatly between in-person and telephone interviews, given the same interview con- tent.31 However, the in-person interview is much more expensive. While mailed ques- tionnaires can provide ease of contact, the quantity and quality of information and the potential for lower response rates can be a problem. POPULATION-BASED SURVEILLANCE OF AGRICULTURAL INJURIES IN THE UPPER MIDWEST Olmsted Agricultural Trauma Study (OATS): Given the limitations that have been identified and that there has been no comprehensive data system to identify the true magnitude of the injury problem in the agricultural community or the variables that might be associated with this problem, Surgeon General's Conference on Agricultural Safety and Health - 1991 767 Surveillance - Agriculture-Related Diseases, Injuries and Hazards a major project was undertaken in Minne- sota in 1986 by a multidisciplinary team of investigators. The purpose of this population-based effort, known as the OATS,15 was to determine the magnitude of the injury problem, using a methodology that could serve as the basis for long-term surveillance efforts at the state, regional, and national levels. OATS, which served as the basis for the current regional five-state effort, was implemented in Olmsted County, Min- nesota due to the ability to validate telephone interview-based injury data using the Mayo Clinic's comprehensive Roches- ter Epidemiology Project.`SV32 This interna- tionally recognized unique data base con- tains health care records for virtually all residents in the county. Definition of Terms Two basic issues our research team dealt with, initially, were the elusive definition of a farm and the definition of an injury. The definition of a farm was based on the USDA's Master Sampling Frame; their definition is "an operation with annual sales of $1,000 or more of agricultural products." An injury event was defined as one, which restricted normal activities for at least four hours, involved a loss of consciousness, loss of awareness, or amnesia for any length of time, or required professional health care, or any combination of these three. This included both farming and non-farm- ing activity-related injuries classified either as intentional or unintentional. The injury definition was based on experience in previous research endeavors and is com- patible with definitions used by the NCHS." 168 Data Sources The sources of data included both tele- phone interviews and medical record re- view. Demographic and exposure data were collected from both male and female heads of household by trained telephone interviewers, using specially designed, pre- tested data collection instruments. The female head of household was the pre- ferred respondent for demographic infor- mation on the family and whether or not any family members, workers, or visitors had been injured during the designated one-year time frame. The male head of household was the pre- ferred respondent for the farming opera- tion exposure information. Injured persons were interviewed, directly, to obtain infor- mation concerning the injury events, with the exception of children under the age of 18, in which case the female head of household was asked to respond pertaining to their injuries. The injury data collected included type, severity, source, mechanism, and contribut- ing factors. Injury events reported through the telephone interviews were validated by review of the health care records in the Mayo Clinic medical records linkage sys- tem."' 32 Selected Results and Discussion Among the total eligible farms in the cou- nty (n= 892), there was an overall partici- pation rate of 82 percent, with 75 percent completing all components of the inter- view. The distribution of the farm house- hold members by age and gender revealed nearly identical mean ages for males and females (34.7 and 34.6, respectively). Examples of the exposure data that were collected included the types of farming Papers and Proceedings operations, which enabled calculation of specific injury rates. For example, the rates for farming and non-farming activity- related injury events per 100 farms per year were 16.0 and 21.6, respectively. Similarly, the injury event rates per 100 farm residents for farming and non-far- ming related activities were 4.6 and 6.2, respectively. The fact that non-farming injury rates exceeded the farming-related rates is of particular interest. Consideration of the total injury picture is essential to address the overall impact of injuries on the farm- ing operation and potential intervention strategies that might ultimately be imple- mented. The age- and gender-specific rates provid- ed further information. It is important to note that the conclusions drawn from any such data can vary with the use of different denominators. For non-farmwork related injuries, among males (whose overall rate was 6.3 injury events/100 persons), those less than. 14 years of age (8.8/100) and 14- 24 years of age (11.9/100) had the highest rates; among females (whose overall rate was 5.1 injury events/100 persons), the highest rates occurred in those age groups less than 14 years (5.2/100), 14-24 years (7.0/100), and 25-44 years (5.6/100). In contrast, when considering the farmwork-related injury events per 100 farm residents, the older age groups emerged as being primarily involved. Among males (whose overall rate was 6.5/100), the hi hest rates were shown in the 25-44 (12.3 100) and 45-64 (7.6/100) f year age groups; among females (whose overall rate was 1.5/100), the highest rate was in the 45-64 year age group (2.6/100). Surveillance of Injuries in Agriculture, May 1, 1991 In order to target groups for potential intervention efforts, it is also critical to consider the total exposure time with re- gard to farming-related injuries. Given this information, a very different pattern was demonstrated, whereby the children and younger adults were shown to be at greatest risk. Among the males, the highest injury rate per 100,000 hours worked per year was in the age group involving those less than 14 years of age (8.3); the next highest rate was among those 25-44 years of age (4.7). Among females, the highest rate was found in the 15-24 year age group (6.0), followed by the 45-64 year age group (2.8). To identify potential risk factors, the sourc- es of the injury events were documented for both the farming and non-farming related injuries. The primary sources of the farming operation-related injuries were machinery (23 percent), animals (18 per- cent), general farm sources (16 percent), and tractors (12 percent), while sports and recreational sources (38 percent), vehicles other than farm machinery (12 percent), and home activity sources (12 percent) were primarily involved in the non-farming related injury events. These data, together with other comprehensive data that have been collected, provide a basis for identify- ing potential risk factors that might be investigated through specifically designed analytic efforts and serve as a springboard for development of prevention and control strategies. Descriptive information pertinent to the injury can also be generated from this type of effort. The three major types of farmwork-related injuries were sprains and strains (27 percent), contusions (17 per- cent), and fractures (14 percent). Similar types of non-farmwork related injuries Surgeon General's Conference on Agricultural Safety and Health - 1991 769 Surveillance - Agriculture-Related Diseases, Injuries and Hazards were also identified: sprains and strains (28 percent), lacerations (18 percent), and fractures (17 percent). Of particular relevance are the proportions of injury cases that required hospital- ization-8 percent of the farmwork-related injuries and 10 percent of the non- farmwork related injuries. As indicated previously, this finding has implications pertinent to the limitations imposed when only hospital-based surveillance is used. Consideration of restricted activity must also be taken into account when assessing the total impact on the farming operation. The fact that a large proportion of injured individuals were actually restricted for a week or more as a result of either a farm- ing-related injury (21 percent) or a non- farming related injury (24 percent) is'very important when looking at the overall impact. Moreover, a large proportion, when interviewed, still had some type of persistent problem, including some perma- nent disabilities (farming and non-farming related injuries, 27 percent and 25 percent, respectively). These findings constitute only a very small proportion of the total analyses, but give an indication of the possibility of identify- ing the extent of the problem in a compre- hensive manner. OATS data were also used as a basis for conducting sub-studies, including analytic efforts, to further ad- dress the agricultural injury problem. These efforts included a case control study to identify human and environmental risk factors for farming-related injuries.33 In addition, a pilot on-site investigation of machinery-related injury events was con- ducted by a team of engineers and epidem- iologists to identify factors for consider- ation in subsequent engineering studies." A sub-study of inter- and intra-rater 770 reliability in the assignment of ICD E- codes provided a further contribution to the use of this system for classifying far- ming and non-farming-related injuries.% Regional Rural Injury Study The research design that was evaluated in OATS served as a basis for the current Regional Rural Injury Study (RRIS),= involving Minnesota, Wisconsin, North Dakota, South Dakota, and Nebraska. This new project has been designed to serve as a national model for conducting surveillance in agricultural populations. In addition to its value as a comprehensive surveillance system, the five-state RRIS also provides a basis for specific analytic studies, as well as the potential for ongoing surveillance that can facilitate evaluation of specific intervention efforts. In the RRIS, data were collected from 4,201 households, identified through a stratified random sampling process, using the USDA Master Sampling Frame. These data were collected in two phases to cover a 12 month period (January 01-June 30, and July Ol-December 31, 1990) To accomplish this, the data collection instru- ments designed for OATS were converted to a computer-assisted telephone interview (CATI) system, which facilitates the inter- viewing and the data management and analyses. The interviewing has been completed and initial analyses have been implemented. The final analyses will include age- and gender-specific rates for farmwork and non-farmwork related injuries in the region and for each state. Rates adjusted accord- ing to hours worked on the farm will also be calculated. Analyses, including types of injuries, body parts affected, and relevant sources and Papers and Proceedings Surveillance of Injuries in Agriculture, May 1, 1991 mechanisms, are integral to this effort. Other more comprehensive and analytical analyses will be conducted on a variety of substudies, including case-control studies focused on animal-human injuries and tractor rollovers. This effort will also result in a workshop in July 1992, at which time the regional par- ticipants as well as other experts and the investigators involved will meet to develop state action plans for the prevention of agricultural injuries. Data generated from the RRIS will be used as the basis for development of prevention and control strategies in the five-state region that may also be applied at the national level. SUMMARY This presentation has provided a back- ground on the surveillance of injuries and specifically with regard to agricultural injuries. The need for ongoing, systematic data collection, not only to identify the magnitude of the problem but also to provide a basis for analytic studies, is clear. Identification of specific risk factors will facilitate more appropriate planning and implementation of strategies. Finally, application of surveillance to monitor the effects of prevention and control programs that have been implemented will enable evaluation of their efficacy and identify necessary modifications to ensure optimal reduction of agricultural injuries.0 TABLE II. Data Sources Utilized in Agricultural Injury SurWiflanCe: Advantages and Limitations DATA SOURCES AGENCIES/ ADVANTAGES LIMITATIONS AUTHORS Occupational o Bureau of Labor o Approximately 95% of all Safety and Health Statistics farms are not covered Administration under OSHA, i.e., those with 10 or less employees. Workers' Compen- o Limited proportion of sation farms included. Fatal Accident o National High- o Detects roadway farm o Off-roadway vehicle Reporting way Traffic Safety vehicle-related fatalities. events not included. System (FARS) Administration o No identification of o Gerberich, specific type of vehicle. Robertson, Gibson et al, 1991" Surgeon General's Conference on Agricultural Safety and Health - 1991 171 Surveillance - Agriculture-Related Diseases, Injuries and Hazards DATA SOURCES "AGsT"Hcd;;/ ADVANTAGES LIMITATIONS Death Certificates o Welsch et al., o Easily accessible. o Fatality rate less that 1 98912 o Includes intentional and 1 /lOO of 1% assuming no o Gunderson, et unintentional events. more than one farmer per al., 1990" farm. o Extremely difficult to assess accurate count--occupation. fre- quently misclassified. o Information inadequate on death certificate relevant to primary/secondary causes of death. o "at work" box infrequently checked. o Source/mechanism of injury information limited and/or missing. o National Institute for Occupational Safety and Healtt+ National Traumatic Occupational Fatalities (NTOF), Myers, 1990% o Excludes individuals under 18 years of age. o All limitations, identified above, apply. Newspaper Clip- ping Services- National/State Newspaper Clip- ping Services o Welsch et al., o May facilitate recognition of 1 98912 emerging as well as persistent o Gunderson et al., injury problems. 1 9905 o Authors included death certificates for verification. aDetects fatal events not readily accessed through death certificate data o Identifies agricultural- related fatalities and catastrophic injuries. o 50% of fatalities may be missed as well as a large proportion of non-fatal injuries. o Reporting is biased ac- cording to gender/other variables. 172 Papers and Proceedings Surveillance of Injuries in Agriculture, May 1, 1991 DATA SOURCES ADVANTAGES LIMITATIONS Hospital Records o Gerberich et al., o Identification of specific o Confidentiality makes 1989,1990,1991 diagnosis and treatment. records difficult to access. (Used to validate o Bias--only most severe telephone inter- injury cases included. view)"* la o inadequate data on cir- cumstances of event. o Non population-based. o Oriented toward diag- nosis, treatment and, pos- sibly, rehabilitation. 0 Long-term consequences not identifiable. 0 very few persons are hospitalized; only 8% of all farming-related injury cases. o Miss those who die before reaching hospital or are transferred elsewhere. o Biased due to type of insurance, if any. Hospital Records- All hospitals (n = 25) in 15 county sample Emergency Room o McKnight, 1984% o Provides national estimates. o Product-related injuries Cases U.S. Con- only . sumer Product 0 Sample of emergency Safety Commission rooms is not representative (CPSC), National of those in the United Electronic Injury States. Surveillance System o identification of manufac- (NEISS) turer not released. o Fuortes et al., 1 9903' o Active system employed. 0 Selection of sample not identified. o Occupation-related in- juries only. o Procedures regarding confidentiality not iden- tified--cases were followed up by investigators with no apparent consent procedures. o No indication of par- ticipation rate of either hospitals or patients. Emergency Room o Jansson, 19873Q o May facilitate recognition of o Descriptive data on in- Cases Part of o Jansson and emerging as well as persistent jured cases only project to develop Svanstrom, 1 98g4' problems. o No exposure data col- systems for con- lected. tinuous and periodic injury surveillance Surgeon General's Conference on Agricultural Safety and Health - 1991 773 Surveillance - Agriculture-Related Diseases, Injuries and Hazards DATA SOURCES AGENCIES/ ADVANTAGES LIMITATIONS AUTHORS Emergency Room and Urgent Care Cases Outpatient Facilities Primary Care Prac- titioners In-Person Inter- views Telephone-Based Interviews-Olmsted Agricultural Trauma Study (OATS); Provided basis for Regional Rural Injury Study adn Subsequent Surveillance (valida- tion with medical records) o Stueland et al., o May facilitate recognition of 1991" emerging as well as persistent Injury problems o Potential to detect greater range of severity. o Potential to detect greater range of severity. o National Safety o Contact reportedly every Council three months--minimized recall bias. o Gerberich et al., 199115 o Population-based, enabling. o Utilized U.S. Department of Agriculture's (USDA) Master Sampling Frame to identify all farms in Olmsted County. o Ensured qualification as an operating farm during period of study. o Collected demographic and farm exposure injury data on all participating farms in the county. 0 Overall participation rate = 82%, full interview par- ticipation = 75%. o Provided a basis for the following multiple sub-studies, including: 1) Case-Control Study of Farmwork-Related Injuries. 2) E-Coding Study. 3) .Follow-up site visit, machinery-related studies. o Descriptfve data on in- jured cases only o No exposure data col- lected. o Diagnosis may not be ascertained initially. o No denominator infor- mation. o No denominator infor- mation (age/gender com- position is overestimated, Eylenbosch and Noah, 1988).' o Typically a passive sys- tem. 0 Quality of classification underestimated. 0 Sample selection unclear 0 Use of local volunteer interviewers. o Confidentiality of records necessitates access through USDA office resources only. 174 Papers and Proceedings Surveillance of Injuries in Agriculture, May 1, 1991 DATA SOURCES ADVANTAGES LIMITATIONS Telephone-Based o Gerberich et al., Interviews-Regional 1989-199235 Rural Injury Study (RRIS) Provides a basis for national surveillance Mailed Question- naires 545 dairy farms in Otsego County o Stallones, 198642 o Ease of contact. Mailed Question- naires * Fuortes et al., 1 9903' o Ease of contact. o Population-based, enabling o Confidentiality of records identification of specific rates. necessitates access a Utilized USDA Master through USDA office Sampling Frame to select resources only. stratified random sample of farms in fife states. o Ensured qualification as an operating farm during period of study. o Collected demographic and farm exposure injury data on participating farms in five states. o Participation Rate-78%. o Data are entered directed into the Computer Assisted Telephone Interview (CATI) system, enabling efficient monitoring, data management, and analysis. o Provides a basis for multiple studies, including the foi- lowing: 1) Case-control study of trac- tor rollovers. 2) Case-control study of animal related injuries. o Response rate 45% o Self-selected sample. o Response rate 41%. o Biased populations of hospitalized individuals. o Identification of oc- cupation relatedness and event characteristics in medical records are notoriously poor. o No control for days of hospitalization. o High potential for misclassification. Surgeon General's Conference on Agricultural Safety and Health - 1991 775 Surveillance - Agriculture-Related Diseases, Injuries and Hazards REFERENCES 1. 2. 3. 4. 5. 6. PoUack, Es, Keimig, DG: Counting Injkes and Illnesses in the Workplace: Proposals for a Better System. Washington, D.C.: National Academy Press, 1987. Eylenbosch, WJ and Noah, ND Editors: Surveillance in Health and Disease, Commission of the European Communities, New York: Oxford University Press, 1988. Webster's New Twentieth Century Dictionary, Second Edition, New York: Simon and Schuster, 1979. Committee on Trauma Research, Commission on Life Sciences, National Research Council, and the Institute of Medicine: Injury In America: A Continuing Public Health Problem, Washington, D.C.: National Academy Press, 1985. Gunderson, PD, Gerberich, SC, Gibson, RW, Adlis, S, Carr, WP, Erdman, AG, Elkington, JM, French, LR, Melton, LJ III, and True, JA: Injury surveillance in agriculture, American Journal of IndustliaZ Medicine 18:169-178, 1990. Panel on Occupational Injury Prevention, Draft Position Paper on Occupational Injury, June 3, 1991. - Presented at the Third National Injury Control Conference, Denver, Colorado, April 1991. National Safety Council: Accident Facts. Chicago: National Safety Council, 1990. Bureau of Labor Statistics, United States Department of Labor: Occupational injuries and illnesses in the United States by industry, 1989, Washington: Bureau of Labor Statistics 1990. Bell, CA, Stout, NA, Bender, TR, Conroy, CS, Crouse, WE, Meyers, JR: Fatal occupational injuries in the United States, 1980 through 1985. Journal of American Medical Association 263 (22): 3047-3054, 1990. 10. Kraus, JF: Fatal and nonfatal injuries in occupational settings: A review, Annual Reviews of Public Health 6: 403-418, 1985. 11. Rivara, FP: Fatal and nonfatal farm injuries to children and adolescents in the United States, Pediatrics. 76(4): 567-573, 1985. 12. Welsch, A, Gerberich, SG, Gunderson, PD: A unique approach to surveillance of severe and catastrophic injuries: An agricultural case study, Proceedings: Public Health Conference on Records and Statistics, National Center for Health Statistics, USDHHS, PHS, CDC, July 1989; pp. 474-480. 13. Stallones, L: Surveillance of fatal and non-fatal farm injuries in Kentucky. American Journal of Industtial Medicine 18: 223-234, 1989. le. Gunderson, PD, Gerberich, SG, Gibson, RW, Melton, IJ III, French, LR, Renier, CM, Erdman, AG, True, JA, Carr, WI', and Elkington, JM: An analysis of variables potentially associated with trauma in the agricultural community, Proceedings: First World Conference on Accident and Injuly Prevenfion Stockholm, Sweden, September 1989. 15. Gerberich, SG, Gibson, RW, Gunderson, PD, French, LR, Melton, LI, III, Erdman, AG, Smith, P, True, JA, Carr, WP, Elkington, JM, Renier, CM and Andreassen, LR: Tke Olmsted Agricultural Trauma shrdy (OATS): A Population-Based Effoq Report to the Centers for Disease Control, 1991. 16. Layde, PM: Beyond surveillance: Method&logic considerations in analytic studies of agricultural injuries, American Journal of Industrial Medicine 18: 193-200, 1990. 176 Papers and Proceedings Surveillance of Injuries in Agriculture, May 1, 1991 17. Gerberich, SG, Gibson, RW, and Carr, WP: Minnesota Injury Prevention and Control Program I. (Comprehensive review of the surveillance literature and documentation of all data sets pertinent to injury in Minnesota; initial evaluation of suitability for surveillance) Minneapolis: Report to the Minnesota Department of Health, 1987. 18. Gerberich, SG, Gibson, RW, Gunderson, PD, Melton, W III, French, LR, Renier, CM, Erdman, AC, True, JA, Carr, WP, and Elkington, JM: Validity of trauma reporting in the agricultural community, Journal of Occupational Accidents 12: 200, 1990. 19. Gerberich, SG, Gibson, RW, San Juan, L, and Carr, Wp: Minnesota Injury Prevention and Control Program I.. (Comprehensive feasibility analysis of Minnesota injury data sets for use in surveillance of injuries), Minneapolis: Report to the Minnesota Department of Health, 1990. 20. Vogt, RT, Larue, D, Klaucke, DN, Jillson, DA: Comparison of an active and passive surveillance system of primary care providers for hepatitis, measles, rubella, and salmonellosis in Vermont, American JoumaZ of Public Health, 73: 795-797, 1983. 21. Thacker, SB, Redmond, S, Rothenberg, RB, Spitz, SB, Choi, K, and White, MC: A controlled trial of disease surveillance strategies, American Journal of Preventive Medicine 2(6): 345 350, 1986. 22. Thacker, SB and Berkelman, RL: Public health surveillance in the United States, Epidemiologic Reviews 10: 164-190, 1988. 23. Ing, RT: Surveillance in injury prevention, Public Health Reports lOO(6): 586-588, 1985. 24. Robertson, LS: Injuries: Causes, Control, Strategies, and Public Policy, Lexington, Massachusetts: Lexington Books, Incorporated, 1984. 25. National Injury Prevention and Control Committee (NIPCC): Injury Prevention: Meeting the Challenge, American Journal of Preventive Medicine, Volume 5 (Number 3), New York: Oxford University Press, 1989. 26. French, LR, Carr, WP, Gerberich, SG, Gunderson, PD, Gibson, RW, Melton, LJ III, and Elkington, JM: Reliability of "El'-coding farm-related injuries using the International Classification of Diseases, Ninth Revision (ICD-9) and a modified version of ICD-9, American Journal of Epidemiology 130(4): 826, October 1989. 27. Gerberich, SG, Robertson, LS, Gibson, RW, and Renier, CM: An epidemiological study of roadway fatalities related to farm vehicles, In review, 1991. 28. Melius, JM, Sestito, JP, and Seligman, PJ: IX. Occupational disease surveillance with existing data sources, in Baker, EL, Editor: Surveillance in Occupational Safety and Health, American Journal of Public Health Supplement; 79:46-52, 1989. 29. Baker, EL, Editor: Surveillance in Occupational Safety and Health, American Journal of Public Health Supplement; 79:1-63, 1989. 30. Marine, WM, Garrett, C, Keefer, SM, Vancil, R, Hoffman, McKenzie, L: Occupational Injury Deafhs in Colorado 1982-1987. Denver, Colorado: Colorado Department of Health, 1990. 31. Thornberry, OT: An experimental comparison of telephone and personal health interview surveys, Data Evaluation and Methods Research, Series 2, Number 106, United States Department of Health and Surgeon General's Conference on Agricultural Safety and Health - 1991 177 Surveillance - Agriculture-Related Diseases, injuries and Hazards Human Services (USDHHS) Publication Number Public Health Service (PHS) 87-l.380, HyattsviIIe, Maryland: USDHHS, PHS, National Center for Health Statistics, August 1987. 32. Gerberich, SG, Gibson, RW, Gunderson, PD, Melton, LJ III, French, LR, Renier, CM, Erdman, AG, True, JA, Carr, WP, and Elk&ton, JM: Validity of trauma reporting in the agricultural community, Proceedings: Occupational Accident Prevention Conference, Stockholm, Sweden, September 1989. 33. Elkington, JM: A Case-Control Study of Farmwork Related Injuries in Olmsted County, Minnesota, Doctoral Thesis, Minneapolis, Minnesota: University of Minnesota, December 1990. 34. Kolstad, OC, Erdman, AG, Elkington, JM, True, JA, Gerberich, SG, Gunderson, PD, Gibson, RW, Carr, WI', and Renier, CM: Hazard analysis of farm equipment, Proceedings: American Society of Agricultural Engineers Annual Meeting Chicago: December 1990. 35. Gerberich, SG, Gibson, RW, Gunderson, Pb, French, LR, Martin, FB, True, JA, Shutske, J, Carr, WP, Renier, CM, and Stasch, BD: Regional Rural Injury Study, Funded Grantxenters for Disease Control, 1989-1992. 36. Myers, JR: National surveillance of occupational fatalities in agriculture. American Journal of Industrial Medicine 18:163-168, 1990. 37. Fuortes, LJ, Merchant, JH, Van Lier, SF, Burmeister, LF and Muldoon, J: 1983 occupational injury hospital admissions in Iowa: A comparison of the agricultural and nonagricultural sectors, American Journal of Industrial Medicine, 18: 211-222, 1990. 38. M&night, RH, Hetzel, GH: Annual trends in farm tractor and machinery deaths, 1975-1981, Paper number 84-5507. St. Joseph, Missouri: American Society of Agricultural Engineers, 1984. 39. Jansson, B: The yield of systems for continuous and periodic injury surveillance in emergency care with emphasis on farm-work-related accidents, Scandinavian Journal of Social Medicine 15: 247-252, 1987. 40. Jansson, B and Svanstrom, L: Evaluation of a system for injury surveillance in Swedish emergency care, Scandinavian Journal of Social Medicine 17: 7-l&1989. 41. Stueland, D, Lee, B, and Layde, PM: Surveillance of agricultural injuries in Central Wisconsin: Epidemiologic Characteristics, Journal of Rural Health 7(l): 63-71, 1991. 42. Stallones, L: Reported frequency of dairy farm associated health hazards, Otsego County, New York, 1982-1983, American Journal of Preventive Medicine, 2: 198-191, 1986. Reprints: Susan Goodwin Gerberich, Ph.D., Division of Environmental and Occupational Health, School of Public Health, University of Minnesota, Box 807-UMHC-420 Delaware Street S.E., Minneapolis, Minnesota 55455, Telephone: 612-625-5934, Fax: 612-626-0650. 178 Papers and Proceedings Surgeon General's Conference on Agricutturai Stity and Health FARMSAFE 2000 . A National Coalition #br Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, lows MUSCULOSKELETAL DISORDERS AND HAZARDS By John 1. Coumbis, M.D. Oak Ridge Fellow Agency for Toxic Substance and Disease Registry There have been numerous and, in my opinion, quite excellent presentations on the basic principles of surveillance, and I will try in my talk not to repeat them too much as I think they were made quite clear. What might be of particular interest to you is how you get started. In the previous presentations some very elaborate studies were spoken about. You should not feel that you necessarily need to have the world of resources or help from the most tech- nical government agency. The study that I am going to present is one that I did dur- ing my training in occupational medicine, my master's thesis. It concerns health effects in greenhouses. How many of you have ever been in a greenhouse? May I have a show of hands? That is good. Does anybody own a home greenhouse? Well, there will be more of you next time we have a conference. The first record of a greenhouse dates back to ancient Greece half a century before Christ, the Gardens of Adonis. But there was a physician of a famous Roman named Tiberius Caesar who also made quite a milestone when he prescribed a cucumber a day for Caesar. Caesar in turn told his gardener, "You have to provide me with a cucumber a day." So, this fellow did, indeed, model a greenhouse and was able to produce a cucumber a day, from what I have read. History looks favorably upon the gardener who, is nameless, and the physician is fortunate in that his name has been lost. But the modem greenhouse is founded on technologies that are drawn from agricultural/engineering sciences. It is a very specialized environment that produces homeostatic conditions that are favorable for the growth of plants. Well, you might say, Why study green- houses? That is usually the question I am asked when I talk about my master's thesis. This audience already has a handle on that to some degree. In the greenhouse you find an unusual ensemble of physical and chemical hazards, each of which have been identified else- where as a human health hazard. The second reason would be to safeguard the health of thousands of greenhouse workers and address the public health concerns surrounding environmental hazards for those who live around greenhouses. I am a city boy: grew up in Flushing, New York. Greenhouses can be found in New York City and can be found in other com- munities, and very often there are ques- tions that come up about, well, am I at risk of being contaminated via the greenhouse chemicals? What of the washoff? That is another subject, but I just wanted to make mention of it, because I think it is a very important issue. It is, also, one that con- cerns the Agency for Toxic Substances and Disease Registry. Surgeon General's Conference on Agricultural Safety and Health - 1991 779 Surveillance - Agriculture-Related Diseases, Injuries and Hazards I should mention that what I intend to do is show you that you can do a very infor- mative study without a lot of money and resources, but you should take advantage of those that are free, and there is a net- work of clinics called the American Occupational Environmental Clinics. I believe that the Iowa City Medical School is a member of that. In fact, they have the only other program, besides the University of Kentucky, where the word "occupation- al" appears in the name of the Department of Preventive Medicine. Let us go on and talk about the green- house industry. The 1988 figures, which are released in a recent USDA pub- lication, would suggest that it is a greater than $7 billion industry and is one that is growing. I believe that there is a great market for greenhouse vegetables in the future as different chemicals become more restricted, because so many fewer chemi- cals are needed to produce food in an enclosed environment. DEMOGRAPHICS The number of farms has jumped con- siderably from 1982 to 1987, as well as the actual size of the greenhouse capacity. Most important of all, though, this study is about people-people who love flowers, people who grow their own food. We want to make sure that they are healthy. The objectives of this study were to deter- mine the demographics of greenhouse workers, to ascertain the nature of green- house work, to identify the materials as well as an understanding of how they were used, and to survey the workers themselves for self-reported health effects. I am really grateful to Dr. Dosman, who pointed out that surveys are a useful tool in surveil- lance studies. 780 I would like to point out that there were eight greenhouses that participated in this study. Only one declined. There were 62 workers out of 92 potential workers that were there. So, it is a very high participa- tion rate. The workers in their 20's and their 30's, together, made up 61 percent of the work force. This is a very young work force. The females outnumbered the males three to one. Females were very well represent- ed, being highest at either extreme of age. Now, what is an important thing to know about this? Is it a good job? Is it a bad job? That is generally a function of how long people stay. When you add up those who worked less than a year and those who worked one year and two years, that is already 55 per- cent of the work force. I found that 64 percent of the workers with less than two years of exposure were less than 30 years of age. Those with more than five years of experience, they were not represented at all in the population less than 30. What I am trying to bring across is the point that a lot of information can be de- rived just by defining the characteristics of the work force. Here you have an industry with primarily young people, primarily fe- male, and with a very high turnover. That, in and of itself, suggests that there is probably something wrong there. Well, let us go into the greenhouse, and we will talk about what is to be found there. I am very fortunate that I did not do the study in the summertime because the temperatures would have been out- rageously high. The other problem is that greenhouse work is very seasonal. There is not much going on in terms of growth of new plants. Papers and Proceedings In the greenhouse you have lots of water. with water, and air is blown in, which It is a very hot and humid environment. produces cooling by evaporation. Water not only comes from hoses, but through water conduits. You also have the same sort of conduits that go into ceramic You might ask, Why am I telling you all these things? Well, the reason is that I cylindrical structures that are placed right inside the bed so that erosion does not want to impress upon you that you have got to know these things if you are going occur. to be able to communicate with the green- house operators and workers. This is the A feature that is only found in the most basic premise that transcends oc- modem greenhouses is a water cupational/environmental medicine. modification area, where different nutri- ents or a diverse ensemble of chemicals Asbestos is no longer used as a construc- can be added. That water mixture, in turn, tion material in greenhouses, but it is still is distributed widely throughout the green- a part of old greenhouse (planting bed) house. construction. In fact, if they wanted to dispose of it, it would be quite an expen- A primary mechanism of cooling the sive process. The asbestos does not greenhouse is by circulating tremendous weather, but the edges of it do get de- volumes of air. In the more modern stroyed through use and, of course, release greenhouse, the top of the glass houses will dust. open according to a temperature sensor. If the wind becomes too great, it shuts Well, not only plants grow in greenhouses, down so that the entire door will not be algae does too. Also, around the green- torn off. house you see a tremendous growth of other plants, which were not intended. Many greenhouses have a heating device that I presume works with propane or A surveillance technique used by the some sort of natural gas. These have the greenhouse operator is a specialized fly potential to produce large amounts of paper. Based on what will be stuck on the carbon monoxide, but I am not aware of paper, the farmer will know when to use any reports of carbon monoxide poisoning, chemicals to control pests. The advantage but certainly where you have such an in- is that, because it is ongoing, you can make strument there is that potential. early intervention and you do not have to do prophylactic or periodic spraying with Another means of heating a greenhouse is different chemicals. through pipes that go underneath the plan- ting beds. They transfer hot water. This is Steam is used to sterilize soil, and a better system because it distributes the chemicals-particularly dibromochloro- heat to the roots of the plant; they grow propane, which is an extremely hazardous much faster. The heat sources are chemical-have been used. Of course, if no generally provided by coal stoves, which is one follows this population, it would be the least expensive form of fuel. very hard to find out if there were any side effects from that chemical. A crude air conditioner has strips of cardboard-like material. They are sprayed Musculoskeletal Disorders and Hazards, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 787 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Other kinds of material are used. One is called Perlmix. It is a mixture of peat, perlite, and vermiculite. Each of those substances carries its own health problems. Workers are exposed to tremendous volumes of this material on a regular basis. One worker took the process outdoors as a means of mitigating exposures. ERGONOMICS Let us get into some of the hard-core problems of ergonomics. A worker will prepare either flat trays or different kinds of potting material or fill the pots with the potting material. The workers take small immature plants, called plugs, and place them in larger trays. It is a series of transplantations and is very labor-intensive. It is quite difficult to pick them up. It is a pinching maneuver. I found a loose electrical line on a vapor- izer. I am sure that it would be recognized as a severe electrical hazard, even by non-electricians. I also saw an electrical wire just strung across the top of the vaporizer and an unenclosed electrical box. 1 . . . you find some of the reports of back pain in roughly a third of the work force, pain in multiple joints in 19 percent, pain of the upper extremities in 11 percent of the workers, lower extremities in 8 per- cent, and neck pain in 2 percent. Pathways were not level, which was from the constant accumulation of the potting materials. It is not just the potting materi- als, but it is all the other chemicals that 182 have been used. Residues will also persist there. Ideally, if the grower had enough funds, he would make the whole floor cement. That way it is much easier to keep clean, Pipes that I saw, which were in the way of workers, can be corrected with modern tables that are commercially available. They place the heating pipes up just un- derneath the level of the table. The height of the table is also critical. Imagine a woman who has just started her shift. She is going to manipulate every plant on the table all the way down its length, most likely without even taking a break. That is a lot of stuff to move. The table is wide, and later, she will be stretch- ing out further over it. That, of course, is not a very natural position to assume, and it predisposes workers to back problems and shoulder and neck pains. A different greenhouse that I saw had three or four different levels, if you count the hanging baskets above. Hanging bas- kets are wonderful because they increase the space without having to add extra tables, but you are working over your head when you have to manipulate those plants. The metal line that held them up was barbed so that the plants would remain in place and not slide. I saw a cutting tool that a worker was operating. It did not have a particularly good ergonomic design because he had to extend his wrist. Fortunately it did not re- quire a whole lot of pressure to cut the plants. Pinching of flowers (by fingers) is done for two reasons. One is to make older plants of equal height so that they will fit in a box or wherever they are putting them. Papers and Proceedings Musculoskeletal Disorders and Hazards, May 1, 1991 It is also done in a process called disbud- ding, where you will have different buds and either you will remove the center one or you will remove the peripheral ones. Imagine doing a whole row of plants. That is a tremendous volume. FREQUENCY OF MUSCULOSKELETAL SYMPTOMS Now, those that reported any form of mds- culoskeletal pain were 31 workers, which was half the work force. Approximately half of those were taking analgesics. I did not dif- ferentiate between prescription and nonprescription. I found reports of back pain in roughly a third of the work force, pain in 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. I would like to hold off here because this is where the musculoskeletal portion ends. The other components were respiratory; related to skin changes; mouth, throat, and nose ir- ritation; certainly all the respiratory findings are also quite striking. But considering the late hour I think we can end it right here. The take-home point is that this is a study that was done. The costs were the transportation from one place to another and the film used and, perhaps, some xeroxing for the surveys. A lot of information can be derived about an industry in a local area without terrifically big resources. Thank you very much. I hope you all enjoyed the session.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 783 Surgeon General's Conference on Agricuttwa/ Silrety and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute tk Occupatkmel Safety and Health April 30 - May 3, 1991, Des Moines, lowa A GOVERNMENT PERSPECTIVE / By Todd M. Frazier, Sc.M. Chief, Surveillance Branch Division of Surveillance, Hazard Evaluation and Field Studies National Institute for Occupational Safety and Health It is presumptuous of me to talk about the government's perspective. My first disclaimer is that much of what you will hear here today is my interpretation of the government's perspective. I want to talk about three aspects sf the government perspective: the challenge that we received, the response that we have given to date, and some ideas that we have gleaned from the conference during the past few days. THE CHALLENGE First, I would like to talk about the chal- lenge. The challenge came to us in 1988, as a result of attendance at the National Coalition for Agricultural Safety and Health (NCASH) meeting and the subse- quent publication of Agriculture at Risk, the NCASH report. Specifically, the challenge appeared as a legislated initiative designed to promote surveillance, research, and interventions. The specific challenge was to the National Institute for Occupational Safety and Health (NIOSH) to conduct a National Occupational Hazard Survey for Agriculture and to survey agricultural workers exposed to certain risk factors. The second challenge was from the ap- propriation language in two programs that comprise the surveillance component. I will talk about one; Dr. Freund will talk about another of the NIOSH agriculture initiatives. 784 The third challenge is something that we have been aware of for some time and periodically read about in such scientific journals as Anierican Demographics or its parent publication, The WaZZ Street Journal. On the 24th of April, the Journal carried this article, front page, left-hand side, "Iowa Towns Shrivel as Young People Head for the Cities." They were talking about Alden, Iowa. From my reading of the map, that is a little tow-h probably about 50 or 60 miles or so north of Des Moines. It is a towh in which the young people are leaving and the old people are staying behind to farm and to run the town, The article gives some very interesting demographics about the State of Iowa, demographics that may apply to other agricultural states. I will just give you a couple of these. The new data from the 1990 census show that 29 of Iowa's 99 counties had more deaths than births, a natural decrease. During the 5 years that preceded 1990, only four coun- ties reported natural decreases. So, here in Iowa, they have gone from 5 counties to 29 counties with a natural decrease. Natural decrease is an unusual demographic phenomenon. Most of us think in terms of continued growth of a country and a natural increase about 1 percent, but here we have a natural decrease. The median age of Iowa's Papers and Proceedings A Government Perspective I, May 2, 1991 \ O FFHHS A RN + Cancer + * Centers + Health Promotion Figure 1. N-91 NIOSH Agricultural Initiative Programs. population increased from 30 in 1980 to more than 33 in 1989. Read on. The situation is so bad that 3 years ago Iowa became only the second state in the nation where the number of people over 75 was greater than the num- ber under 5. I will let you guess at the other state. If you guess Florida, you are right. Because I am from a public health back- ground 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. With that background, I would like to go on to tell you a little bit about the response to some of these challenges. Now, the demographic challenge goes on. The response from NIOSH is broad. It in- The flight of young people and mid- cludes surveillance, research, and inter- dle-aged people from Iowa's rural towns vention. Our particular interest here today has spawned a sub-crisis of its own: an is in the surveillance component. I would aging population of people who not only be remiss, however, if I did not remind you have no doctors nearby but no young that we are part of this triad that uses relatives or neighbors to look after their surveillance signals to trigger either health or even do their marketing if they research or intervention. The same sur- are sick. veillance systems may be useful later on to Surgeon General's Conference on Agricultural Safety and Health - 1991 785 Surveillance - Agriculture-Related Diseases, Injuries and Hazards evaluate the effectiveness of these inter- vention stratagems. Figure 1 shows a map of the total NIOSH agricultural initiative FY-1991 funding. The different codes show the different types of programs being funded by NIOSH. I will speak about the Farm Family Health and Hazard Survey (FFHHS); Dr. Freund about the nurses in rural communities. There are cancer projects in four states. There are two centers of excellence, and, I believe, 15 health promotion states. You can see how there is a clustering in certain states. That provides an oppor- tunity for collaboration or a symbiotic relationship between these projects. You will also note there are parts of the country that have nothing. Now, a few words about FFHHS. The purpose of this descriptive survey is, first of all, to describe the health status of farm families and to recognize work-related hazards-chemical, physical, biological hazards. In doing this, we are borrowing some of the techniques used by our colleagues in the National Center for Health Statistics (NCHS). They are expert in survey design, questionnaire development, training of interviewers. We are also borrowing from our own experience with the National Occupational Hazards Survey, the National Occupational Exposure Survey, and the recognition of work-related hazards. We have, in effect, two groups working on this project. One group is concerned with the health effects. That group is headed up by Ms. Nina Lalich. Her colleague on the hazard side Dr. Alice Greife, heads the hazard section of our unit. We have now decentralized to a point where we 186 have the specialists working with the states that we have funded. In late FY-1990, we awarded six cooperative agreements. I am sure that some of you in the room know what a cooperative agreement is because you have been awarded one. It is positioned bet- ween a grant and a contract. It allows our staff to work very closely with the awar- dee's staff. We feel that it is an excellent way to begin to build the kind of infrastructure and continuing collaboration that we have been hearing about in this conference, The average award was $194,000 per year with the expected duration of 5 years. The awards went through the competitive process and were awarded to two health departments and four university-based awardees, spanning from the east to the west coast of this country. We are busy working with these people now. They have all visited Cincinnati, and we are about to undertake a series of visits to each site. We are also preparing our OMB packages for clearance with the questionnaire part of the surveys. As you might expect, these are quite diverse surveys. Agriculture has a long tradition of being state-based. We see this in the strength of the land-grant university system. We see it in the county extension agent system. We felt that it was impor- tant to build on the existing infrastructure. We had a hard decision to make whether to try to do a national survey with limited resources or to do a state-based survey in states where there was the capability, the interest, and the likelihood of carrying surveillance findings on into research, intervention, and, ultimately, prevention. Papers and Proceedings We elected to do state-based surveys. Given that construct, it is not surprising that we encounter many variables that are state-determined. For example, some states elected to look at a particular com- modity. Other states, in terms of the geographic coverage, elected to go to a subset of counties rather than statewide. In one or two states, there was a demographic slice, and they elected to look at a sample of young and old farmworkers-the very young and very old. This is both a disease and injury survey. There is no question that injuries are a very important part of the farm family's assessment of their hazards. They see this every day on their own farm; they see it with their neighbors. Injuries predominate. That is reflected in many of the proposals. We are looking at injury patterns. We are doing this in collaboration with our col- leagues in the Division of Safety Research in Morgantown. In addition, we are looking at disease components. Here again we are col- laborating with the Division of Respiratory Disease Studies in Morgantown. Dr. Castellan has been a faithful and valu- able contributor to this aspect of it. Be- yond that, we are trying to look at a wide spectrum of disease and also look at the hazards, the physical, chemical, and biological hazards that cause these diseases or injuries. This is an attempt to show in matrix form a summary of health interview and examination topics that were elected by the six states. I should point out that we were insistent on one or two topics. A Government Perspective I, May 2, 1991 We want a good demographic base. We felt we should have consistency in age, sex, and race types of questions. That presents very little problem. We are all used to using the kind of ques- tions the Census and NCHS use to get that kind of information. Beyond that, we wanted to look at medical access. What are the barriers to medical care? Do people have health insurance? If they have it, how did they get it? Many of these people are self-employed. Does the health insurance come as a result of one, or maybe both, adult members of a family taking employment off the farm in order to be eligible for health insurance? These are questions that I think are par- ticularly important in juxtaposition with the Wall Street Journal article I referred to, which made the point about the break- down of the medical care delivery system in rural America. The barrier-the economic barrier-may not be the problem. It may be that there is nobody in practice; there is no hospital. These are things we need to find out. Injuries are being recorded. We are also interested in musculoskeletal, respiratory, dermatologic, mental health, neurologic, cancer, spirometry testing, and hearing and audiometric testing. These are the types of things that are being built into surveys using what we call modules. We developed these suggested patterns or models. States are picking up on one or more modules and putting these in their survey proposal. The proposal will then be packaged for OMB review and approval. Hazards are next. Borrowing from our experience with the National Occupational Surgeon General's Conference on Agricultural Safety and Health - 1991 187 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Exposure and Hazard Surveys, we are working toward an on-site walk-through in much the same way we would walk through an industry or industrial setting. We are looking at pesticides. We will do some sampling. We will look at chronic trauma. We will look at safety risk factors, injuries, ergonomics, rollovers, PTO's, and secondary occupations. We need the information on secondary occupation for a number of reasons. One I cited was health insurance. The other is a bit more along the lines of traditional industrial hygiene interests. If a person has an off-farm job that has certain hazards that may result in a disease, we want to know about that job. We want to know the potential for those hazards. Otherwise, we may attribute that particular disease to something that is being done on the farm. It is very important to look at the relationship between off-farm and farm employment. [REMARKS FOLLOWING NEXT SPEAKER] Mr. Todd M. Frazier: One thing about a conference like this is that you are hit with so many thoughts and ideas that it is hard to put them all together in any meaningful way. I am not going to attempt to do that for even a small part of this conference. I went back through my notes last night and picked out words-words that, if you forced me to, I could attribute to a speaker but right now they are just words. They are words that I am going to take home from this conference to see if what we are doing somehow addresses the concerns we have heard from people at the Surgeon's General's Conference. Here are some of the words. Of course, "change." Times are changing. For most of us in NIOSH it went from a smokestack to haystack type of change (i.e., change in the direction of our own organization). "Cooperation, communication, education"-in many different forms, we have heard that. "Infrastructure"-we are dealing with that. That is why we are here in many respects. "Children." "Women." "Older farmers." "Disabled farmers." "Ta- rget groups." "Exposure assessment." "Weaving the ideas of industrial hygiene into agricultural aspects." "Shortage of rural health care personnel." "Stress." Back to the WaZZ Street Journal. Here is a man whose kids are leaving the farm. He says: "We expected to live here forever. Be sur- rounded by our family. We planned on it, but things change; and I'm seeing that all change is not for the better. Things aren't going to work out the way I thought they would." So here is a 70-year-old man who is going to farm whether he likes it or not. You have farmer-provider interaction. You have that phrase I do not want to forget. John May used it, "teachable moment." Then, I have to say this. Did you read the paper this morning about that old guy that pitched his seventh no-hitter? So, if we build it, they will come.0 188 Papers and Proceedings Surgeon General's Confemce on Agtkdtud Safety and Health FARMSAFE 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 A GOVERNMENT PERSPECTIVE II By Eugene Frecm$ Jr., M.D. Chief, Surveillance Branch Division of Surveillance, Hazard Evaluation and Field Studies National Institute for Occupational Safety and Health Over the past two days I have been sitting in the audience and hearing talks from people who are able to report vast experi- ences with agriculture and farming. So it is with some trepidation that I got up here. I reminded myself, "Hey, Gene, you have more than 35 years of experience as an end-user of agricultural products and that is it." But I do know what it is like, briefly, to be a practicing physician, seeing agricul- tural injuries, and-when I recognize them-illnesses, Frequently, I did not know where to go for preventive as opposed to curative or palliative help. Nurses have a long history of public health care. They are in immunization programs, in tuberculosis control, women, infant, and children programs, STD programs-virtually all aspects of public health. What I want to do now, with these few minutes, is de- scribe what we are doing. We are calling it the Nurses' Project, which will extend that model of public health nursing into the agricultural-occupational arena. I will try to fit this program into what I have heard from other talks. It is still developing. It is already a pro- gram that will act locally and, I believe, has national impact. May I go to that first slide with the map of our projects (Figure 1). The Nurses' Pro- ject is the green triangles. I think I will center the world on Iowa today and do an Iowa-centered perspective. You can see that we have the Nurses' Project located in Iowa, Minnesota, and North Dakota. New projects have just been awarded starting in July in Ohio and Kentucky. The project is also in California, Georgia, New York, Maine, and North Carolina. Each project has three to five nurses. They will be, for the most part, regionally located. That varies from state to state. They are all in state health departments, but they will be based in districts, counties, or quadrants of the state, depending on the state and its population and the differences that each applicant engineered into its programs. The important part is that each of these nurses is expected to become involved with the target communities. That means get- ting to know health-care providers of all types, getting involved with the Extension Service, land-grant universities, educational institutions, the Farm Bureau, the Grange, or whatever is important in taking care of the health and safety of the population, which they will be helping. I think of the program as providing a pub- lic health infrastructure. It does that with three functions. Two of them are part of the surveillance, intervention, and research triad-surveillance and intervention. Those are enabled by what I expect to be the nurses' ability to forge links between their efforts, their health department's efforts, and other efforts and resources from Surgeon General's Conference on Agricultural Safety and Health - 1991 789 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Agricultural Projects Figure 1. States with NIOSH Projects. NIOSH projects, such as the Farm Family Health and Hazard Survey (FFHHS) that Todd just described, to all the groups I have mentioned, extension, educational groups, and the like. I want to use Bill Halperin's surveillance topology from yesterday to help think through the surveillance aspects of this program. 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. For example, they may hear from a physi- cian about a case of diagnosed or suspect- ed organic dust toxic syndrome. They can identify that as a problem and trigger ef- 190 forts to prevent it from happening again. Since they will be located in their own regions, they will often be able to identify all cases of a given condition, tractor roll- overs or power take-off injuries. They can identify the scope of those problems, use that information to target intervention efforts, and after intervention efforts, eval- uate how effective they have been. The case surveillance also can work for targeting efforts in and of itself. An identi- fied case of a sentinel event, which should not happen, such as a child injured from falling off a tractor on a farm, could trig- ger educational campaigns, press releases, on whatever would be appropriate in the community. This is active surveillance for these conditions because they will be there. Papers and Proceedings A Government Perspective II, May 2, 1991 The other function is intervention. There are a number of ways to intervene. Some are education (not just by going to schools and talking, which is something the nurses could do); giving presentations (sometimes it is very helpful to have someone who is a health professional provide that information); and also working with the already considerable efforts of the Extension Service. Another intervention is educating providers by giving them lists of reportable or desired reportable conditions or putting them in touch with contacts in the academic com- munity, or referral sources that they are aware of. Another educational intervention, which I think has the potential to be very powerful, is the dissemination of surveillance and research results. If they can show a com- munity that these problems are real and happening to their neighbors, I think they can have an impact on people's behavior. Again, they can be links to other resources. The Extension service have people who know how to retrofit tractors with rollover protection, if that is something someone wants to do. We at NIOSH have quite a lot of expertise in doing health hazard evaluations. That is an intervention that, when appropriate, could be performed. By having some utility to providers in the community-and this brings things full circle-they can have an influence on sur- veillance. If you are asked to contribute to surveillance, you as a provider or an indi- vidual in the community are asked to con- tribute to something you perceive as use- ful. You, therefore, are going to be more likely to contribute. That is the outline of the infrastructure, which with variations through our 10 coop- erative agreement partners is being imple- mented. We have got a number of chal- lenges ahead of us. We have work to do in terms of defining the most appropriate target conditions for this project. I think ihjury clearly has much potential. Physicians are able to identify it. Some of the work on illness remains to be seen. I believe that there are physicians and other providers out there who, as I have done, would-with a structure to support them in their interest in doing public health efforts-be eager to report. They would be eager to get their patients and their communities plugged into a public health system to prevent illness and injury. There is plenty of work to be done in designing interventions. Of course, evalu- ating and identifying are the most success- ful elements of the varied projects that are part of this program. All these tasks need to be taken in concert with those at the local level that these people will be work- ing with, the farmers, the Extension Ser- vice, the providers. All of these have a stake and a potential contributi0n.U Surgeon General's Conference on Agricultural Safety and Health - 1991 191 Surgeon General's Conference on Agriculturai SatWy and Health FARMSAFE 2000 o A National Coalition lix Local Action Convened by the National Institute for Occupational Salty and Health April 30 - May 3, 1991, Des Moines, Iowa THE CONSUMERS' PERSPECTIVE By Craig Merrilees, BA. Director, Consumer Pesticide Project Thank you very much, and thanks to NIOSH and to the Surgeon General for inviting consumer and environmental spea- kers here today. We appreciate the plural- istic way you have approached "coalition building," the theme of this conference. I have been inspired by many of the folks I have met at this conference during the past couple of days, and cannot help but notice that your tone is upbeat. Many of the participants are activists. You are consid- ering new approaches. We all know these have not been the best of times for occupational safety and health, so coalition building has become even more important. It is essential for making progress and improvement in the work- place, particularly on the farm. I want to tell you about some of my back- ground and orientation. I work closely with the National Toxics Campaign. This is a federation of over 1,000 grass-roots environmental activist organizations. Most of these people are angry. They are un- happy- They feel that environmental policy is out of their control. They are demanding that industry and government be more account- able to the community and workers. Most of the members are women. Many of them are directly concerned about environ- mental occupational issues in agriculture. 792 On a personal level, I have been involved in these issues from four perspectives: 1. Public health: I am a former county health commissioner and took a great interest in farmworker safety and health when I served in that position. Also, I helped establish a neighbor- hood-based health maintenance or- ganization to deliver affordable, high- quality health care services. 2. I am heavily involved in environmental policy and politics right now. I recently finished work on the 1990 Farm Bill and other legislation. 3. I have members of my family that are still surviving on a farm-God knows how-in Ohio. They are trying to grow corn and soy beans for a living. They will not be in business much longer for reasons that I am going to explain. I am deeply concerned about the future of family farming in this country and the way in which smaller-scale agricul- ture is being destroyed by Federal policies that have brought about tremendous changes on the farm-and not necessarily for the better-from an occupational or an environmental perspective. 4. Finally, I have worked as a journalist. I investigated many stories about oc- cupational hazards and environmental scandals. Papers and Proceedings I will begin talking about coalition building and about some practical experience that our organization, the National Toxics Cam- paign, has had in building coalitions and in promoting what we call "source reduction," removing of fundamental problems. In this case we are removing pesticides by utilizing consumer and environmental pressure, along with cooperation from farmers and industry people, to eliminate use of the most dangerous classes of pesti- cides. However, first I want to quickly talk about the structure and the politics of agriculture in this country, how that bears on health and safety issues. If you were here earlier, you heard that there are some interesting trends under way. We have an increasing number of large capital-intensive farms. We have a decline in small family farms. If you had a chance to analyze some of the data we heard earlier, you would have found that by the end of the day we will have lost 50 family farms in this country; 125,000 farms will be gone by the end of this decade. That is a sentinel event. Something is wrong in the country. Some- thing fundamentally dangerous is under- way, particularly if you happen to live on a farm or if you live in a community region or city like Des Moines. I was walking the streets last night. You can see the conse- quence of that policy in the boarded-up stores and empty office buildings. The third element is a direct link between the intensification of agriculture, a policy that has been promoted by the U.S. De- partment of Agriculture (USDA) and indi- rectly by the Congress and the Administra- tion, and the increased use of chemicals in agriculture, at a rate of 500 percent since World War II. That has a direct bearing The Consumers' Perspective, May 2, 1991 on occupational safety and health prob- lems. Yields are up. Incomes are down. Is that not strange? People work hard, they pro- duce more, and they get paid less to do it. Ask any farmer in the Midwest. Ask any farmworker in California. They have not reaped many of the benefits from increasing productivity. Those benefits should have included improvement in occupational safety and health. Health and safety improvements come only when people are organized and when they are able to control their own destiny. L If you were to compare, for example, the budget the USDA is advocating for bio- technology versus their budget for low-inp- ut sustainable agriculture, you would get a clear picture of where the priorities are in this country. They are wrong and detri- mental for farmers and farmworkers. I think if we have learned anything in the past, it is that health and safety problems are influenced by these policies. Health and safety improvements come only when people are organized and when they are able to control their own destiny. I want you to look at some priorities that the USDA is currently pursuing. Just look at the way the U.S. Government is promoting the development of herbicide- tolerant plants. This is serious issue that has been ignored in terms of the health and safety effects. We know that farmers who work with certain classes of pesticides have Surgeon General's Conference on Agricultural Safety and Health - 1991 193 Surveillance - Agriculture-Related Diseases, Injuries and Hazards non-Hodgkin's lymphoma at five and six times the rate of those who do not. We do not know exactly why, but we think it has something to do with pesticides. Do you not think it is curious, then, that the USDA is currently promoting programs to increase the use of these herbicides by promoting and subsidizing the develop- ment of herbicide-tolerant potatoes? They are doing some of these experiments in California. The pesticide that they are using is 2-4D. The same thing could be said for bromoxy- tolerant cotton, or atrazine, which is re- sponsible for extensive ground-water pollu- tion. There are 40 states now that have serious ground water pollution, much of it caused by atrazine. Why is the USDA working so hard to promote atrazine-tolerant canola? Some of the work is being done in Canada. I can guarantee you, however, it will not be long before the USDA is petitioning to encourage our farmers to use those products here. Farmers are the ones who drink more contaminated water than those of us that live in the cities. Farmers are the ones who are exposed more to pesticides and other hazards. I want to have some dialogue with you about how some of my people view science and research. A lot of my activist friends have, I believe, false hopes in scientific research. The victims, as they call themselves, demand the EPA come in and ATSDR come in. Their basic position is, "We are sick. We are being poisoned. We know this is happening. We want you to document it." 194 You come in. You spend thousands, som- etimes millions of dollars. Then you come up with negative associations or no associ- ations whatsoever between the exposure and any negative outcomes. Folks walk away disgruntled and angry. They think there is a conspiracy or cover- up. This is wrong. I think our people are increasingly wondering whether this is a good use of resources. I think they are going to be questioning whether we should be doing this kind of epidemiological research. I say this, knowing that their naivete has led them to believe that scientists can prove and document environmental damage to people when, in fact, it is much more elusive. It may require a different approach than scientific proof obtained through epidemiological studies. I also think there is some naivete on the part of researchers and academics who believe that somehow, if we could simply document facts, things will change. They believe somehow political leaders will be influenced by facts and rational arguments. This is not how things change in this coun- try- I would challenge anyone here to give me an example where facts and rational argu- ments alone persevered in the face of strong, powerful corporate interests. The facts and scientific evidence were available long before OSHA set lead standards, mercury standards, asbestos standards, and benzene standards. That evidence was clear for decades before the Congress and the Administration even saw fit to estab- lish OSHA! Every single sentinel health improvement in this country came because two things were present: Papers and Proceedings 1. There was scientific research to show it; but that was never the determining factor. 2. People were organized where they worked. They had political power. They built coalitions. They made change. Those are the ways that changes have happened and health outcomes have been improved in this country. Therefore, I think it calls for all of us to have a much closer relationship with workers and their organizations. Look no further than the agriculture-im- plement lobby here today. This lobby has blocked rollover protection in this country for 30 years with knee-jerk, protective, self-interested arguments that continue to allow farmworkers to die in this country, out of their narrow interest. That is wrong. The reason that it hap- pened is not because we have not done enough scientific research to document the problem. What kind of research can make a differ- ence? I think we have a phenomenal amount of talent here. People are doing all sorts of interesting studies. People are beginning to reach out to ATSDR. OSHA is maybe waking up from a deep sleep and a very depressed situation that they en- countered after being savaged during the Reagan and the Bush years. I think there are good examples where universities are trying to work with people who are facing these problems firsthand, Some of the extension folks are doing that. Look at the excellent work done by Don Villarejo at the University of California at Davis. The Consumers' Perspective, May 2, 1991 We have to ask if money is being wasted on research. I question, for example, whe- ther money in my state was well-spent to try to look into the problems of the cancer cluster at McFarlane. What we found is that there were an excess number of can- cers and too many kids that had cancer, according to the statistics. We ended up spending millions of dollars to research that problem, however. The one fact that the research turned up was that most of the people there have terrible health care because they are poor. They do not have good quality primary health care and that may have something to do with the outcomes that were generating cancer. It may; it may not. What we found is that 70 percent of the people who live in that community do not have any decent health care. That is the most profound finding we discovered. It leads us to the conclusion that more communities should be demanding ser- vices. They should be demanding changes in the health care delivery system so that they receive more services and put less emphasis on empirical scientific studies that try to prove slight elevations in certain rates are occurring in their community. That is what we are thinking about. We recognize that environmental solutions will require good scientific research: epi- demiology and surveillance. In many cas- es, the science is already finished. We are going to be focusing on eliminating haz- ards that are known, that are understood. We know that parathion is a dangerous chemical. We have known that for 30 years. We know that it kills people. We know that there is no reason for it to be Surgeon General's Conference on Agricultural Safety and Health - 1991 795 Surveillance - Agriculture-Related Diseases, Injuries and Hazards used. There are safer substitutes that are out there. There are different ways to organize agri- culture that can produce the results we need in terms of productivity without using that pesticide. There are people in this country who will pay a lawyer $300 an hour to work around the clock to lobby EPA to keep that product in the market- place. No matter how many studies you do and how many deaths you document, it is going to keep being sold despite the scientific evidence. Therefore, our campaign is going to focus on getting rid of that pesticide. We are going to focus on the acutely toxic pesti- cides, the ones with strong neurotoxicity, the ones that are potent carcinogens. There is no reason for those pesticides to be on the market and to be used. We are going to be emphasizing the need for new technology. We are going to be exposing the hidden cost of using these products. There is no reason that these costs have to be socialized in this country when the folks who benefit do not socialize their profits. I will talk about a strategy we have devel- oped that may be of interest to you in terms of how to achieve these reductions. You know that we failed in California when we proposed that all of the B2 carci- nogenic pesticides-those that EPA says are probable human carcinogens-be phased out over an &year time period. That was considered to be an extreme proposal. It was opposed by the Farm Bureau. It was supported by family farmers. The Farm Bureau and the major chemical companies worked together in a coalition to defeat that proposal. 196 What we have done in California is to promote more dialogue with people that could make a difference, the farmers that are growing the fruits and vegetables. Fruit and vegetable production has dou- bled in past decades. That means there are going to be more farmworkers out there, more exposure. With the kind of intensification we are using, there will be more exposure to dangerous pesticides. We went to the farmers. We went to the supermarket industry. We said to the farmers, "How would you like to receive a slight premium for the fruits and vegetables that you grow, if you could grow them with fewer and safer pesticides? Not necessarily entirely with- out pesticides right off the bat, but those of you that can move into an organic sys- tem or a regimen of pesticide reduction, do it. We will support you. We will lobby for you. We will try to get your products carried in the stores. Those of you who could reduce your use of the B2 carcino- gens and provide lettuce grown without DBCP's, we want to support you. We went to the supermarket industry. We said, "How would you folks like to be able to sell a product that has a unique environ- mental distinction and that provides you with a marketing niche?" This is an indus- try that is viciously competitive, where executives live or die over fractions of a tenth of market share. Some of these executives were interested in ex- perimenting with pesticide reduction. The environmental and consumer groups also were interested. They want to see change happen. It is not happening now in gov- ernment. Papers and Proceedings Finally, the farmworker organizations, as well, were obviously concerned about this. Probably the most important reason agri- culture has done so poorly in terms of occupational safety and health is because there are practically no unions there. And I think the single strongest correlation bet- ween mediocre safety and health outcomes has to do with the lack of organization within that industry. We did work a little bit with farmworkers, together with farmers, supermarkets, and consumers. What we did is arrange a deal that benefited everyone. Not long ago, we had 1,200 supermarkets that represented $10 billion worth of pur- chasing power in the country who went on record that USDA EPA, FDA, the Califor- nia Department of Food and Agriculture, and other organizations have spent too much of their time defending the status quo. They said, "We are on record calling for the phase-out of all B2 carcinogens." Period. End of discussion. We are going to be favoring growers who can provide us supplies of fruits and vege- tables without pesticides that are acutely neurotoxic, eliminating pesticides that lack any practical analytical detection method. They took a very progressive policy. They were immediately attacked by the USDA, by the FDA, and by the EPA as unnecessarily alarmist, threatening the integrity of people's confidence in the food supply. The Administration wanted the rest of the industry to continue mimicking their mantra, which is that "We have the world's safest food supply; the food supply is safe; do not worry, be happy; do not worry about the people who work on a daily basis with these pesticides. Trust us. The Consumers' Perspective, May 2, 1991 The system will protect you and the envi- ronment." That position is wrong. That position has to change. It is a dinosaur position. It is one that is based on defending the status quo; eventually those people will lose out. In the meantime, we have built an interest- ing coalition with supermarket executives. They are not a liberal bunch, on the whole. They do have an economic advan- tage in promoting this, which we are happy to support. We think that is a great thing. To the extent that we can use market forces to encourage these things, we are going to do that. Certainly the farmers are happy to see that they can demand and receive a small pre- mium. That is the kind of coalition that we have attempted to build. The National Toxics Campaign has pro- moted some similar approaches in more traditional industry, One of them is replacing TCE (trichloroethylene) solvent with detergent compounds for washing circuit boards. Before we negotiated we spent our time beating up some of the major electronics firms. They refused to acknowledge that there were safer alternatives that would not cause some of the occupational and environmental problems that TCE was causing. After a certain amount of head banging, and a certain amount of rational argument, and a certain amount of objec- tive studies, things got to the negotiations point. Now, IBM and other major industry leaders have replaced TCE solvents with Surgeon General's Conference on Agricultural Safety and Health - 1991 197 Surveillance - Agriculture-Related Diseases, Injuries and Hazards more benign detergent compounds to wash their circuit boards. The same things happen with refineries. We lost a chemical plant yesterday that killed eight people. Refinery work is one of the most dangerous occupations in the country, after agriculture, of course. We have fought a major battle with Chevron's Richmond refinery that has released tons of benzene and other chemicals every year into a black neighborhood. That is now going to end. It did not end, however, because the government made it happen. It happened because we used third-party pressure to make it happen. In fact, the government was giving Chevron a permit every year to dump that benzene into the air and dump heavy metals into the water. That is something that the government was willing to tolerate, but we were not. I believe what it is going to come down to is this: we want to work with you. We want to see interesting, provocative re- search. We hope that it is going to be oriented towards helping farmworkers and helping farmers and moving it down to that level. Too much of our research has tended to benefit people that already have the re- sources to do their research. We need research that can help the folks who are working in the granaries and the mills, the folks who are picking those fruits and vegetables, and the farmers who are strug- gling to make a living in these difficult times for family farmers. We would like to work with you to make sure that your research is appreciated and that it does the most good for the most people.0 198 Papers and Proceedings Surgeon General's Conference on Agricultural S&ly and Health FARMSAFE 2000 o A National Coalition lor Local Action Convened by the National institute for Occupational Safety and Health April 30 - May 3, 7997, Des Moines, Iowa AN AGRICULTURAL SAFETY PERSPECTIVE By Dennis Murphy, Ph.D. Professor, Penn State University The first thing I want to say is that, being an agricultural person, my opinions are unbiased. Everything I am going to tell you is completely unbiased. I did not realize what a miracle person I was, grow- ing up on a farm and being happy. I did not realize I was so abused. I thought I had a relatively happy child- hood. I continue to know a lot of people who are pretty happy about being out on a farm. I am probably confused, but I thought that our life expectancy was in- creasing instead of going down. I thought people were still dying to get into this country instead of out of it. I was not asked to make a presentation per se. Rather, I was asked to get up and respond to other presentations. I think that has been called a "rebuttable," or something like that. Dr. Herrick said "don't worry about actual- ly preparing something." Since I do not pay attention to a lot of things, I went ahead and prepared something. I am glad that I did because I have not heard many people talking about the con- cepts of dealing with surveillance issues. Very few people have talked about that. We have had actual research studies pre- sented, which is one thing. That is fine. This does not mean that all positions and all the things that have been talked about are not important. They are not the things that I consider important issues in surveil- lance of agricultural safety and health hazards and problems. I am going to get to the categories of specific exposure groups because we have talked about descriptive statistics. We are finally getting beyond descriptive statistics. Some of the papers presented earlier have illustrated this. In the last two, three, or four years, public health has gotten more interested in agricultural safety and health issues, and particularly in certain aspects of them. I keep reading papers that are just dis- covering that there is a problem out there. We keep discovering the same problem over and over and over. There are a whole bunch of new people here again. I am afraid that in the next couple of years we are going to keep read- ing a lot of papers that are saying the same thing over and over again. The descriptive stuff is out there and has been for 20 or 30 years now. I strongly encourage you to get beyond that. If that is all that you can do, you are not going to contribute very much to literature. STANDARD TERMINOLOGY We talked about the standard terminology. What I keep hearing here through the use of agricultural statistics, is that we are Surgeon General's Conference on Agricultural Safety and Health - 1991 799 Surveillance - Agriculture-Related Diseases, Injuries and Hazards either the first, second, third, or fourth most hazardous industry. We heard all of those numbers within an hour and a half the other day. That is because we define things in different ways. If we are going to let data guide us, we have to get to some specific categories to One of the things we talked about earlier was that 300 kids are killed every year on the farm. If you go back and look at the original study, those really were children and adolescents. I have not heard the work "adolescents" used at all at this con- ference. That statistic included adoles- cents through the age of 18. It was all fatalities on the farm. It was not agricultural work. Yet everybody uses agricultural work as a justi- fication for getting into this area. A lot of those fatalities were hunting accidents and other leisure types of things. This 300 number is firmly entrenched and everybody uses that number. They fail to mention that it involves adolescents, not just children. Nobody identifies that it is not just farm work fatalities included in that statistic. There is much to do in straightening out our language. I am not sure that the pub- lic health people are really addressing this issue. Category-specific exposure data is an issue. I think it is very important. We have heard about exposure assessment. We are moving in that direction. I know that the family farm health surveillance program is dealing with this. 200 What I would caution is that it is not total exposure that is important. If we are going to do something meaningful, we have to get down into categories. Not all expo- sures are equal.' The quality of exposure is not necessarily equal when you get into tractors, or into age groups, or into other machinery or respiratory hazards. If we are going to let data guide us, we have to get to some specific categories to have some guidance. Otherwise, we are throwing away money, effort, and a lot of time on something that may or may not exist. The same is true with categories. The "children" category is one of the best exam- ples. Again, we have heard much about children and about the elderly. Thus far, "children," at this conference, means every- one 19 and under, 18 and under. We just had 17 and under; 16 has not been men- tioned yet, but 15 and 14 have been men- tioned. So, what is the "children" catego- ry? I do not think it is as important whether it is 14, 16, or 18. It is important that we all should use the same thing. When you look in the literature, it is all different. Every- body has a different group. It is hard to understand and communicate with each other exactly what the problem is with children because they are all different age categories. The same thing is happening with the elderly. We have 55, 60, and 65 for most of the elderly categories. It is not helping us to have these different categories. We have the same problem with other categories. Sometimes machinery includes tractors and sometimes it does not. That makes a big difference on the farm when you are talking about statistics, whether Papers and Proceedings you are including tractors in agricultural machinery. I am suggesting that we need to take time to work on some of these kinds of things before we rush out and do something that might prove to be inappro- priate or ineffective. Another issue is useful categories. From the beginning, we have known that there are more injuries among kids during the summer months than there are during the school year. That makes a lot of common sense to me. They are out there during the summer months. The rest of the time, they are in school. Their exposure is lower and ob- viously they are hurt less often. There is data that says that tractors are involved in injuries at certain times of the year. That is because they are being used more at some times of the year than oth- ers. These are common sense things that I am hoping the public health researchers are not going to go back and tell us again. Data is already there. It has been there for a long time. We need to define groups and categories and come to some agree- ment on what those are. I am not saying that what I do is the right thing. It is just that we all should get together and come to some kind of agreement on these kinds of issues. DATA AND NONFATAL DIFFERENCES Another issue is the fatality and nonfatality descriptions. They are different. This is combined with the priorities issue. What are our priorities, long-term or short? I find myself in a difficult position because I have to argue something in order to get it identified as a issue. An Agricultural Safety Perspective, May 2, 1991 When we talk about fatalities, the picture is clear. You may not realize it but there is a very clear picture of the fatalities on farms, fatalities associated with farm work and with farm worksites. If we are concerned about doing some- thing, about saving somebody's life next week, next month, or this year, we need to work on that. We need to let that give us some guidance. If we are taking a longer view, we look at nonfatal injuries because they involve a different group of exposures, different kinds of agents. So, we approach things and we do some things differently. LONG-TERM AND SHORT-TERM VIEWS Much of the discussion during this confer- ence has been about pesticides and chemi- cals. The public health system is obviously knowledgeable and concerned about chro- nic health effects, whether from pesticides or respiratory or other kinds of things. When we talk about those issues from my perspective, those are quality-of-life issues. I am worried about keeping the poor guy alive to begin with. I may not be right, but I think that is an issue. We do not talk about it as an issue. We are jumping on all kinds of bandwag- ons and talking about things that affect people 15 or 20 years down the road; that is important. That is why I have difficulty talking about this because I am not trying to argue against being concerned about long-term effects. Given the real world and limited resources to put into anything, if we are going to prioritize, and if we are going to Surgeon General's Conference on Agricultural Safety and Health - 1991 207 Surveillance - Agriculture-Related Diseases, Injuries and Hazards use data to help do that sort of thing, I think this is an issue we have to discuss. DEATH CERTIFICATES Another issue that I think has been clearly identified is death certificates. Death certificates are not a very good measure of what is going on. They are a starting point. That is about all. You can follow up to get better infor- mation, especially in terms of whether the injury was occupationally related. OUT-OF-FIELD LITERATURE The next issue I have is the awareness and availability of out-of-field literature. This goes back to some of the earlier com- ments. We already know to a large extent what the acute problem is. I will not say we know so much about the long-term, about the pesticides, and long- term effects from that perspective. From the short-term perspective, that infor- mation is already known. You need to look beyond the public health literature, however, to find it. There is the National Institute for Farm Safety literature. There is the American Society of Agricultural Engineers litera- ture. There is the Agricultural Division of the National Safety Council. There are other groups that have been doing things for a long time that some- times have been published and sometimes not. A lot of the people in these groups do not publish in refereed journals because that is not their purpose or mission. You can scan medical ioumals and think that you are going on in agriculture. 202 find out what is going a large extent, it is past history. There is literature out there but you need to try to find it. Then we will not keep saying that there are no studies, there is no documentation, there is nothing. That is not true. LOCAL DATA The last thing I see as an issue is that educational and intervention efforts need more localized data if we are going to do something that is meaningful. There is a purpose for state and national surveillance. I understand and strongly support that. I am involved with it. When it comes to doing something about the problem, the national data in particular is not going to guide us very well. We need local level data to help guide us, pizT--I There are some issues, the ROPS issue is the most typical one, that we can approach from a national perspective. That is just one part of the problem. There are doz- ens and dozens of problems out there. When used on a local level, one to one, or with small groups of farrn people, they see right away that what you are talking about is not a problem in their area. I tried to talk about respiratory hazards to a group of poultry and potato farmers. I was using the Iowa information, I said "Iowa has done a lot of great things. This is the information that is coming from there." They said, "That doesn't mean anything to us; that is in Iowa." I then spent the next half hour, instead of talking about respiratory hazards and what they can do to protect themselves, talking about how a hog in Pennsylvania is the Papers and Proceedings An Agricultural Safety Perspective, May 2, 1991 same as a hog in Iowa. They did not be- ledge of the culture and values of farm lieve that what I was using was relevant to people. You do not need to understand them, the types of diseases they get. that you will be going off on some tangents that are not going to be productive. We Again, this is for the people who are newer need to get down to local levels. We need in this area who do not have a working local level data to help guide us, not just knowledge of farms and a working know- national data.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 203 Surgeon Qeneml's Confimncs on A@ultural Satkv and Heatth FARM&FE 2000 o A National Coalition tibr Local Action Convened by the National Institute k~,r Omqational SaMy and Health April 30 - May 3, 1991, Des Moines, Iowa AIRBORNE DUSTS By Susanna Von Essen, M.D. Assistant Professor of Medicine, University of Nebraska OVERVIEW Exposure to airborne dusts has long been known to cause illness. Rarnazzini wrote that measurers and sifters of grain were at risk for respiratory problems and irritation of the eyes in his book De morbid artijicum, published in 1713.' Hypersensitivity pneumonitis (HP) in farmers was formally described in modern times by Campbell, in the year 1932. He recognized the relationship between ex- posure to spoiled hay and a febrile illness with cough and an interstitial pattern on chest X-ray. HP is a disease about which much is known. A variety of etiologic agents and measures for treatment and prevention have been identified. However, a great deal still remains to be learned about this disease. Organic dust toxic syndrome (ODTS), originally called pulmonary mycotoxicosis, is a disorder that was first recognized in the 1970's in dairy farmers after heavy exposure to moldy silage." The disorder was called "silo unloaders' syndrome" when it was recognized that the symptoms likely were not caused by fungal poisoning." A similar illness, originally called grain fever, was seen after exposure to dust from stored grain? ODTS shares many features with acute hypersensitivity pneumonitis but 204 is without clearly identified long-term se- quelae. Most studies have shown that chronic bronchitis is more common among farmers than in the general population.611 The majority of farmers with chronic bronchitis have a history of exposure to grain dust, which has been linked to this problem in grain workers," or of work in animal con- finement units. However, not all resear- chers agree that exposure to airborne dust places farmers at increased risk for chronic bronchitis.13 Exposure to grain dust causes cough, chest tightness, and dyspnea in some in- dividuals.`"" The environment of swine confinement units causes cough, chest tightness and dyspnea acutely in many individuals who are without chronic symptoms.1'25 It is unclear if there is a relationship between repeated exposures to airborne dust followed by symptoms sug- gesting acute airway inflammation and the subsequent development of chronic bronchitis. It has long been known that individuals with asthma become more symptomatic after exposure to airborne dusts. Charles Thackrah, a British physician, described a relationship between asthma and in- halation of corn dust in a book published in 1832.% A variety of organic dusts have been associated with the onset of asthma symptoms.~-N Whether exposure to these dusts can actually cause asthma remains controversial. Papers and Proceedings Eye, throat, and nasal symptoms, termed mucous membrane irritation, are ex- perienced after exposure to airborne dusts, including grain dust, as well as to the en- vironment of dairy barns and swine con- finement units. Mucous membrane ir- ritation symptoms have been mentioned but not described in great detaiL" HYPERSENSITIVITY PNEUMONITIS Hypersensitivity pneumonitis is the best characterized of the disorders described after airborne dust exposure in the agricul- tural setting.% Acute HP is an immuno- logic reaction to antigens present in or- ganic dust. It has the following clinical features: fever, chills, muscle aches, a dry cough, and malaise experienced four to eight hours after exposure to a causative antigen. Laboratory and X-ray findings include hypoxemia, leukocytosis, infiltrates on chest X-ray, and restriction and a low diffusing capacity for carbon monoxide (DLCO) on pulmonary function testing. The symptoms usually improve over 12-24 hours. Repeated exposures to the offen- ding antigen may lead to further attacks. A small number of the individuals at risk for this disease actually develop HP. At this time, there is no predictor for suscep- tibility to this disorder. Occasionally, HP presents as a subacute process, lasting for weeks. The course of this illness can be shortened using systemic corticosteroids. Rarely, HP leads to pul- monary fibrosis and respiratory failure. At this time, it is not possible to identify those individuals with HP who are at risk for pulmonary fibrosis. There are no firm recommendations for surveillance Programs, using pulmonary function testing Airborne Dusts, May 1, 1991 or other means, for identifying those who are likely to have this outcome with con- tinued exposure to the offending antigens. The cause of HP is known to be repeated exposure to antigens from a variety of substances, including the microorganisms Faeni rectivindga (previously known as Micropolyspora faeni), Thermoactinomyces and Aspergihs spp. and others that are found in spoiled hay and grain as well as in silage. Avian proteins, including those from chickens, and wheat weevils have also been implicated as causes for HP. The dairy farm is an environment where HP is common. However, this problem is also seen in other agricultural settings, including farms where grain is stored in drying bins, in poultry houses, and in mushroom growing facilities. Estimates of prevalence of HP, or farmer's lung, on dairy farms range from l/1,000 to 2 to 4/ 10,000? 3a Epidemiologic studies remain to be done to determine the prevalence of this problem in other farm settings. Epidemiologic studies are complicated by a lack of definitive means of making a retrospective diagnosis. Many farmers do not seek medical care for episodes of HP, so that there is no supportive information available from medical records. Serum allergic precipitins identify in- dividuals who have been exposed to antigens that can cause HP, but do not point to the subjects who have the disease. Serum allergic precipitins may have become negative after a bout of HP ex- perienced in the remote past. Open lung biopsy reveals characteristic findings in the presence of the disease, but should not be performed routinely for this problem. Surgeon General's Conference on Agricultural Safety and Health - 1991 205 Research - Chemical and Biological Hazards Additional difficulties are posed by the similarity between the clinical pcture of acute HP and that of ODTS.m In ab- sence of a clear history of repeated episodes of illness and supportive labora- tory and X-ray information, it is often impossible to determine which disorder is or was present. Recently, a study was published that in- dicated that use of corticosteroids shortens the course of subacute HP." However, there is no agreement on the dose and duration of treatment required. There is some evidence that episodes of HP may be prevented by the use of dust masks or full-face respirators.`l In spite of being aware of the potential benefit of wearing protective devices, farmers often fail to do so. Reasons given include lack of comfort as well as excessive expense. There is a need for better designed devices to reduce ex- posure to airborne dust as well as formal testing of the efficacy of these products. In addition, it is possible, though still unproven, that improved ventilation in farm structures will decrease the risk for HP. ORGANIC DUST TOXIC SYNDROME ODTS is a febrile illness associated with myalgias, malaise, dry cough, chest tightness, and headache, which begin 4-12 hours after eyosure of large amounts of organic dust.* 1% `MJ Common causes of ODTS include uncapping of silos on dairy farms, cleaning of grain bins and moving moldy grain. Recently, it was also des- cribed as bein common in swine confine- ment workers. fi It is possible that it will be identified in other farm settings as well. The exact incidence of ODTS is unknown, because of difficulties similar to those for HP in making a retrospective diagnosis results of previous studies conducted in Scandinavia indicate that the incidence of ODTS ranges from 10 to 190/10,000." A more complete understanding of the epidemiology of ODTS, as well as other disorders caused by airborne dust, has been hampered by a lack of validated questionnaires tailored for use in the farm environment. A recently published ques- tionnaire designed specifically for evaluat- ing organic dust exposure likely will help solve this problem." ODTS may occur without prior sen- sitization, which is required for HP. Laboratory findings are notable for the presence of leukocytosis but an absence of hypoxemia, restriction, and a reduced DLCO on pulmonary function tests and infiltrates on chest X-ray. However, there is a need for more specific diagnostic tests indicating the presence of this disorder. Farmers with ODTS have been studied with bronchoscopy and bronchoalveolar lavage, revealing neutrophilic airway inflammation.44 52 A neutrophilic lower respiratory tract inflammation is also seen in acute HP.% However, the mediators of inflammation present in the lung, or systemically, have not been identified. Organic dust toxic syndrome typically resolves in 24 hours, but may last 2-5 days. Therefore, it can cause significant morbidity and time lost from work. Corticosteroids have been used as treatment in several patients with ODTS, but little is known about their efficacy in this disorder.n There have been no sequelae described for ODTS, unlike for HP. However, farmers 206 Papers and Proceedings with bronchial hyperactivity often attribute the onset of their asthma to an organic ODTS-like episode occurring after an abnormally severe dust exposure. Others date the onset of their chronic bronchitis or an increased susceptibility to having respiratory symptoms back to an episode which may have been ODTS. A small study published recently did not definitively establish a connection between airway disease and a history of ODTS." More work needs to be done to determine if a relationship exists between ODTS and chronic pulmonary disease. Farmers are often told to wear dust masks to prevent ODTS when heavy exposure to airborne organic dust is anticipated. However, there are no studies published that attempt to answer the question of whether or not ODTS can be prevented by wearing dust masks. Again, improved ven- tilation may reduce the amount of airborne dust present and, therefore, might decrease the risk for developing ODTS.9P6' The component(s) of airborne organic dust that causes ODTS remains controversial. There is strong evidence that endotoxin causes ODTS, as it is present in high levels in the environments where ODTS is com- mon.624 In the laboratory setting, en- dotoxin has been shown to cause fever and neutrophil influx into the lung.*@ How- ever, there has been a study suggesting that the risk for ODTS did not correlate well with endotoxin levels70 Since ODTS is often reported after exposure to moldy organic material, mycotoxins must also be considered as potential causes of ODTS." Tannins are polyphenols present in various plant materials. Work done with tannins found in cotton bract has demonstrated their ability to cause neutrophilic lower Airborne Dusts, May 1, 1991 respiratory tract inflammation, raising a question of their potential contribution of the inflammatory changes seen in ODTS.72 CHRONIC BRONCHITIS Chronic bronchitis, defined as bringing up phlegm on most days for at least three months per year for at least two con- secutive years, has been shown to be more common in farmers than in the general population.47 In several studies, a two- or three-fold difference is demonstrated. The healthy worker effect may help lower the number of farmers with chronic bronchitis after airborne dust exposure as well as other pulmonary disorders, leading to an underestimation of the problem. Extensive epidemiologic work done with subjects exposed to airborne grain dust has indicated that this likely is a factor in the causation of chronic bronchitis in farmers.& lzn However, their airborne dust exposures are more heterogeneous than those of grainworkers, creating difficulties when attempts are made to determine the precise cause of the airway inflammation. At this time, it is not possible to identify those individuals who are at risk for the development of chronic bronchitis caused by inhalation of airborne dust. The role of airway hyperactivity as a predictor of chronic bronchitis remains controversial. Other tests, such as measuring the group- specific component, may prove useful in the future." Many farmers have exposures to airborne dust in animal confinement units as well as from working with grain. Recent studies conducted in Iowa swine confinement workers indicate that up to 25 percent of these individuals suffer from chronic bronchitis.= Surgeon General's Conference on Agricultural Safety and Health - 1991 207 Research - Chemical and Biological Hazards Gases present in confinement units, including ammonia and hydrogen sulfide, may contribute to the symptoms observ- ed. ls, 19, y The airborne dust in swine con- finement units is heterogenous, consisting of feed particles, animal dander, bacteria, and endotoxin.76 Identifying a component of hog dust which is particularly noxious is difficult. Poultry farmers also appear to have respiratory risks, similar in symptoms to those of the swine confinement workers." Dust, endotoxin, and ammonia have also been implicated as a cause. Pulmonary function tests performed on farmers with chronic bronchitis do not reveal the presence of severe obstruction in most individuals unless they are cigarette smokers. However, farmers in swine confinement units do have small decreases in FEVl and FVC values over a workshift. Confinement units are a relatively new innovation in farming, so no individuals have had a lifetime of exposure to air- borne dust and fumes in this setting. It remains to be seen if significant airway obstruction develops in farmers who have been exposed to this environment for their entire working life. Cigarette smoking is the most common cause of chronic bronchitis. It is likely, but not definitively proven, that exposure to grain dust or the swine confinement en- vironment in addition to cigarette smoke works addictively to cause airway obstruc- tion. 20124,78 The mechanisms of this interac- tion are unknown. Several forms of pharmacologic treatment have been approved for use in chronic bronchitis, including inhaled corticosteroids 208 and ipratropium bromide. It has not been demonstrated whether or not these drugs are useful for the treatment of chronic bronchitis caused by organic dust. The components of airborne dust that cause chronic bronchitis are largely unknown. It may be speculated that en- dotoxin, mycotoxins and tannin play a role. Plant lectins have been isolated from grain dust." Lectins cause lymphocyte pro- liferation, which could contribute to ele- vated airway immunoglobulin levels seen in individuals acutely exposed to grain dust.= Most of the work done in the laboratory looking at the effects of inflammatory dust has been done with grain dust extracts.= Repeated inhalation challenge of rabbits with grain dust extracts causes lower res- piratory tract infiltration with macro- phages. Macrophages are known to release a variety of mediators of inflammation, which could play a role in the development of chronic bronchitis." Neutrophils, present in increased numbers in the airway of many individuals with chronic bronchitis, could function in a similar way.8" ACUTE BRONCHITIS The acute pulmonary effects seen after airborne dust exposure include dyspnea, chest tightness, and a cough, which may or may not be productive of sputum. In the non-atopic subject, these symptoms are consistent with acute bronchitis. This has been described in grain farmers as well as in swine confinement workers. A preliminary study done in grain farmers during harvest using bronchoscopy with PaDers and Proceedinas BAL revealed evidence of airway inflam- mation without changes in spirometry." One study has described signs of lower respiratory tract infhunmation in swine confinement workers by also using bron- choscopy with bronchoalveolar lavage.a6 Airborne Dusts, May 1, 1991 include animal dander, pollen, storage mites, and grain. There is no consensus, however, regarding the ability of these substances to cause asthma in the farm setting in a subject who has no have previous exposure to them. Farmers symptomatic after other types of occupational airborne dust exposure have not been studied in this way. It might be useful to better characterize any changes in the lower respiratory tract in order to find therapy specific for these problems. Therapies that could be used prophylac- tically would be optimal. The components of airborne dust that cause acute pulmonary effects have not been identified. Endotoxin is again suspected to play an important role. However, it has been shown that giving an inhalation challenge of grain dust extract to guinea pigs causes greater acute neutro- philic lower respiratory tract inflammation than a challenge with endotoxin alone, given in an amount equivalent to that pre- sent in the grain dust extract (unpublished data). When added to cultures of bronchial epithelial cells, grain dust extracts also cause cell death and the release of neutro- phi1 chemotactic factors.87 Whether or not these observations help explain the pre- sence of acute pulmonary symptoms after airborne dust exposure in the farm setting remains unknown. ASTHMA Exacerbation of asthma by airborne dust is a well-described phenomenon, both as a response to specific allergens and as a nonspecific reaction.34Va89 A host of sub- stances present in the farm setting contain antigens that trigger asthma. These A host of substances present in the farm setting contain antigens that trigger asthma. Ethical considerations complicate studies designed to answer the question raised above. Specific antigen challenges, using extracts made from airborne dusts, can be given in the laboratory in order to help determine the cause of asthma in farmers suspected of having occupational causes for their bronchospasm. There is some evidence that farmers have increased bronchial reactivity presumably related to airborne dust exposures.259o More work remains to be done relating bronchial reactivity to acute and chronic respiratory symptoms in farmers. MUCOUS MEMBRANE INFLAMMATION Symptoms of eye and nasal irritation as well as dry throat are common after ex- posure to airborne dust. This is a common reaction to airborne dust in subjects with allergic rhinitis. However, symptoms of mucous membrane irritation are also seen in individuals without a history of atopy. With some grain dusts, the offending agent appears to be a part of the plant, which causes mechanical irritation. However, endotoxin and mycotoxins must also be Surgeon General's Conference on Agricultural Safety and Health - 1991 209 Research - Chemical and Biological Hazards considered as possible causes for this problem. The presence of inflammation is a com- mon theme in these disorders. I It has not been demonstrated that wearing respirators commonly in use in the farm settings reduces incidences of these complaints. Also, no pharmacologic therapy has been found for these symptoms. Attempts should be made to find agents that prevent as well as treat the symptoms. Little work has been done in the laboratory to further define the problems described. It has been shown that aerosol challenge of human volunteers with grain sorghum dust extract causes an influx of neutrophils into the nose, as demonstrated with nasal lavage.91 SUMMARY A variety of disorders are associated with exposure to airborne dust in the farm setting. These include hypersensitivity pneumonitis, organic dust toxic syndrome, chronic bronchitis, acute pulmonary symptoms, asthma, and mucous membrane irritation. Better ways of preventing these problems must be found, through the use of protective devices and agricultural en- gineering innovations, as well as perhaps by pharmacologic means. The presence of inflammation is a com- mon theme in these disorders. Resear- chers are faced with a variety of challenges in better defining the inflammatory chan- ges. In particular, the causative com- ponents in the airborne dust and the mediators of inflammation must be better described so that specific therapies can be identified.0 REFERENCES 1. Ramazzini B. De MO&US Artifcum. pp. l-360, Modena, 1700. 2. Campbell JM. Acute symptoms following work with hay. Brit Med J 1932; 2:1143. 3. Emanuel DA, Wenzel FJ, Lawton BR. Pulmonary mycotoxicosis. Chest 1975; 67:293-297. 4. May JJ, Stallones L, Darrow D, Pratt DS. Organic dust toxicity (pulmonary mycotoxicosis) associated with silo unloading. Thorax 1986; 41:919-923. 5. DoPico GA, Flaherty D, Bhansali P, Chavaje N. Grain fever syndrome induced by inhalation of airborne grain dust. JAller Clin Immunol 1982; 69~435443. 6. Warren CPW, Manfreda J. Respiratory symptoms in Manitoba farmers: association with grain and hay handhng. 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Surgeon General's Conference on Agricultural Safety and Health - 1991 215 Surgeon General's Corjfemnce on Agricultural SatXy and Health FARMSAFE 2000 o A National Coalition lb Local Action Convened by the National Institute fix Occupational SatMy and Health April 30 - May 3, 1991, Des Moines, lowa INFECTIOUS DISEASES By Russell JK Cunie~ D.ViM. Bureau Chief of Environmental Epidemiology and Chronic Diseases Iowa Department of Public Health INTRODUCTION The infectious diseases associated with farming and agricultural practices are broad in terms of diversity and-owing to general health improvements and signifi- cance of reductions of livestock zoonotic diseases-minimal in terms of morbidity. Nevertheless, there are continuing infec- tious disease problems, mostly sporadic in nature and occasionally episodic, that af- fect agricultural workers and occasionally, via the food chain, their urban counter- parts. Many excellent disease-specific reviews are available to interested parties for further study.13 This review, while not comprehen- sive in nature, is offered to define the scope of current problems as reported and investigated by public health workers and health care givers. Much of this informa- tion was obtained through a recent survey of state epidemiologists and related staff. The review will be divided into four major groups of infectious conditions by nature of source or form of transmission: interper- sonal illness, food-borne illness, environ- mental and vector-borne disease, and zoonoses (not covered in the aforemen- tioned groups). Comment on improved management of these conditions and ex- posures will be provided, as well as recom- mendations for improved prevention and control, including research needs to ad- dress these problems more effectively. 216 INTERPERSONAL ILLNESS This category focuses almost exclusively on migrant farm workers (MFWs) and will be confined primarily to human-host illness. Tuberculosis and sexually transmitted diseases (STDs) are both problems in migrant worker populations. California reports a recent outbreak of chancroid in a migrant camp in Orange County? STD problems were the fourth most prevalent problem at two migrant health clinics in Maryland? Tuberculosis (TB) remains a serious public as well as personal health problem in MFWs. Ciesielski and colleagues" reported on a large random-sample population- based 1988 study of farm workers (n= 543) in three North Carolina counties and demonstrated that skin-test positivity ranged from 33 percent in Hispanics to 54 percent in US-born blacks and 76 percent in Haitians. Active tuberculosis disease occurred in 3.6 percent of US-born blacks (300 times the average U.S. rate) and 0.47 percent of Hispanics. This investigation indicates that TB among MFWs is an occupational problem, not an imported one. Among black American migrant farm workers, risk factors as- sociated with farm work and years of such work were far more important than age, gender, and history of familial TB. These investigators offer strategies to control tuberculosis among MFWs, including: Papers and Proceedihgs 2 . In states with large migrant populations, establish a separate registry, e.g. Florida's special registry. 3. Increase funding for migrant health-care centers. 4. To avoid false negatives, consider use of recall antigens when administering skin tests among high-risk groups. 5. Regulate labor contracts more closely. 6. Occupational Safety and Health Administration (OSHA) should promul- gate regulations addressing TB control. During August 1990, the Wisconsin Department of Health investigated an outbreak of gastrointestinal illness affect- ing an undisclosed number among approxi- mately 1,000 MFWs and their families residing in 40 camps in 3 counties.9 Some infections were due to Giardia and appear- ed to spread through migrant day care centers (DCC). Initial infection is postulated to originate from exposure to contaminated water from a sewer back-up into the shower of the residence of the index case. Known symptomatic cases totaled 21. Other cases of illness in this population were due to Shigella Jexneri 1 and 2 and, owing to limitations of obtaining accurate history and limited microbiological studies of food and water, the exact chain of infection could not be established. 1. Adhere to recommendations of the Strategic Plan for Elimination of Tuber- culosis in the U.S. and TB Among Foreign-born Persons Entering the United States.`. * Infectious Diseases, May 1, 1991 Enterically transmitted viral and bacterial diseases among MFWs do occur at about 10 times the rate of the general population. This can be attributed to a variety of factors, but primarily to poor water and toilet hygiene. Outbreaks subsequently can affect consum- ers of the produce. In August 1990, an outbreak of Salmonella javiana in Minnesota was associated with the con- sumption of contaminated raw tomatoes from a South Carolina distributor. Mary Proctor, an epidemiologist with the Wisconsin Division of Health, has reviewed the literature and cites reports implicating hepatitis A with frozen raspberries and fresh lettuce." Shigella infections have also been implicated in commercially distributed lettuce which were thought to be contaminated at the harvest site. In 1979, Iowa and several other states with Amish settlements sustained polio transmission in these agri-populations; no transmission to surrounding communities was reported.12 More recently, rubella has been reported in Amish settlements in Tennessee.13 In addition to the diseases mentioned, a variety of personal health problems in MFWs and their families are also reported; these problems are influenced by substandard living and working conditions, and include parasitic infections, urinary tract infections, gynecological problems, respiratory infections, and pediatric infec- tions.14* l5 Migrant and farm workers also have a higher percentage of children not immunized against vaccine-preventable diseases." Surgeon General's Conference on Agricultural Safety and Health - 1991 277 Research - Chemical ahd Biological Hazards FOOD-BORNE ILLNESS Improvements in food processing and packaging, coupled with livestock disease control programs, have reduced many zoonotic diseases formerly affecting con- sumers." Examples include tuberculosis, brucellosis, and trichinosis. Since a great deal of this reduction has been effected through improved processing and pas- teurization, many pathogens continue to infect farm workers who consume produce without adequate safeguards or preparation. Unpasteurized milk is a vehicle that still infects large numbers of farmers and their guests. Potter and Currier have sum- marized the hazards of raw milk, but episodes continue to occur.`& l9 A report by Blazer describes an outbreak of Campylobacter infection in a fraternity group which visited a member's farm farnily.m In this outbreak, 22 of 25 students (88 percent) who consumed raw milk for the first time became infected; two who had not consumed raw milk were not infected. Residents of the farm were not affected by virtue of long-term raw milk consumption, and had elevated levels of CampyZobacter. Jejuni-specific serum antibodies provided apparent immunity to symptomatic infec- tion. Numerous episodes and case reports exist in the literature of CampyZobacter outbreaks in children and visitors touring farms and dairies where unpasteurized milk consumption resulted in infection. SaZmoneZZa infections have also been assoc- iated with numerous episodes where raw or inadequately pasteurized milk was con- sumed. It is reasonable to assume that families and workers on dairy farms ex- perience related illness, although less fre- quently from raw milk. In 1987, Vogt reported a case of listeriosis in a 76-year-old female who lived on a dairy farm. Blood culture isolated L. monocytogenes." Isolates subsequently obtained from two cows and the bulk tank were identical to the patient's, as charac- terized by isoenzyme typing and ribosomal RNA typing. The patient regularly consumed raw milk from her farm on her cereal each morning but consumed no other food products from her farm. In addition, North Dakota health officials are currently investigating a case of E. coli 0157:H7 transmitted through raw milk to a farm patient.= In the past 5 years, eggs have been implicated in numerous cases and episodes of gastroenteritis due to SaZmoneZZa enteritidi.s.23 The role eggs play and the extent to which they cause salmonellosis in farm workers are unclear. Brief reports and unpublished inves- tigations have implicated ungraded farm eggs in "home-made ice cream" in transmitting salmonellosis.% These in- cidents may attest to the lack of understan- ding farm workers and families have con- cerning basic food hygiene, and may contribute directly or indirectly to the larger problem. Trichinosis continues to decline in the United States, but in any given year the rate of cases may double or triple as influenced by one or two community episodes. A large outbreak affecting 15 of 25 individuals from four related farm families in Nebraska was investigated in 1973.= Source of infection was uncooked pork-beef sausage from two pigs and one 278 Papers and Proceedings beef animal; these animals were raised in open lots or pastures on the farms and were slaughtered on the premises. Again, there was an apparent lack of con- cern for trichinosis owing to tradition. During 1990, 90 cases of trichinosis in cen- tral Iowa were traced to raw pork con- sumption from a locally procured carcass attesting to the disease's continued pre- sence in swine.% In many states, expanded garbage feeding practices, although well regulated, may serve to enhance transmission to pigs. Overall, food-transmitted illness to farmers is isolated, sporadic and perhaps not al- ways recognized. It points to the need for educating these producers about risks, food sanitation, and desirability of consuming adequately processed, pasteurized, or cook- ed food. It is conceivable that elderly persons on farms, very young children, and farmers with coexistent health problems would be at increased risk of infection or its complications. ENVIRONMENTAL AND VECTOR-BORNE ILLNESS Farmers and farm workers pursue their activities in a diverse environment of land- scapes, buildings and livestock collections. Vector-borne disease does present occa- sional risks to farm workers in outdoor settings. Sylvatic plague, Rocky Mountain Spotted fever, Colorado tick fever, and tularemia (tick and deer fly transmitted) are infre- quently transmitted to farm and ranch workers during ordinary work activities. Oregon and Utah report recent isolated cases of arthropod-borne tularemia in farm and ranch workers.nv28 Infectious Diseases, May 1, 1991 More recently, Lyme disease is being recognized in some farm workers in upper Midwest states. Concern exists not only for exposure to deer ticks in field settings, but also exposure to infected cattle. In a Wisconsin study (to be published later), of 246 dairy workers tested using CDC ELISA, 21 (8.5 percent) had sig- nificant B. burgdo$eri antibody levels, while 6 (4.9 percent) of the 123 crop farmers were seropositive (p C 0.2).9 Concern exists for the role of spirochetes in cattle urine splash as a means of Lyme transmission. Additional studies are planned. In another Wisconsin seroprevalence sur- vey conducted in 1987 at the Marshfield Clinic on asymptomatic residents of north central Wisconsin, the seropositivity rate for farmers was 32 percent versus 16 per- cent in non-farmers.29 Obviously, farm workers are at increased risk from Lyme disease where vectors and conditions favor its presence, and it should to be included in differential diagnoses. Malaria is of greater concern, especially since this disease had been eliminated from the United States in the 1940's. California reports increased activity relating to MFWs. A summary of the California experience from its state mor- bidity report is provided verbatim: Since 1950, California has experienced 16 episodes of introduced autochthonous malaria (malaria acquired by mosquito transmission in an area where malaria does not occur regularly) accounting for 120 cases, all due to P. vivm Ten coun- ties have been the sites of exposure with 7 in the Sacramento Valley and adjacent Sierra Foothills (Butte, El Dorado, Glenn, Nevada, Sacramento, Sutter, and Yolo), 2 in the San Joaquin Valley (Fresno and Surgeon General's Conference on Agricultural Safety and Health - 1991 219 Research - Chemical and Biological Hazards Kings) and San Diego County along the state's southernmost coast. Only 2 coun- ties have experienced more than 1 episode, Sutter (4 episodes), and San Diego (4 episodes). The confirmed or presumptive sources of introduction were an army veteran just returned from Korea and agricultural workers from India (4 episodes) or Mexico (8 episodes). In 3 introductions, the source cases were uncertain but most likely from India or Mexico. Transmission of malaria occurred from May to September, with 3 anopheline species being the likely vectors (An. freeborni and An. punctipennis in the central valley and An. herd in San Diego County). The largest of these outbreaks was in 1952 when 35 cases occurred in a group of Campfire Girls exposed in Nevada County. The second and third largest episodes were in 1986 and 1988 involving 27 and 30 cases, respectively, in San Diego County. The remaining 13 introductions resulted in 1 to 5 cases each. Since 1986 there have been several impor- tant changes in the epidemiology of intro- duced malaria in California. The inci- dence of introductions has risen sharply; 9 (56 percent) of the 16 introduced episodes since 1950 have occurred in the last 4 years. Before 1986 all episodes (7) had oc- curred in Sacramento County northward and in 5 (71 percent), the source(s) of introduction were associated with immi- grants recently arrived from northern India. Since 1986, activity has shifted with 6 of the 9 (67 percent) introductions occurring south of Sacramento County and 8 of 9 (89 percent) being associated with MFWs from Mexico. Until 1986 all outbreaks of mosquito-transmitted malaria had involved only permanent California residents. Since 1986, the great majority of cases (59/71) have occurred in migrant workers though local residents have also been involved in all outbreaks. Paralleling these trends in the epidemi- ology of introduced malaria in California has been a sharp rise in the incidence of malaria in Mexico and the number of imported malaria cases in persons entering the State from that country. Malaria cases reported in Mexico have risen steadily from 25,774 in 1980 to 166,271 in 1988 ( > 6 fold increase) while the number of California malaria cases reported in travelers and immigrants from Mexico has risen steadily from 12 in 1980 to 83 and 81, respectively, in 1988 and 1989 (> 6 fold increase). The episodes of local mosquito transmitted vivax malaria since 1986 (particularly in San Diego County) have features in com- mon which include: 1. Remotely located encampments. 2. Inadequate shelters for MWs residing in areas with Anopheles mosquito vectors capable of transmitting malaria. 3. The reluctance of MWs to seek medical care because of limited access and con- cerns about being identified as undoc- umented aliens. Once a parasitemic individual introduces malaria in such settings, these factors allow substantial transmission of malaria to evolve before outbreak foci can be iden- tified and control measures instituted. Mosquito transmitted viral encephalitis also presents risks to farm workers and 220 Papers and Proceedings rural residents. St. Louis encephalitis (SLE) and western equine encephalitis (WEE) are transmitted by vector mos- quitoes that breed in field irrigation run- off pools. During 1989, California report- ed 29 confirmed cases of SLE but no cases of WEE." While specific occupation was not recorded, cases tended to be older, live closer to fields, and were more likely to be outdoors in the evenings (when mosquitoes are active) prior to illness when compared to cases of viral CNS disease who were seronegative for SLE. Other environmental exposures focus on fungal diseases. Histoplasmosis is fre- quently diagnosed in farm personnel clean- ing up litter and debris from poultry houses, sheds, and barns. A recent outbreak occurred in Iowa during a family reunion, when attendees retreated to a seldom-used barn to seek refuge from a thunderstorm. Old debris and the presence of droppings from birds gaining access through broken windows provided a milieu for the fungus to flourish, and when disrupted by guests, resulted in 10 cases of histoplasmosis among 25 guests exposed to the barn.32 Coccidioidomycosis, or valley fever, is endemic in arid rural areas of western states, particularly California. The ratio of infections that cause clinical disease is very small; children and adolescents display milder illness than adults, and African- Americans, Latinos, and Filipinos tend to have more serious disease when it occurs. New residents in endemic areas are more apt to become ill than permanent resi- dents. Roberto reports that immigrants, especially Philippine natives from cocci- free areas of the world who are employed in farming in the Central Valley of Infectious Diseases, May 1, 1991 California, may develop severe illness and chronic complications. Injury incidental to farming activities often results in cellulitis and at least suggests the need for tetanus-toxoid immunization among adult farm workers-a group that may not be current on vaccine history. Kansas reports three recent adult cases of tetanus in rural/farm individuals." In Iowa, the special class of farm injury relating to inadvertent syringe needle sticks incidental to livestock health programs was studied in 1990.`-' A total of 28 exposures were recorded; 10 involved sticks to legs or feet and 18 sustained injury to hand, wrist, or arm. One involved anaphylactic reac- tion to blood drawn from a vein. Hospital- ization was required for another case of cellulitis of the leg from a syringe stick. While most of these exposures resulted in cellulitis, it is also worth noting that animal vaccines often contain very irritating ad- juvants that enhance tissue injury. There is a definite need for a compendium of patient-management guidelines for in- dividuals with syringe stick exposures to veterinary injectables. In summary of this segment, environmental contaminants do play a role in infectious disease of farm workers. Frequently infec- tions secondary to injury from a variety of sources are the mechanism of transmission. Arthropods also serve to expose farm- ranch workers to disease agents, but are geographically localized and generally sporadic-to-rare in incidence. Systemic fungal diseases also occur, are often episodic, and primarily affect new residents or nonresident workers in agriculture set- tings. Surgeon General's Conference on Agricultural Safety and Health - 1991 221 Research - Chemical and Biological Hazards NON-VECTOR-BORNE ZOONOSES This is a broad, diverse group of disease- causing organisms. Tuberculosis due to M bovk is functionally eliminated from dom- estic livestock, and does not present a threat to farm workers or related person- nel. Nevertheless it should be noted that cer- tain wild or exotic species (e.g., bison, feral swine, and non-human primates) may still be infected and potentially serve as reser- voirs for reinfecting cattle.% This reality speaks to the need for ongoing surveillance programs to monitor potential introduc- tions. Also of concern is the increased commerce in wild exotic animals that may be in- fected. During the past 3 years an eastern Iowa family unsuccessfully managed and finally depopulated their llama herd due to M. bovii infection. Brucellosis has been greatly reduced these past 40 years through livestock control ;ylgrams.% Total U.S. cases for 1989 were . Earlier employment of the milk ring test that monitors producing dairy herds has eliminated "undulant fever" in mostly farm- family consumers of raw milk; pas- teurization assured safe milk for consumers even before herd eradication schemes were successful. During the 1970's and early 1980's, swine brucellosis was eradicated and cattle brucellosis eliminated in all but a few southern states. Wild animal foci of brucellosis also exist, e.g., among bison, elk (Yellowstone National Park), and feral swine." It ap- pears that most recent brucellosis cases remain confined to packing-house workers and international travelers exposed to contaminated foods. Farm workers are rarely still infected from handling aborted feti and placental membranes from infect- ed cows. Standard febrile agglutinin tests are available to diagnosticians who are evaluating farm workers with fevers of unknown origin Serology and often blood culture are of critical importance to early diagnosis and, thus, effective treatment of this disease. Exacerbation of earlier infections still occurs, often decades later, especially in older farmers infected with B. JGS. Other infections may result from B. aborhrs, Strain 19 vaccine from inadvertent syringe sticks, and splash in the eye. These events still occur and call for prophylactic treatment with tetracycline or one of its analogues and streptomycin.36 The exact number of human brucellosis cases by occupational category is not con- veniently available. Leptospirosis cases for 1989 totaled 93, reflecting sporadic incidence except for Hawaii, which contributed 69 cases to the total." Over the past five years (1986- 1990), there have been 192 cases of lep- tospirosis reported in Hawaii, including five fatalities. For this period, 18.75 percent of the cases were in agricultural occupations, while 20.8 percent of the cases had agricultural ex- posure and 9.9 percent had agriculture- related exposures (gardening, yard work).% Again, as in brucellosis, serology is critical to establishing the diagnosis and optimal treatment. 222 Papers and Proceedings Tularemia., as noted earlier, when transmitted by arthropods can result in transmission to farmers. Rare and isolated cases of pneumonic tularemia from grain dust aerosols presumably contaminated with rodent excreta have been recently recorded from Iowa and Oregon.% Here, too, tippropriate cultures and especially serology are critical to diagnosis and ef- fective treatment. Chlamydial bacterial infections (psittacosis) are occasionally recognized in farm workers incidental to exposure to pigeons and domestic fowl, especially turkeys. Interestingly, turkey psittacosis may result in explosive outbreaks in poultry-plant workers after stress of transport and slaughtering processes creates infectious aerosols. Rarely is illness recognized in personnel at the turkey grower-sites of infected flocks. Q fever, anthrax, erysipelas, and other bacterial zoonoses are very infrequently diagnosed in farm workers nationally. Sporadic cases of Q fever have been reported from Arizona in personnel handling aborted feti and bagging sheep manure for commercial sale as fertilizer." Parasitic zoonoses are an eclectic group of minor problems. Giardia infections have resulted from servicing irrigation systems in Utah.28 Echinococcosis, introduced to western sheep-raising states by immigrant shepherds, has been eliminated. Beef cattle infected with cycticerci from Taenia sagirzata continue to be recognized by federal meat inspection service. The occasional recognition of "measly beef" at slaughter speaks to the need of adequate toilet facilities for MFWs in feedlots and cattle production operations. Infectious Diseases, May 1, 1991 There are no known cases of recent transmission of these tape helminths to farm personnel (or consumers). Anecdotal cases of cryptosporidiosis have occurred in farm personnel and are of minor sigriifi- cance to immunocompetent individuals.42 Viral zoonoses, especially rabies, continue to result in exposures to farm workers. Cattle pose special risks, are highly suscep- tible to rabies, and are rarely immunized for the disease. When cattle are unwit- tingly cared for during clinical rabies, ex- tensive exposure to saliva may occur and prompt need for immunoprophylaxis. This is especially true for registered breeding- cattle that often are valued at multiples of market price. During January 1991 in Iowa, a registered beef bull with rabies and a dairy cow with the disease used in an ovum transplant program resulted in 26 farm workers' and veterinarians' being administered vaccine boosters or full immunoprophylaxis."3 During the period 19851989, laboratory diagnoses of cattle rabies in the U.S. ranged from 150-200 cases.@ in earlier Illinois study estimates a ratio of one farm worker's being prophylaxed for each case of cattle rabies." The last recognized case of rabies in a farm worker from cattle exposure occurred in California in 1939.& The real significance of cattle rabies is the uncertainty and anxiety of exposure that prompt farm workers to receive costly-and probably unnecessary-immunoprophylaxis. In Iowa, cats-especially rural and farm cats-are serious vectors of human exposure since these animals frequently exhibit furious behavior and are prone to bite. Farm family members are the single Surgeon General's Conference on Agricultural Safety and Health - 1991 223 Research - Chemical and Biological Hazards largest occupational group exposed to this species.47 Other viral zoonoses exist that occasionally infect farmers, including orf and swine influenza. Specific surveillance informa- tion is unavailable and precludes meaning- ful comment. Other retroviruses and len- tiviruses infect a broad range of animals maintained on farms, e.g. bovine leu- kenlia, feline leukemia, etc. Their role in any human illness is conjectural at this time and remains to be demonstrated if it exists. COMMENT Infectious diseases unique or incidental to 2. Migrant worker health clinics are now agricultural activity can be conveniently networked, which facilitates follow-up of divided into migrant-worker-related illness diagnostic and treatment services, par- and a variety of zoonoses. In the former ticularly tuberculosis. States with large category, many of these MFW illnes- migrant populations should maintain a ses-often episodic-are human host infec- separate TB registry such as Florida's. All tions that may relate to country of origin states should adhere, as much as practical, (e.g., malaria and echinococcosis) or to to CDC published guidelines for TB con- substandard living or working conditions trol in general and foreign-born cases in (e.g., tuberculosis and Shigella dysentery). particular. All these illnesses pose risks to the non- agricultural community through personal contact and potential contamination of foods or environments. For these reasons, as well as for humanitarian considerations, migrant farm workers need resources of improved medical care, education, and adequate living and working accom- modations to reduce their burden of mor- bidity and suffering. The second category mentioned above is infectious disease incidental to farm en- vironmental exposures, primarily zoonoses. Since their occurrence is often sporadic and generally infrequent, problems of recognition and optimal management are obvious. Clearly they are underdiagnosed and underreported. Primary care givers should improve diagnostic acumen through more active consultation with infectious disease specialists and increased use of micro- biologic studies, especially serology. RECOMMENDATIONS 1. Migrant worker health concerns are paramount, as noted in this review. Clear- ly OSHA should exercise more authority in this sector of agricultural activity to assure adequate living and working standards for migrant and non-migrant or permanent employees. 3. USDA should improve regulation of food production and harvesting to assure field sanitation measures are adequate to assure wholesome product. Indirectly, this would increase incentives for producers to provide improved working conditions for both domestic employees and MFWs. 4. Where not already accomplished, state and local health agencies should establish regulatory standards and inspection ser- vices addressing minimal living and health- care accommodations for MFWs, including day care centers. 5. State-federal minority health programs should also include components targeted to MFWs. 224 Papers and Proceedings 6. Conference of State and Territorial Epidemiologists and CDC should require "occupation" on all investigative surveil- lance reports. Summaries should include categories of farm workers, farm service personnel and MFWs. 7. Enhanced recognition of agriculturally related infections through increased utilization of serology is needed. This educational role can be best instituted by state health agencies and laboratories. 8. Since many agricultural disease problems are localized or exist in specific regions (e.g., leptospirosis in Hawaii), federal research grants to study these problems should be targeted to state-level health agencies. This is currently being done by CDC for Lyme disease. Examples of possible research projects include42 a. What is the potential for transmission of enteric pathogens such as Salmonella, Yersinia, and Campylobacter between animals and animal caretakers? b. What is the role of urine shedding, if any, in Lyme disease transmission bet- ween cattle and humans? c. What is the character of viral shed- ding of rabies in cattle and horses (to facilitate meaningful quarantine or obser- vation periods)? d. What is the role of stray and rural farm cats in terms of health risks, e.g., rabies, toxoplasmosis, and visceral larva migrans? 9. Federal agencies which license injec- table veterinary biologics (USDA) and drugs (FDA) should require manufacturers to distribute specific management guidance Infectious Diseases, May 1, 1991 to all poison control centers concerning accidental exposures. 10. In at least one state, there has been an increasing trend of using treated sewage effluent for irrigation of crops.* Outbreaks of gastrointestinal illness have occurred in Israel from this practice. Specific surveil- lance studies of enteric illness in personnel exposed through employment or food con- sumption of produce from this practice would be indicated. 11. Indirectly, infectious disease in farm workers and family members may be ad- versely influenced by several psychological and economic factors. Many individuals who live on farms are less able to afford health care due to lack of health in- surance. Most are self-employed without sick leave and workers' compensation, as noted. Also, the availability of health care may be limited or difficult to access. Sociological and epidemiology studies are needed to put these issues and concerns in perspective to reduce morbidity and its attendant cost.4S 12. State-federal regulation of commerce in exotic and wild animals should be increased to assess presence of infectious diseases or vectors among livestock that may adversely affect domestic livestock and their handlers, ultimately including the consumer. Economic studies are needed to determine feasibility of indemnity payments for depopulation programs. 13. Enhanced research on farming prac- tices that increase the risk of food- microbial contamination and/or may en- hance risk of human exposure to infectious diseases should be implemented. Positive developments should be published for the agricultural community. Surgeon General's Conference on Agricultural Safety and Health - 1991 225 Research - Chemical and Biological Hazards SUMMARY Infectious disease remains a serious problem in U.S. agriculture in two distinct populations: o Migrant farm workers experiencing human-host illnesses, often episodic and exacerbated by substandard living and employment conditions. o All other farm workers experiencing sporadic, isolated illness that is most fre- quently zoonotic, vector-borne, or environ- mentally acquired in nature. REFERENCES Both populations may present risk of ex- posure to the non-farm population through personal contact, indirect exposure (enviro- nment or vector), or contamination of food produce. Obvious innovations and tech- nologies exist to improve disease recog- nition, management, and control for both groups specifically, and non-farm in- dividuals generally. The broad and varied scope of this problem is presented, including areas that should be targeted for additional research or enhanced program support.0 1. American Public Health Association, Control of Communicable Diseases in Man. Benensen AS ed, 15th Ed; 1990. 2. Amer Vet Med Association, Zoonoses Updates (published compilation), JAKU4. Amer Vet Med Ass'n, Shaumburg IL; 199Q. 3. Currier RW. Iowa Department of Public Health, Des Moines IA; March 1991. 4. Roberto RR. Personal communication. California Department of Health Services, Berkeley CA; April 1991. 5. Armstrong CW. Personal communication. Virginia Department of Health, Richmond VA; April 1991. 6. Ciesielski SD, Seed JR, Esposito DH, and Hunter N. The epidemiology of tuberculosis among North Carolina migrant farm workers. JAMA 265: 17151719; April 3, 1991. 7. Centers for Disease Control. A strategic plan for the elimination of tuberculosis in the United States. MMWR. 1989; 38: S-3. 8. Centers for Disease Control. Tuberculosis among foreign-born persons entering the United States: recommendations of the Advisory Committee for Elimination of Tuberculosis. M.. 1990; 39(No. RR18). 9. Davis JP. Personal communication. Wisconsin Division of Health, Madison WI. March 1991. 10. Proctor M. Unpublished investigation. Wisconsin Division of Health, Madison WI. 1990. 11. Proctor M. Internal agency report. Wisconsin Division of Health, Madison WI. 1990. 12. Centers for Disease Control: Poliomyelitis Surveillance Summary 1979, Issued April 1981. 13. Hutchins R. Personal communication. Tennessee Department of Health, Nashville TN. April 1991. 226 Papers and Proceedings Infectious Diseases, May 1, 1991 14. Stevens GA. Testimony prepared for the Occupational Safety and Health Administration on Proposed Field Sanitation Standards. Dehnarva Rural Ministries. July 1984. 15. Federal Register, 29 CFR Field Sanitation; Final Rule Vol52, No 84, p 16049-16096. May 1, 1987. 16. McChesney TC. Personal communication. 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JAMA. 259: 2103-2107. 1988. 24. Gunn R4 and Markakis G. Sahnonellosis associated with homemade ice cream. JAMA 240:1885-1886. 1978. 25. Currier RW, Rapp WF, Juranek DD. A community outbreak of trichinosis in Nebraska: report of an epidemiologic investigation. Nebraska Medical Journal. Jan-Feb, 1982. 26. Centers for Disease Control. Trichinella spirilis infection - United States, 1990. MMKR. 1991; 40 : 57-60. 27. Williams LP. Personal communication. Oregon Department of Health, Portland OR. April 1991. 28. Staff Epidemiologist. Personal communication. Utah Department of Health, Salt Lake City UT. April 1991. 29. Marx J. Unpublished data. Marshfield Clinic, Marshfield WI. April 1991. 30. California Morbidity. Mosquito-transmitted malaria in California: 1988-1989. Part 2 of 2. Nr 52, Jan 5, 1990. (Pub1 by Calii Department of Health Services.) 31. California Morbidity. Arboviral disease surveillance - California, 1989. Nr 21/22. June 1, 1990. 32. Fuortes L. Unpublished data. College of Medicine, Univ of Iowa, Iowa City IA. April 1991. 33. Wood C. Unpublished data. Kansas Department of Health and Environment, Topeka KS. April 1991. 34. Currier RW. Farm injury surveillance (SPRAINS Program) - unpublished data. Iowa Department of Public Health, Des Moines lA. Feb 1991. Surgeon General's Conference on Agricultural Safety and Health - 1991 227 Research - Chemical and Biological Hazards 35. Thoen CO. Zoonoses Update: Tuberculosis. JAKV.4 (Pub1 collection of Zoonoses Updates.) 132-135. 1990. 36. Currier RW. Zoonoses Update: Bruceiiosis. JAK'v&4 (Pub1 collection of Zoonoses Updates.) p 25-27. 1990. 37. Music S. Personal communication. Wyoming Department of Health, Cheyenne WY. March 1991. 38. Sasaki DM. Personal communication. Hawaii Department of Health, Honolulu HI. April 1991. 39. Williams LP. Personal communication. Oregon Department of Health, Portland OR. April 1991. 40. Durfee PT, Pullen MM, Currier RW and Parker RL. Human psittacosis associated with commercial processing of turkeys. JAK'U 167: 804-808. Nov 1, 1975. 41. Doll J. Personal communication. Arizona Department of Health, Phoenix, AZ, April 1991. 42. Smith KA. Personal communication. Ohio Department of Health, Columbus, OH, April 1991. 43. Iowa Department of Public Health. Bovine rabies in Iowa. Iowa Disease Bulletin. Feb 1991. 44. Centers for Disease Control. Rabies surveillance - 1988. Issued Aug 1989. 45. Martin RJ. Personal communication. Illinois Department of Health, Springfield, IL, April 1991. 46. Baer G. Personal communication. Centers for Disease Control, Atlanta, GA., 1990. 47. Currier RW. Unpublished data. Iowa Department of Public Health, Des Moines LA. 1990. 48. Sewell CM. Personal communication. New Mexico Health and Environment Department, Sante Fe NM. March 1991. 228 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 ftr Occupational Safety and Health April 30 - May 3, 7991, Des Moines, Iowa AN OVERViEW OF POTENTIAL HEALTH HAZARDS AMONG FARMERS FROM USE OF PESTICIDES By Aaron Blair, Ph.D. Occupational Studies Section National Cancer Institute Beginning in the mid-1940's, pesticides have become an increasingly important weapon in the attempt to control troublesome agricultural pests. Conse- quently, agriculture has become a major consumer of pesticides and now accounts for about 65 percent of the total domestic use.' Pesticide use varies by the crops and livestock raised, but a majority of farmers report application of some. In a 1982 survey, approximately 75 percent of the farmers with crops and 70 percent with livestock used pesticides.' With 2 million farmers, 6 million additional farm family members, and nearly 3 million hired farm workers, there is a large number of persons with potential contact with pes- ticides through agricultural use.3 Use of pesticides has been an integral component of the agricultural revolution, which over the past 50 years has greatly increased yields. Losses that would occur without the use of pesticides are difficult to estimate, but they could be sizable." Despite efforts to tailor the toxicologic properties of pesticides to specific pests, the fundamental similarity of all organisms at the subcellular level raises concerns about potential pesticide exposure of a large segment of the population. Although we should not lose sight of the benefits pesticides provide, the purpose of this review is to evaluate the potential for, and evidence of, adverse health outcomes from pesticide exposure in humans. Acute effects have been well established, and the major focus of this presentation will be on chronic effects. ACUTE EFFECTS Effects from acute exposure to pesticides are well established, but statistics on injury and death from acute exposures are in- complete for the United States as a whole. Some results indicate that the number of fatalities fell between the 1950's and the 1970's? Based on extrapolation from a survey of a small number of hospitals, EPA estimated that there were fewer than 3,000 annual admissions to hospitals for pesticide poisoning.' In California, however, where physicians are required by law to report suspected pesticide poisonings to the Department of Food and Agriculture, approximately 2,000 poisonings have been reported annually in recent years.' About 50 percent of these were from occupational exposures. More effective reporting systems are needed before the magnitude of adverse health conditions from acute exposures can be well monitored. Assessments in agricul- ture should include migrant workers, farm laborers, and dependents of farmers, as well as farm operators. Surgeon General's Conference on Agricultural Safety and Health - 1991 229 Research - Chemical and Biological Hazards CHRONIC EFFECTS Of growing concern are chronic health outcomes that do not occur immediately after exposure, including carcinogenic, developmental, immunological, reproduc- tive, and neurological effects.&' The lengthy interval between exposure and chronic effects makes risk assessment for these outcomes more difficult to evaluate than acute effects. As testing procedures have improved, concern has increased over long-term health effects from pesticides. Today sig- nificant efforts are devoted toward ex- perimental and epidemiologic evaluation of pesticides. The quantity and quality of the data available, however, vary by disease outcome. Establishment of a formal testing program by the National Cancer Institute (NCI) in 1968 and continued by the National Toxicology Program (NTP) in 1978 gave carcinogenicity screening of chemicals, of which pesticides were an important con- cern, an early start. This experimental effort stimulated epidemiologic inves- tigation of pesticides and cancer. The availability of cancer registries also enhanced opportunities for cancer research by providing a readily available source of well-diagnosed cases. Registries for other chronic disease endpoints are only begin- ning to be established. Since we lack some of these resources, the occurrence of non- malignant chronic disease from pesticide exposure has not been evaluated as thoroughly. CARCINOGENIC EFFECTS Some 47 pesticides have been evaluated in the NCI-NTP bioassay program (Table I)." Information from other sources is available, but is not considered here because study protocols sometimes deviate from the preferred model and because the purpose of this paper is to provide an indication of hazards presented by pes- ticides and not to provide a comprehensive review of all available data. In the NCI-NTP assays, six pesticides, or 13 percent(chlordecone, dichlorvos, aminotrizole, sulfallate, dibromochloropropane (DBCP), and EDB) were positive in both sexes in mice and rats. Another 10 (21 percent) were positive in both sexes of one species (chlordane, chlorobenzilate, dieldrin, hep- tachlor, tetrachlorvinphos, toxaphene, nitrofen, captan, chlorthalonil, and dichloropropene). Five (11 percent) were positive in one sex of at least one species (aldrin, dicofol, piperonyl sulphoxide, chloramben, and trifluralin). For 19 (40 percent) there was no evidence of car- cinogenicity in any sex/species group and seven (15 percent) provided inadequate or equivocal evidence for carcinogenicity. Several of the pesticides positive in bioas- says are no longer on the market, or their use is severely restricted, but others are widely used. The 16 chemicals positive in both sexes in at least one species include organochlorine and organophosphate in- secticides, herbicides, fungicides, and fumigants, suggesting that no chemical class of pesticides can be considered problem free. Pesticides are selected for testing for various reasons, including suspicion of carcinogenicity. With 45 percent of the pesticides tested showing some evidence of carcinogenicity, the concern about chronic human exposure would seem well founded. 230 Papers and Proceedings An Overview of Potential Health Hazards among Farmers from Use of Pesticides, May 1, 1991 Table 1. Results of Carcinogenicity Testing of Pesticides from the National Toxicology Program of Bioassays in Mice and Rats (modified from reference 10). INSECTICIDES Aldicarb Aldrin Azinphosmethyl Chlordane Chlordecone Chlorobenzilate Coumaphos Diazinon Dichlorvos Dicofol Dieldren Dimethoate Dioxathion Endosulphan Endrin Fenthion Heptachlor Lindane Malathion Maloxon Methoxychlor Methyl parathion Mexacarbate Parathion Phosphamidon Photodieldrin Piperonyl butoxide Piperonyl sulphoxide Tetrachlorvinphos Toxaphene MICE I!!! v + + + + t t + I E t t + t t t RATS I!!! ? E E L t I HERBICIDES Aminotriazole Chlorambene Fluometuron Monuron Nitrofen Sulfallate Trifluralin FUNGICIDES Anilazine Captan Chlorthalonil Fenaminosulf 0-Phenylpheno-I Pentachloro- nitrobenzene Triphenyltin-OH M 7 t : + + t FUMIGANTS DBCP t Dichloropropene I EDB t E = Equivocal I = inadequate evidence M = Male F = Female MICE t t + RATS M . t : t t t t t Pesticides may exert their carcinogenic effects through several mechanisms, including mutation, inhibition of gap- junctional cellular communication, in vivo and in vitro tests, the nine chemicals were found to, be active in most assays. These included organophosphate insec- ticides (acephate, demeton, mono- pcroxisome proliferation, and other promotional activities." In an evaluation crotophos, and trichlorfon), phthalimide of genetic damage from 65 pesticides in 14 fungicides (captan and folpet), and thio- Surgeon General's Conference on Agricultural Safety and Health - 1991 231 Research - Chemical and Biological Hazards carbamate herbicides (diallate, sulfallate, and triallate).`* Another group of 26 chemicals were positive in some tests, but were generally less active than the nine chemicals above. Pesticides in this group included phenoxy herbicides (2,4-D and 2,4-DB); organo- phosphate insecticides (azinphos-methyl, crotoxyphos, disulfoton, and methyl parathion); ethylenebisdithiocarbamate fungicides (manzeb, maneb, mancozeb, and zineb); and pyrethroid insecticides (allet- hrin, chrysanthemic acid, and ethyl chysan- themate). Thirty pesticides gave no evidence of genetic toxicity. Some pesticides may influence the car- cinogenic process in an epigenetic manner. For example, inhibition of intercellular communication can disrupt development or promote cancer." Broad occupational surveys from around the world have noted rather consistent excesses of leukemia, non-Hodgkin's lymphoma, multiple myeloma, soft-tissue sarcoma, and cancers of the brain, skin, lip, stomach, and prostate among farmers. A number of pesticides have been shown to inhibit gap junction intercellular com- munication including DDT, dieldrin, chlor- dane, heptachlor, Kepone, mirex, and endrin.14 Several of these pesticides have been shown to have a promotional effect on liver carcinogenesis in the rat.l' Peroxisome proliferation and the resultant increased generation of hydrogen peroxide represent another possible non-genotoxic carcinogenic mechanism. Phenoxy acid herbicides appear to be peroxisome proliferators in several rodent species." Much of the epidemiologic data available on the carcinogenicity of pesticides comes from studies of persons employed in agriculture. Broad occupational surveys from around the world have noted rather consistent excesses of leukemia, non-Hodgkin's lym- phoma, multiple myeloma, soft-tissue sar- coma, and cancers of the brain, skin, lip, stomach, and prostate among farmers."-" These excesses occur against a background of lower overall mortality, particularly for heart disease and other cancers including lung, colon, bladder, kidney, esophagus, and liver. This pattern of low mortality from most causes of death, but excesses for a few cancers, suggests a role for work- related factors. The low prevalence of smoking among farmers is probably related to their more favorable rates for heart disease and can- cers of the lung, esophagus, and bladder.15 High levels of physical fitness may contribute to their lower rates of colon cancer and heart disease." Case-control and other studies provide further evidence that farmers are at higher risk for selected cancers than the general population. In a recent survey of the literature," excesses among farmers were seen in 12 of 13 studies of leukemia, 12 of 15 studies of Hodgkin's disease, 14 of 19 studies of multiple myeloma, 18 of 29 studies of nqn-Hodgkin's lymphoma, three of three studies of lip cancer, three of three studies of skin cancer, five of seven studies of brain cancer, three of five studies of soft-tissue sarcoma, six of six studies of stomach cancer, and two of three studies of prostate cancer. 232 Papers and Proceedings The excesses for specific cancers among Although farmers come into contact with a farmers may have broad public health variety of potentially hazardous substances, implications, since several of the high-rate pesticides have received the most attention tumors appear to be increasing in the in epidemiologic studies, possibly because general population of many developed several pesticides are carcinogenic in countries.le Of special interest are the bi0assays.l' Early epidemiologic inves- rising rates for multiple myeloma, non- tigations evaluated cancer risks associated Hodgkin's lymphoma, melanoma, and with pesticide exposure in general. cancer of the brain. The International Agency for Research on In England and Wales" and the United Cancer (IARC) in a recent deliberation State?, prostate cancer has also been concluded that exposures occurring during increasing. Changes in diagnosis and the application of insecticides were reporting may account for some of the probably carcinogenic in man." Cohort increase for these tumors."*" studies of applicators and manufacturers of The rising rates for non-Hodgkin's lym- insecticides have tended to show excesses phoma, multiple myeloma, and leukemia in of cancers of the lung and the lymphatic agricultural areas of the central United and hematopoietic system, although some States, however, is a further indication of investigations show deficits.lO~ll the possible involvement of agricultural exposures. Excesses of cancer of the brain In these studies it was not possible to and lymphatic and hematopoietic system determine the specific chemicals accoun- have also been observed in rural farm ting for these excesses, but most subjects populations in Quebec."2 were employed during a time when or- ganochlorine insecticides were the Risks were correlated with pesticide usage chemicals used predominately. Although and were observed among women, as well many epidemiologic studies have evaluated as men, raising the possibility of effects cancer risks among farmers and other from nonoccupational exposure. The pesticide-exposed workers," only recently specific agricultural factors that might have there been attempts to assess risks account for the cancers excessive among from exposure to specific pesticides." farmers have not been definitively iden- tified, but a number of etiologic clues exist. Among those studies that have, soft-tissue sarcoma, Hodgkin's disease, non-Hodgkin's Exposures of interest include pesticides, lymphoma, leukemia, and lung cancer have fertilizers, fuels and engine exhausts, or- been associated with DDT;42"`28 non- ganic and inorganic dusts, solvents, Hodgkin's lymphoma with organophos- ultraviolet light, and zoonotic viruses.3 phates;25 soft-tissue sarcoma with a variety Many, perhaps even most, of the members of animal insecticide?; leukemia with of the general population may also have crotoxyphos, dichlorvos, famphur, pyreth- contact with some of these substances. rins, methoxychlor, and nicotine%; and non- Studies of farmers may, therefore, provide Hodgkin's lymphoma'5*29-33 and soft-tissue explanations for the rising incidence of cer- sarcoma34'38 with phenoxyacid herbicides. A tain cancers among the general population. potential problem for other cancers is suggested by an important study of workers engaged in the production of 2,4,5- An Overview of Potential Health Hazards among Farmers from Use of Pesticides, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 233 Research - Chemical and Biological Hazards Table II. Pesticide Effects on the Immune System (modified from reference 39). Pesticide Species Summarv of Effects t ORQANOPHOSPHATES Methylparathion . . . . . Rabbit Thymus atrophy and reduced DTH response. Mouse Decreased host resistance to infection Salmonella typimurium. Parathion . . . . . . . . . . . . Mouse Altered colony forming activities of bone marrow stem cells. Malathion . . . . . . . . . . . Mouse Suppression of CTL response in vitro. b ORQANOCHLORINES DDT . , . . . . , . . , . . , , , . , Rabbit Thymus atrophy and reduced DTH response. Mirex . . . . . . . . . . . . . . . _ Chicken Decreased IgG levels. Hexachlorgbenzene . . Mouse increased sensitivity to endotoxin and malaria challenge. Rat Increased humoral immune responses to tetanus toxoid and delayed- type hypersensitivity to ovalbumin. Dieldrin . . . . . . . . . . . . . Mouse Decreased AFC response and increased susceptibility to viral infection. Chlordane . . . . . . . . . . . Mouse Decreased contact hypersensitivity after in utero exposure. Mouse Suppression of AFC responses and T-cell activity in a MLC reaction following in vitro exposure. p CHLOROPHENOXY COMPOUNDS Pentachlorophenol . . . Mouse Decreased host resistance to virus-induced tumor metastases. 2,4-D . I.. . . . . , . . , , . . . Mouse Enhanced T- and B-cell responses following dermal application. t CARBAMATES Carbofuran . . . . . . . . . . Rabbit Reduced DTH response. Mouse Decreased host resistance to Salmonella tvphimurium infection. Aldicarb . . . . . . . . . . . . . Mouse Decreased AFC response to sheep erythrocytes. Human Increased response to Candida antigen, increased number of lym- phocytes expressing CD8 markers and decreased CD4 + /CD8 + cell ratio. Mouse No alterations in AFC response, B- or T-lymphocyte mitogenesis, host resistance to influenza virus infection, CTL response or percentages of T-cells, T-cell subpopulations or B-cells. DTH = delayed-type hypersensitivity. CTL = cytotoxic T lymphocytes. AFC = antibody-forming cells. MLC = mixed lymphocyte culture. trichlorophenol and derivative herbicides, those employed for less than one year. products contaminated with 2,3,7,&tetra- chlorodibenzo-p-dioxin.3' In this report, 20 Risks were elevated for soft-tissue sar- years after first exposure, a significant 50 comas and cancers of the esophagus, stom- percent excess of total cancer occurred ach, intestines, larynx, lung, and prostate. among workers employed for more than In the 20-year latency category, lung can- one year while no excess occurred among cer increased with duration of exposure 234 Papers and Proceedings with standardized mortality ratios (SMRs) of 96, 126, 146, and 156 for duration of exposure categories of C 1 year, 1 to < 5 years, 5 to < 15 years, and 15 or more years, respectively. Immunologic evaluations of pesticide ex- posure in humans are in their infancy. Effects observed in animals are not always seen in human studies.40 For example, altered numbers of T-cells and a decreased ratio of CD4/CD8 T-cells were found in IMMUNOLOGIC EFFECTS women exposed to aldicarb-contaminated drinking water." In investigations of al- Pesticides have immune effects that are of dicarb in mice, one noted an inverse dose- interest in their own right, but they may related suppression of antibody response,44 also be an important mechanism in car- while the another study did not.45 cinogenesis. A critical role for suppression of immune responsiveness by pesticides has been demonstrated for infectious disease A critical role for suppression of im- and maybe for other diseases.39 mune responsiveness by pesticides has been demonstrated for infectious disease Pesticides have displayed a variety of ef- fects on the immune system (Table II), and maybe for other diseases. including suppression of cytotoxic T lym- phocyte (CTL) response by malathion, thymus atrophy and delayed-type hypersen- There is also the possibility of a linkage sitivity (DTH) response by methyl- between immunologic effects from pest- parathion and DDT, decreased antibody- icide exposure and cancer. It is well forming cells (AFC) responses from documented that patients with naturally dieldrin and chlordane, enhanced T-and B- occurring or medically induced immuno- cell responses by 2,4-D, and reduced DTH deficiencies experience striking excesses of and host resistance by carbofuran. As with non-Hodgkin's lymphoma.46M carcinogenicity, immunologic effects are observed from pesticides in various In addition, excesses of leukemia and chemical classes (organochlorines, or- stomach cancer have been observed among ganophosphates, carbamates, and phenoxy- persons with primary immunodeficiency acids). In vitro studies of human leukocyte syndromes, while increases of soft-tissue functions have also shown inhibition of sarcoma, melanoma of the skin, and blastogenic stimulation". squamous carcinomas of the skin and lip have been observed in renal transplant Lymphocyte PHA stimulation was reduced patients.""" The fact that several of the 10 percent by carbamates, 11 to 18 percent tumors excessive among farmers (e.g., non- by organophosphates, and 11 to 17 percent Hodgkin's lymphoma, leukemia, skin, lip, by organochlorines. Contact dermatitis and stomach) also occur among im- and allergic chemical dermatitis are well- munodepressed patients could be a coin- recognized health effects from pesticide cidence, but it may suggest that effects on exposure and can occur from exposure to the immune system play a role in farming- various insecticides, fungicides, and related cancers. fumigants.4uz Epidemiologic investigations of alterations of the immune system are difficult because An Overview of Potential Health Hazards among Farmers from Use of Pesticides, May 1, 1991 SUrQeon General's Conference on Agricultural Safety and Health - 1991 235 Research - Chemical and Biological Hazards of large interindividual variability and the confounding effects from infections, drug use and other factors that influence im- mune responses. Alterations in immune responses may also be short lived. Monitoring of the immune system over an extended period may be necessary to determine the relevance of any alterations to subsequent disease risk. Consequently, it may be necessary to rely primarily upon experimental investigations in the near future. Thomas, et aE.,"O note two impor- tant criteria in extrapolating experimental results to humans. b First, the pharmacologic pattern for the pesticide should be the same in humans as in the animal model. This is difficult to achieve because information on absorption, distribution, biotransformation and excre- tion for the chemical of interest is rarely available in both humans and the animal model. b Second, the human end point of interest must be appropriate for the species selected. NEUROTOXIC EFFECTS The nervous system of the pest is the tar- get for many pesticides, so the fact that there are acute neurotoxic effects in humans is not surprising. Anecdotal case reports and epidemiologic studies also suggest that some neurologic symptoms may persist for years.`l Chronic effects observed include tremors, anorexia, anemia, muscular weakness, hyperexcitability, EEG pattern changes, insomnia, irritability, convulsions, headache, dizziness, and depression. These occur from various insecticide class- es including organochlorines, organo- phosphates, and carbamates.S1 Many of the above symptoms developed among workers with prolonged exposure to Kepone (chlordecone) in the Hopewell incident.s2 The symptoms gradually disap- peared over an 18-month period, but symp- toms persisted after several years in seven of the 23 most severely affected patients.n Less information is available concerning neurotoxic effects from herbicide exposure. Neuromuscular rigidity has been observed in rats after phenoxyacid exposure (2,4-D and MCPA)SIV 55 and peripheral nerve con- duction velocities were slowed among workers engaged in the manufacture of 2,4-D and 2,4,5-T.= Other nervous system conditions may be associated with pesticide exposure. A case report of Guillain-Barre syndrome noted recent skin exposure to the cotton de- foliant, merphosn An association with spraying of pesticides was reported in a case-control study of idiopathic Parkinson's disease.JB Risk of Parkinson's disease was also associated with longer duration farming and exposure to pesticides in a study in Hong Kong.s In another case-control study, however, it was associated with a rural residence and drinking well water, but not with use of pesticides."0 The subjective end points noted in most human studies of neurologic conditions make epidemiologic investiga- tions difficult. Evaluation of these end points is generally not possible in animals. Closing the gap between the two approaches is critical for a thorough evaluation of neurotoxic effects of chronic pesticide exposure. 236 Papers and Proceedings REPRODUCTIVE EFFECTS Mattison et al. classify reproductive toxicants as direct-acting or indirect- acting.6l Direct-acting toxicants may increased estrone metabolisms by liver microsomal enzymes by lindane, reduced egg production by organophosphates, and reduced fertility by carbamates. resemble a biologically important molecule CONCLUSIONS and function as agonists or antagonists in the reproductive process. Experimental and epidemiologic inves- tigations indicate that pesticides can cause They may also have direct effects because a variety of adverse effects including car- of their chemical reactivity. Most cinogenicity, immunotoxicity, neurotoxicity, chemically-reactive substances are and reproductive cytotoxic, carcinogenic, or mutagenic. toxicity. From this brief review several points stand out. Indirect-acting reproductive toxicants include chemicals that must be meta- b First, the carcinogenicity of pesticides bolized to produce effects, those that inter- has been more thoroughly evaluated than fere with critical enzyme systems, or those other toxic effects and approximately 45 that enhance or suppress secretion or percent of the chemicals tested had an clearance of critical control chemicals. effect in at least one sex of one species in Some chemicals may act both directly and NCI-NTP bioassays. If this experience is indirectly. For example, activities for or- relevant to other end points, the potential ganochlorine insecticides are suspected to for any type of adverse outcome from act directly through estrogen receptors and pesticide exposure could be considerable. indirectly through prohormone hepatic induction. b Second, the specific pesticides that are positive in the various toxicologic tests do Reproductive effects of specific pesticides not appear to be restricted to a few have recently been reviewed by Mattison et chemical classes. Effects are noted from al., 1990."' Adverse outcomes in experi- insecticides (organochlorines, or- mental and/or epidemiologic investigations ganophosphates, carbamates, and pyreth- have been reported for DBCP, chlorde- rins), herbicides, and fungicides. cone, ethylene dibromide, and carbaryl in males and DDT, chlordecone, lindane, or- b Third, adverse outcomes have been ~~~a~~sosphates, and carbamates among noted in epidemiologic, as well as ex- . perimental investigations, indicating that humans are also at risk. Effects among males have included disrup- tion of spermatogenesis by DBCP, reduced RECOMMENDATIONS sperm motility and viability by chlorde- cone, abnormal sperm morphology and 1. Given the evidence for adverse health sterility by ethylene dibromide, and sperm outcomes from pesticides, enhanced efforts abnormalities by carbaryl. In animals, are needed to control exposures in agricul- studies have noted reduced egg shell thick- ture and elsewhere. nesses from DDT, reduced egg production and number of offspring from chlordecone, An Overview of Potential Health Hazards among Farmers from Use of Pesticides, May 1, 1991 Surgeon General's Conference on AgriClJkUral Safety and Health - 1991 237 Research - Chemical and Biological Hazards 2. More thorough evaluations (experime- ntal and epidemiologic) are needed to more fully characterize the potential ad- verse effects that may occur from pesticide exposures. 3. Epidemiologic investigations must focus on exposures to specific pesticides. This will require detailed exposure assessment procedures to characterize the type and intensity of exposures. 4. Studies of farm populations should receive a high priority given the widespread use of pesticides in agriculture and the potential for exposure among farmers and farmer laborers, and their dependents. Retrospective designs can be used to ad- dress specific questions, but prospective studies should also be initiated. Prospec- tive investigations provide the opportunity to obtain information on exposure as it occurs, which would eliminate the potential for response bias and would minimize exposure misclassification. Once exposures are well characterized, prospective designs can also be used to evaluate a number of adverse health outcomes, a highly efficient approach in these times of funding limitations.0 REFERENCES 1. Eichers T, Andrilenas PA, Anderson TW. Farmers' Use of Pesticides in 1976. U.S. Department of Agriculture. Agricultural Economic Report No. 418. Washington, D.C., 1978. 2. Duffy M. Pesticide Use and Practices, 1982. U.S. Department of Agriculture. Agriculture Information Bull. No. 462. Economic Research Service. U.S. Government Printing Office, Washington, DC., 1982. 3. National Coalition for Agricultural Safety and Health. AgricuZhue at Risk. A Report to the Nation. 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Blair A, Malker H, Cantor KP, Burmeister L, Wiklund K. Cancer among farmers: A review. Scaltd J Work Environ Health 11: 397407, 1985. 16. Pearce N, Reif JS. Epidemiologic studies of cancer in agricultural workers. Am J Ind Mtid 18: 133-142, 1990. 17. Blair A, Zahm SH. Cancer among farmers. In: Health Hazard of Farming. Occupational Medicine - State of the Art Reviews. (Eds.) Cordes DH, Rea DF. Hanley and Be&s, Inc. Philadelphia, PA. (In press). 18. Davis DL, Hoe1 D, Fox J, Lopez A. International trends in cancer mortality in France, West Germany, Italy, Japan, England and Wales, and USA. Lancet 336: 474-481, 1990. 19. Office of Census and Population Surveys. Reviews of the National Cancer Registration System (Series MBA, No. 17). London: HM Stationery Office, 1990. 20. Devesa SS, Silverman DT, Young JL, Pollack ES, Brown CC, Horm JW, Percy CL, Myers MH, McKay Fw, Fraumeni JF Jr. Cancer incidence and mortality trends among whites in the United States, 1947-84. JNCI 79: 701-770, 1987. 21. Doll R, Peto R. The causes of cancer: Quantitative estimates of avoidable risks of cancer in the United States today. JNCI 66: 1191-1308, 1981. 22. IARC (International Agency for Research on Cancer): IARC Monographs on the Evaluation of the Carcinogenic Risk of Chemicals to Humans. Occupational Exposure in Insecticide Application and Some Pesticides, Vol. 53. Lyon, France. (In press). 23. Axelson 0. Pesticides and cancer risks in agriculture. Med oncol Tumor Pharmacother 4: 207-217, 1987. 24. Zahm SH, Blair A, Holmes FF, Boysen CD, Robe1 RJ. A case-referent study of soft-tissue sarcoma and Hodgkin's disease - farming and insecticide use. Stand J Work Environ Health 14: 224-230, 1988. 25. Zahm SH, Weisenburger DD, Babbitt PA, Saal RC, Vaught JB, Cantor KP, Blair A. A case-control study of non-Hodkgin's lymphoma and the herbicide &4-dichlorophenoxyacetic acid (2,4-D) in eastern Nebraska. Epidemiology 1:349-356, 1990. 26. Brown LM, Blair A, Gibson R, Everett GD, Cantor KP, Schuman LM, Burmeister LF, Van Lier SF, Dick F. Pesticide exposures and other agricultural risk factors for leukemia among men in Iowa and Minnesota. Cancer Res 50: 6585-6591, 1990. 27. Woods JS, Polissar L, Severson RK, Heuser LS, Rulander BG. Soft tissue sarcoma and non-Hodgkin's lymphoma in relation to phenoxyherbicide and chlorinated phenol exposure in western Washington. JNCI 78: 899-910, 1987. Surgeofl General's Conference on Agricultural Safety and Health - 1991 239 Research - Chemical and Biological Hazards 28. Flodin U, Frederiksson M, Persson B, Axelson 0. Chronic lymphatic leukemia and engine exhausts, fresh wood, and DDT: A case-referent study. Br J Ind Med 45: 33-38, 1988. 29. Hoar SK, Blair A, Holmes FF, Boysen CD, Robe1 RJ, Hoover RN, Fraumeni JF Jr. Agricultural herbicide use and risk of lymphoma and soft-tissue sarcoma. JAMA 256: 1141-1147, 1986. 30. Hardell L, E&son M, Lenner P, Lungren E. Malignant lymphoma and exposure to chemicals, especially organic solvents, chlorophenols, and phenoxy acids: A case-control study. Br J Cancer 43: 169--176,1981. 31. Persson B, Dahlander A, Fredriksson M, Brage HN, Ohlson CG, Axelson 0. Malignant lymphoma and occupational exposures. Br J Ind Med 46: 516-520, 1989. 32. Wigle DT, Semenciw RM, Wilkins K, Riedel D, Ritter L, Morrison HI, Mao Y. Mortality study of Canadian male farm operators: Non-Hodgkin's lymphoma mortality and agricultural practices in Saskatchewan. JNCI 82: 575-582, 1990 . 33. Bond GG, Wetterstroem NH, Roush GJ, McLaren EA, Lipps TE, Cook RR. Cause-specific mortality among employees engaged in the manufacture, formulation, or packaging of 2,4dichlorophenoxyacetic acid and related salts. Br J Ind Med 45: 98-105, 1988. 34. Hardell L, Sandstrom A. Case-control study: soft-tissue sarcoma and exposure to phenoxyacetic acids and chlorophenols. Br J Cancer 39: 711-717, 1979. 35. Eriksson M, Hardell L, Berg NO, Moller T, Axelson 0. Soft tissue sarcomas and exposure to chemical substances: A case referent study. Br J Ittd Med 38: 27-33, 1981. 36. Vineis P, Terracini B, Ciccone G, Cignetti A, Colombo E, Bonna A, Maffi L, Pisa R, Ricci P, Zanini E, Comba P. Phenoxy herbicides and soft-tissue sarcomas in female rice weeders: A population-based case- referent study. Stand J Work Environment Health 13: 9-17, 1986. 37. Lynge E. A follow-up study of cancer incidence among workers in manufacture of phenoxy herbicides in Denmark. Br J Cancer 52: 259-270, 1985. 38. Fingerhut MA, Halperin WE, Marlow DA, Piacitelli LA, Honchar PA, Sweeney MH, Greife AL, Dill PA, Steenland R, Suruda AJ. Cancer mortality in workers exposed to 2,3,7,8tetrachlorodibenz-p-dioxin. N Engi J Med 324: 212-218, 1991. 39. Thomas PT, Busse WW, Kerkvliet NI, Luster MI, Munson AE, Murray M, Roberts D, Robinson M, Silkworth J, Sjoblad R, Smialowicz R. Immunologic effects. In: The Effects of Pesticides on Human Health. (Eds.) Baker SR, Wilkinson CF. Adv Modern Environ Toxic01 Vol XVIII. Princeton Sci Pub1 Co, Inc. Princeton, NJ: 261-295, 1990. 40. Thomas PT, Faith RE. Adult and prenatal toxicity induced by halogenated aromatic hydrocarbons. In: Immunotoxicology and Immunophatmacofogy. (Eds.) Dean J, Luster M, Munson A, and Amos H. Raven Press, New York, NY, 1985. 41. Lee TP, Moscati R, Park BH. Effects of pesticides on human leukocyte functions. Res Cotnm Ghan Palhol Pharmacol23:597-609, 1979. 42. Sullivan JB Jr. Immunological alterations and chemical exposure. Clinical Tox 27: 311-343, 1989. 240 Papers and Proceedings An Overview of Potential Health Hazards among Farmers from Use of Pesticides, May 1, 1991 43. Fiore M, Ander CHA, Hong R, Golubjatnikov R, Seiser JE, Nordstrom D, Han&an L, Belluck D. Chronic exposure to aldicarb-contaminated groundwater and human immune function. Environ Res 41: 633-645, 1986. 44. Olson LJ, Erickson BJ, Hinsdill RD, Wyman JA, Porter WI', Binning LK, Bidgood RC, Nordheim EV. Aldicarb immunomodulation in mice: An inverse dose-response to parts per billion levels in drinking water. Arch Environ Confam Toxkoi 16: 433-439, 1987. 45. Thomas PT, Ratajczak HV, Eisenberg WC, Furedi-Machacek M, Ketels KV, Barbera PW. Evaluation of host resistance and immunity in mice exposed to the carbamate pesticide aldicarb. Fundam Appr Toxicol 9: 82-89, 1987. 46. Hoover R, Fraumeni JF Jr. Risk of cancer in renal transplant recipients. Lancet 2: 55-57, 1973. 47. Filipovich AH, Spector BD, Kersey J. Immunodeficiency in humans as a risk factor in the development of malignancy. Prev Med 9: 252-259, 1980. 48. Blohme I, Brynger H. Malignant disease in renal transplant patients. Transplanfarion 39: 23-25, 1985. 49. Penn I. Immunosuppression and skin cancer. Clin Plast Surg 7: 361, 1980. 50. Kinlen L, Doll R, Peto J. The incidence of tumors in human transplant recipients. Transplant Proc 15: 1039-1042, 1983. 51. Ecobichon DJ, Davies JE, Doull J, Ehrich M, Joy R. McHillan D, MacPhail R, Reiter LW, Slikker W Jr, and Tilson H. Neurotoxic effects of pesticides. In: The Ejfecti OfPesticides on Human Health. (Eds.) Baker SR, Wilkinson CF. Adv Modern Environ Toxic01 Vol XVIII. Princeton Sci Pub1 Co, Inc. Princeton, NJ: 131-199, 1990. 52. Taylor JR, Selhorst JB, Houff SA, Martinez AJ. Chlordecone intoxication in man. I. Chemical observations. Neurology 28: 626-630, 1978. 53. Taylor JR. Neurological manifestations in humans exposed to chlordecone: Follow-up results. Neurotoxicology 6: 231-236, 1985. 54. Squib RE, T&on HA, Mitchell CL. Neurobehavioral assessment of 2,4-dichlorophenoxyacetic acid (2,4- D) in rats. Neurobehav. Toxicoi Teratol5: 331-335, 1983. 55. Elo H, Ylitalo P. Distribution of 2-methyl-4 chlorophenoxyacetic acid and 2,4-dichlorophenoxyacetic acid in male rats: Evidence for the involvement of the central nervous system in their toxicity. Toxicol Appl Phamacol51: 439-446, 1979. 56. Singer R, Moses M, Valciukas J, Lilis R, Selikoff IJ. Nerve conduction velocity studies of workers employed in the manufacture of phenoxy herbicides. Environ Res 29: 297-311, 1982. 57. Fisher JR. Guillain-Barr& syndrome following organophosphate poisoning. JAMA 238: 1950-1951, 1977. 58. Golbe LI, Farrell TM, Davis PH. Follow-up study of early lie protective and risk factors in Parkinson's disease. Movement Disorders 5: 66-70, 1990. 59. Ho SC, Woo J, Lee CM. Epidemiologic study of Parkinson's disease in Hong Kong. Neurology 39: 1314- 1318, 1989. Surgeon General's Conference on Agricultural Safety and Health - 1991 241 Research - Chemical and Biological Hazards 60. KoIIer W, Vetere-Overfield B, Gray C, Alexander C, Chin T, DolezaI J, Hassanein R, Tanner C. Environmental risk factors in Parkinson's disease. Neurology 40: 1218-1221, 1990. 61. Mattison DR, BogumiI RJ, Chapin R, Hatch M, Hendricks A, JarreII J, LaBarbera A, Schrader SM, Selevan S. Reproductive effects of pesticides. In: The Effects of Pesticides on Human Health7 (Eds.) Baker SR, Wilkihson CF. Adv Modern Environ Toxic01 Vol XVIII. Princeton Sci Pub1 Co, Inc. Princeton, NJ: 1297-1389, 1990. 62. Godon D, Lajoie P, Thouez J, Nadeau D. Pesticides et cancers en milieu ruraI agricole au Quebec: Interpretation geographique. Sot Sci Med 29: 819-833, 1989. 242 Papers and Proceedings Surgeon General's Confemnce on Agricultuml Safety and Health FM&&FE 2000 . A National Coalition for Local Action Convened by the National Institute f0f Occupational Safety and Health April 30 - May 3, 7991, Des Moines, Iowa GASES, VAPORS, LIQUIDS, AND DRUGS By WZliam Popendorf, Ph.D., C.I.H. Institute of Agricultural Medicine, University of Iowa INTRODUCTION A wide range of gaseous and liquid hazards exists in agriculture (Table I).l*' Virtually all of the gaseous hazards from which we can anticipate health effects exist in one form or another in general industry. While we know of their existence in agriculture, only a few of these hazards have been surveyed in farm settings. We do not know how frequently (on the aver- age) farmers are exposed to individual agents. We do not know the range of con- centrations of such exposures. We do not know the extent of the health effects ex- cept for the occasional severe case report or fatality. And if we really did know these para- meters, we face yet another challenge; how to translate them into "agricultural hygiene," the industrial hygiene paradigm of "anticipation, recognition, evaluation, and control" learned in general industry over the past 50 years., As we begin to apply this paradigm, another challenge is to understand the limitations of rote transfer-ml of this paradigm from general industry to agriculture without also understanding its nature and its culture. This presentation will begin with a review of some of these agents, their sources on the farm, and some of the limitations of the traditional hierarchy of controlling these hazards either at their source, along the pathway of the exposure route, or at the receiver (in this case the farmer or farm worker). A discussion of health ef- fects will be minimized except for agents that are by-and-large unique to agriculture. Table I. Typical Toxic Agricultural Liquids, Gases, and Vapors. Ammonia ............................. from urine, urea, and anhydrous Carbon dioxide ...................... animal respiration and combustion Carbon monoxide ................... combustion sources Hydrogen sulfide .................... manure gas Nitrogen dioxide ..................... from fresh silage Oxygen Depletion ................... asphyxiation in confined spaces Pesticides ............................. primarily dermal absorption hazards except fumigants Welding ............................... fumes and gases Fuel storage .......................... leaks and fires Fuel and waste oil ................... skin cancers and dermatitis Ltquified Propane [LPI gas ........ fires Liquified anhydrous ammonia ..... dermal injury Surgeon General's Conference on Agricultural Safety and Health - 1991 243 Research - Chemical and Blologlcal Hazards DEFINITIONS I feel obliged to define a few terms and concepts ingrained into industrial hygiene folklore. The first (Figure 1) is the para- digm of anticipation, recognition, evalua- tion, and control. Historically, this process began with the recognition of adverse health effects existent within a working population. Anticipation Is the prospective application of dose-response knowledge generated either in the laboratory or in other industries. Recognition requires the commitment of farmers, interested farm groups, and governmental agencies to survey both the farming environment and the health status of farmers. Evaluation must develop new ways to interpret surveillance data from the farm set- ting for the agricultural population. Control includes not only "hazard com- munication" but also modified sources and interruptions in the pathways of exposure before the farmer, with or without personal protection, is dosed. 1 Figure 1. The Agricultural Hygiene Paradigm. Today, we can anticipate (and hopefully avoid) adverse health effects based on toxicology or prior experiences in other work settings. To evaluate the degree of risk, we have developed a system of "per- formance based" exposure limits guidelines (guidelines called Threshold Limit Values [TLVs] and their regulatory equivalents called Permissible Exposure Limits [PELs]), the goal of which is to prevent 244 adverse health effects by keeping expo- sures and doses to acceptable low levels without specifying the method or "work practices" to achieve those levels. The second is a concept that adverse health effects are the culmination of an often-complex chain of events beginning with the agent emanating into the working environment from a sometimes nebulous source and traveling through a physical pathway to create either an airborne, dermal, or even oral dose; the dose is generally dependant upon the duration of exposure and the degree of personal pro- tection being used by the worker; the agent may act at the site of contact or be absorbed into the body and be transported to some biological target organ where it acts toxicologically to create a clinically identifiable effect. Over the years, a hierarchy of control options has been inculcated into the profession whereby controlling the source is the preferred option, controlling the pathway between the source and worker is the second option, and controlling the re- ceiver is the third and least preferred op- tion. Hygienists believe that respirators or other forms of personal protective equip- ment are not a quick cure-all, contrary to popular belief. And even when they are recommended, good practice dictates (and OSHA now requires) that the respirator should be selected based on the measured level of exposure. GASES AND VAPORS The following history of silo gas is representative of the fragmented progres- sion of anticipation, recognition, evalua- tion, and control of a potentially common agricultural health hazard. Papers and Proceedings Gases, Vapors, Liquids, and Drugs, May 1, 1991 Occupational hazards associated with silo gas were first reported in 1914 via case studies of four fatalities of farmers working in and among their freshly filled silos. Their deaths were attributed to carbon dioxide (CO,). It was not until the 1950's (30 to 40 years later) that investigations revealed the presence and importance of nitrogen dioxide (N01).46 The major portion of toxic NO, appears to be produced from organic nitrates, aggravated by the addition of heavy nitrate fertilizer and/or drought conditions.6 The process of NO, production begins within hours of ensilage, peaks in three to seven days, but may last for up to two weeks. Levels of NO, as high as 200 ppm have been reported seven days after fill- ing;" this is well over its current TLV of 3 ppm (with a 5 ppm STEL). Our broad understanding of the magnitude and frequency of this hazard is limited by a lack of systematic environmental surveil- lance and poor reporting of farm injuries and fatalities. Our understanding of its overall impact on the health of farmers is further limited by the difficulty in diag- nosing nonfatal cases of the disease due to the multiple and usually latent phases of its clinical manifestations.`l' Thus, the severe and fatal cases of silo fillers' disease that are reported probably represent the tip of the proverbial iceberg. A few systematic surveys have recently been made of chronic gaseous hazards in modern semi-enclosed animal production buildings. Mulhausen" found that air quality in poultry barns frequently ex- ceeded exposure limits of 25 ppm for am- monia (NH,) during fall and winter and sometimes even exceeded its S'I'EL of 35 ppm; H,S was undetected. Donham et al." l3 surveyed similar swine barns and found 50 percent exceeded the TLC for ammonia; many of these buildings also ex- ceeded the TLC for CO, H,S, and CO (from un-vented space heaters). Source: urine (urea)-wet floors, slats, gutters, etc. Anticipated Health Hazards: Irritating to eyes, nose, trachea (wet body parts) . . . . . . . . . . IO-15 ppm TLV = recommended exposure limit (for gas) . . . . . . . . . . . . . . . . . . . . . . 25 ppm Absorbed into an aerosol may provoke bronchitis, asthma, or other pulmonary effects . . . . . . . . . . . . . . . . , ~20 ppm Figure 2. Ammonia (NH,). At these concentrations, ammonia by itself would only be a strong irritant to the eyes, nose, and throat. However, in both poultry and swine farm settings, it may be impor- tant to consider the simultaneous presence of both ammonia and organic dust aerosols at levels often in excess of 5 mg/m3. The hypothesis here is that the pulmonary damage caused by ammonia could be con- siderably greater if the gas were adsorbed onto a respirable-sized aerosol (Figure 2). In addition to hydrogen sulfide, mercap- tans and organic acids (such as methyl and ethyl-mercaptan, carbonyl-sulfide, skatole, and propionic, butyric, and valeric acids) have been identified in the gases emanating from the anaerobic decay of manure typically stored in a pit under most Surgeon General's Conference on Agricultural Safety and Health - 1991 245 Research - Chemical and Biological Hazards hog and some dairy barns.14dU It should be acknowledged that under normal barn conditions, hydrogen sulfide is not at levels of great health concern (Figure ,).I2 I3 Source: anaerobic manure digestion Anticipated Health Hazards: Threshold of odor detection . . . . . . 0.1-0.2 ppm Offensive odor . . , . . . . . . . . . . . . . . . . . . 3-5 ppm TLV = recommended exposure limit , , . . . , . . . , , . . . . . . . . . . . . . . . . . . 10 ppm Olfactory paralysis (cannot be smelled) . . . . . . . . . . .25-100 ppm Serious eye injury (gas eye) . . . . .50-100 ppm Bronchitis (dry cough) . . . . . . . . . loo-150 ppm Pneumonitis and pulmonary edema . , . . , , . . . . . . . . . . . . . . . . 200500 ppm Rapid respiratory arrest (death) . . > 1000 ppm Figure 3. Hydrogen Sulfide (H,S). However, when the manure is agitated prior to pump-out to be returned to the fields as fertilizer, it is rapidly released into the air above the frothing liquid.lsW19 During agitation, the author has measured levels of H,S as high as 300 ppm at pig breathing height and 1500 ppm in the pit (Figure 4). o Methyl-mercaptan o Propionic acid o Ethyl-mercaptan o Butyric acid o Carbonyl-sulfide o Valerie acid o Skatole Figure 4. Mercaptans and Organic Acids As- sociated with Hydrogen Sulfide from Manure. Manure gas deaths often involve multiple victims during futile rescue attempts.17,20 As was the case with silo gas, manure gas deaths even as recently as 1989 are sometimes m&diagnosed as asphyxiation from methane.M Control of agricultural respiratory hazards should rely first on reduction at the source, second on ventilation or some other physical barrier to its movement, and third on personal protection. Control of the source of most of the above agents will require further research before the process of gas generation is sufficiently understood to be reduced or avoided. High rates of ventilation of farm shops or animal confinement building is often resisted by operators who prefer to conserve heat in cold winter climates, and if too much ventilation were installed without consideration of make-up air re- quirements, high levels of CO could be drawn back down heater exhaust vents (Figure 5). Source: improperly adjusted heaters or no make-up air Anticipated Health Hazards: TLV = recommended exposure limit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 ppm Induces spontaneous abortions in swine . . . . . . . . . . . . . . . . . . . . 100-l 50 ppm Asphyxiation dependent upon duration of exposure . . . . . . . . (2-3 hours at 500 ppm) cl5 mins >2000 ppm Figure 5. Carbon Monoxide (CO). As in any other industry, the use of respirators should be considered a temp- orary and supplemental protection. In agri- culture there are no trained persons avail- able to assist in the selection, fit, or main- tenance of respirators. Thus, when pur- chased at all, respirators are selected 246 Papers and Proceedings without knowledge of measured levels of exposure and often without even the benefit of an adequate "work practices" evaluation as shall be discussed below. Table II. Major Groups of Field-Use Agricultural Pesticides. INSECTICIDES LIQUIDS Pesticides are formulated as solids (such as granules and wettable powders), liquids, and gases and vapors (mostly fumigants). Pesticides can present a hazard to applica- tors,21-P to harvesters re-entering a sprayed field, 24* 25 and to rural residents via air, water, and even food contamination.s28 Organophospates . . . . . . . . . . . . . . . Counter, Parathion, Guthion, Lorsban, Rabon Carbamate . . . . . . . . .._........ . . ..Temik, Furidan, Lannate, Sevin Organochlorines . . . . . . . . . . . . . . , . , Dieldrin, Lindane, Chlordane HERBICIDES Phenoxy-aiiphatic acids . . . . . ...2.4-D. 2,4,5-T, Trioxone Bipyridyis . . . . . . . . . . . . . . . . . . . . . _ Paraquat, Diquat Triazines . . . . . . . . . . . . . . . . . . . . . . . . . . Atrasine, Blasex, AAtrex OTHER/MISCELLANEOUS Thiocarbamates (fungicides) . Thiram, AAtack, Mabam, Maneb, Zineb Arsenicals (herbicides) , . . . . . Paris Green, Cacodyiic acid Acentaniiides (herbicides) . . . . . Alachlor, Lasso, Ramrod Dicarboximides (fungicides) . . . Difolitan, Captan Dinitrotoluidine (herbicides) . . . Amex, Prowl, Treflan Toxicologically, the major field- use pesticides can be broken down into six major chemical groups shown in Table II. Most of these agricultural chemicals present dermal hazards either from ab- sorption directly through intact skin and/or from dermatitis. Some of these insect- icides are also used indoors, especially in greenhouses were exposure is often higher,. Gases, Vapors, Liquids, and Drugs, May 1, 1991 Common Commercial Names There are two additional groups of non- field agricultural chemicals: one is fumigants (such as phosphine [usually aluminum phosphide or Phostoxin] or a volatile organic like carbon disulfide or ethylene dichloride) used in produce storage areas, and the other is disinfectants (such as chlorine, quaternary ammonia compounds, organic iodides, and cresol- based compounds) used in indoor animal production facilities.' Certain of these chemicals present respiratory hazards par- ticularly when used in combinations; other of these liquid chemicals present a risk of contact or an allergic dermatitis.30 While a review of pesticide toxicities is being presented separately, they are presented here because they demonstrate an approach to anticipation, recognition, evaluation, and control quite different from general industry. Some level of an- ticipation was available from the time of registration, but much of that interest was directed toward consumers rather than users who are exposed at much higher lev- els. Given that starting point, it is unfortunate that the recognition of hazards to users has often been a protracted process, in some ways no better than the history of many chemicals used in general industry. How- ever, evaluation of exposure, when it final- ly started to be conducted, was not site nor user specific but was conducted in re- sponse to more recent EPA pesticide regis- tration requirements. EPA then promulgated what amounts to a "use practices standard" in the form of Surgeon General's Conference on Agricultural Safety and Health - 1991 247 Research - Chemical and Biological Hazards label instructions, which specify the ways the chemical can be safely and legally used. The implication is that if all users follow these instructions, exposure will be sufficiently low to prevent adverse health effects. This process contrasts sharply with general industry where employers are ex- pected to "assure a workplace free from recognized hazards." Controls under these circumstances have also differed from general industry. It can be argued that the registration process is itself a form of controlling the source, screening out chemicals deemed too hazar- dous for agricultural use and restricting certain others to "licensed users." In that sense, a form of hazard com- munication was adopted by agriculture a little before general industry. However, the EPA registration and labelling process has yet to address the machinery control- ling the pathway of exposure. When it comes to personal protection, control has for a long time been mis- directed at airborne versus the dermal route of exposure; and those respiratory controls which are specified, were estab- lished without a decision logic common to general industry for over 30 years3'p3'. I am happy to report that EPA is currently developing a respirator selection decision logic at least consistent with a "use prac- tices standard." One might ask why a "use practices stan- dard" versus a "performance standard" approach used in agriculture. The one asking the question must not be a farmer. Even if the administrative and support structure were in place to conduct on-site monitoring at each farm or "place of employment," the activities, working en- vironments, and chemical exposure levels in most agricultural settings vary suf- ficiently by season, day, and even by hour as to make such measurements moot, which is not to say that measurements and even performance standards have no place in agriculture. For instance, work in animal production facilities is amenable to the application of traditional TLVs, environmental monitoring, and respirator selection criteria. "Use practice standards" have their own limitations; they must account for many variables, thus often making them overly restrictive conducive to low compliance. It remains a challenge for the future to define the conditions favoring either form of standard or to determine if either is even adequate. The other category of agricultural chemicals is fertilizers. Anhydrous am- monia is the most heavily used fertilizer in production agriculture. Anhydrous am- monia is hazardous to the skin and especially to the eyes because it is highly hygroscopic, highly caustic, and extremely cold (-280F under pressure). Almost any eye contact with this chemical will result in permanent blindness." In- haling high concentrations of ammonia can result is severe damage to the upper respiratory tract, resulting in bronchiectasis as a possible sequela." Most of the occupational injuries from anhydrous ammonia occur because of faulty couplings, bleeder valves, shutyoff valves, broken hoses, or plugged applicator tips. In addition to an established program of preventive maintenance, a pro-active hazard communication for both commer- cial and private applicators is essential to establish consistent wearing of eye protec- 248 Papers and Proceedings Gases, Vapors, Liquids, and Drugs, May 1, 1991 Table III. Skin Conditions of Agricultural Workers (adapted from reference 2). Classification of Skin Condition Irritant contact dermatitis . . . . . . . . . . . . . . . . . Allergic contact dermatitis . . . . . . ._. . . . . Photo-contact dermatitis . . . . , . . , . . . . . . . . . Sun-induced dermatoses ................. Infectious dermatoses ..................... Heat-induced dermatoses ................ Arthropod-induced dermatoses .......... Aaents (examblesl ammonia fertilizers animal feed additiies vegetable crops and bulb plants insecticides, herbicides, and fumigants herbicides and insecticides antibiotic feed additives plants creosota feed additive plants containing furocoumarins sunlight cattle, swine, and sheep moist and hot environments chiggers, bees, and wasps tion and ensuring the availability of clean water to flush eyes and skin in case of contact. In addition to their fire hazard and intrin- sic toxicity, many of the liquids involved in agriculture can produce dermatitis (Table III). Compared to other occupational groups, farmers have a proportionately higher prevalence of skin diseases."," Irritant contact dermatitis is perhaps the most common type of agricultural der- matoses.3539 Irritant substances are ubi- quitous and include ammonia fertilizers, several pesticides, soaps, petroleum products, and solvents. Avoidance schemes must include work practices to eliminate or reduce exposure to the most irritative substances and/or the use of personal protection equipment. Allergic contact dermatitis is typified by Poison ivy or poison oak reactions. These are exquisite sensitizers as are certain herbicides and pes- ticides? These reactions are more difficult to control, because suscep- tible farmers are ex- quisitely sensitive to very small amounts of offen- ding liquids. VETERINARY DRUGS Veterinary drugs are broadly divided into two classes of biologicals and antibiotics (Table IV). Biologicals are made from living products to enhance the immunity of an animal to a specific infectious disease or diseases. Users of biologicals are at risk of either accidental inoculation or splashing the product into the eyes, mucous membrane, or broken skin. Users at risk include not only veterinarians and their assistants, but also farmers, ranchers, and their employees, except for certain diseases for which a government-regulated control program is in effect (e.g., brucellosis, rabies, pseudorabies). The most frequent reports of occupational illnesses associated with biologicals involve veterinarians, whether splashing brucellosis strain 19 in their eyes or accidental inoculating themselves. Symptoms may include infection, inflammation, severe localized swelling and pain, and/or an allergic reaction. The infection mimics the acute infection seen from acquisition of the disease directly from either cattle or swine. Disability may last for days to weeks in the worst cases."' Surgeon General's Conference on Agricultural Safety and Health - 1991 249 Research - Chemical and Biological Hazards Table IV. Veterinary Drugs Potentially Hazardous to Users. Biologicals Brucellosis strain 19 Newcastle disease vaccine Contagious exthyma (orf) vaccine Jhone's disease bacterin Escherichia co/i bacterins Erysipelas vaccines Antibiotics Penicillin Tetracycline Sulfamethazine Erythromycin Virginiamycin Other products that have been associated with occupational illnesses include New- castle disease vaccine, contagious ecthyma vaccine, Jhone's disease bacterin, ES- clzetichia coli bacterins, and erysipelas vaccines. Newcastle disease and con- tagious ecthyma (orf) vaccines are live products used in chickens and sheep, respectively. Workers may contaminate their eyes with Newcastle vaccine as it is being applied inside poultry buildings via a nebulizer, resulting in a moderate conjunctivitis with influenza-like systemic symptoms. Orf vac- cine can cause the same pox-like lesions at the site of inoculation as a naturally ac- quired infection. Both of these diseases are self-limited and disability will only last for a few days, unless the orf lesions are numerous.41342 Injuries induced by the bacterins for Jhone's and E. Coli, and by most erysipelas vaccines are limited to the inflammatory response induced by the adjuvants. Control of these hazards again resides largely in "use practice standards," good animal handling techniques and facilities to prevent the uncontrolled and untimely movements of stressed animals." The use of pneumatic syringes, lock-on needle hubs, and multiple dose syringes will also help reduce injuries. Eye protection is indicated in many instan- ces. A full-face respirator is recommended while aerosolizing vaccines such as New- castle, but the other components of a full respirator program are rarely instituted. Antibiotics are products derived or syn- thesized from living organisms, mainly mold species of the genus streptowtyces. Antibiotics are used to treat infectious diseases therapeutically or to improve the rate of gain and feed efficiency in cattle, swine, and poultry. Again not only veterinarians but also live- stock producers and feed manufactures and formulators are exposed to these agents via aerosols of antibiotic-containing feeds within livestock buildings or via aerosols or direct contact while preparing feeds either on the farm or in feed manu- facturing plants. The two main occupa- tional hazards are allergic reactions and the development of antibiotic-resistant infections. The main products used as feed additives include penicillin, tetracycline, sul- famethazine, erythromycin, and vir- giniamycin. These same products plus many more are used therapeutically. Pen- icillin is the primary agent that may induce an allergic reaction manifest in the form of a skin reaction from direct contact, or 250 Papers and Proceedings possibly a systemic reaction from inhala- tion or inoculation. A variety of these agents may induce development of resistant organisms in the gut flora of exposed individuals. In one case, a severe resistant salmonellosis was traced to animal contact by people who were treated with antibiotics for a con- dition unrelated to salmonella." Again the importance of antibiotics as an agricultural health hazard is unknown either in terms the frequency or the mag- nitude of exposure levels or health effects. It seems that the evaluation of risk from antibiotics is amenable to air sampling and the development of "performance" oriented exposure guidelines. Control should strive toward removing as feed additives those antibiotics used for humans and rotating the use of those still added. Other prudent control measures where antibiotics are used include en- closing feed formulating, grinding, mixing, and storing operations, and utilizing general dust control procedures in small feeding operations, supplemented by dust masks. CONCLUSIONS The industrial hygiene paradigm of "an- ticipation, recognition, evaluation, and control" can, in principle, be applied to agriculture with the following translations: 1. Anticipation of health and safety hazards in agriculture can be accomplished with the prospective application of dose- response knowledge generated either in the laboratory or in other industries. 2. Recognizing health and safety hazards in agriculture requires the interest and Gases, Vapors, Liquids, and Drugs, May 1, 1991 commitment of farmers, farmer groups, local community organizations, manufac- tures, and governmental agencies to survey both the farming environment and the health status of farmers. 3. Evaluation of health and safety hazards in agriculture can in most cases use exis- ting surveillance technologies, but new ways must be developed to interpret sur- veillance data from settings for farmers. 4. Controlling health and safety hazards in agriculture must go beyond "hazard com- munication" to modify the sources and interrupt the pathways of exposure before the farmer, with or without personal protection, is dosed. Organizationally, the hazards from gases, liquids, vapors, and veterinary drugs are not uncontrollable. By and large, we can anticipate the health effects of individual agents, and we know how to measure both the agents and their effects in a population. We have not utilized these skills in agricul- ture as yet, probably both because of the cost of surveillance studies in such a scat- tered and diverse population and because of the perception that "agriculture" was not interested in someone intervening in their affairs. We are at the dawn of the age where the interest and funds are being put into agricultural health and safety. I hope that in our rush to study and improve the statistics upon which future preventive health and safety decisions will be made, we do not lose sight of agricul- ture as way of life. Kelley Donham and I recently have been referring to agricultural hygiene as the application on farms of in- dustrial hygiene principles learned in general industry. Surgeon General's Conference on Agricultural Safety and Health - 1991 251 Research - Chemical and Biological Hazards We like to think (with tongue in cheek) that agricultural hygiene is a growing op- to be easier to train industrial hygienists portunity. The open question is, is it going about farming than it will be to train farmers to be agricultural hygienists?0 REFERENCES 1. W. Popendorf, K.J. Donham, D.N. Easton, and J. Silk. A synopsis of Agricultural Respiratory Hazards. American Industrial Hygiene Association Journal. 46(3): 154-161, (1985). 2. W. Popendorf and KJ. Donham: Agricultural Hygiene. Chapter 19 in Pafry's Industrial Hygiene. 4th Edition, pages 575608, J. Wiley & Son, NY 1991. 3. 4. E.R. Hayhusrt and E. Scott, Four Cases of Sudden Death in a Silo. JAVA 63:l570-1572, (1914). R.R. Grayson, Silage Gas Poisoning: Nitrogen Dioxide Pneumonia, a New Disease in Agricultural Workers. Ann. hf. Med., 45:393-408, (1956). 5. T. Lowry and L.M. Schuman. Silo-filler's Disease: A Syndrome Caused by Nitrogen Dioxide. JM 162: 153-160 (1956). 6. W.H. Peterson, R.H. Burris, S. Rameshchandra, and H.N. Little. Production of Toxic Gas (Nitrogen Dioxides) in Silage Making. Agric and Food Chem, 6:121-126, (1958). 7. B.T. Commins, F.J. Raveney, and M.W. Jesson. Toxic Gases in Tower Silos." Ann. Occupational Hygiene 14:275-283, (1971). 8. R.J. Ramirez and A.R. Dowell. Silo Filler's Disease: Nitrogen dioxide-induced Lung Injury. Long-term Follow-up and Review of the Literature. Ann. Intern. Med. 74569-576, (1971). 9. E.G. Scott and W.B. Hunt. Silo-filler's Disease. Chest 63:701-706, (1973). 10. E.D. Horvath, GA. do Pica, and RA. Barbee et al. Nitrogen dioxide-induced pulmonary disease. Journal of Occupational Medicine. 20:103-110, (1978). 11. J.R. Mulhausen, E.E. McJilotn, P.T. Redig, KA. Janni. Aspergillus and Other Human Respiratory Disease Agents in Turkey Confinement Houses. American Industrial Hygiene Association Journal. 48(11):894-899, (1987). 12. K.J. Donham, M. Rubino, T.D. Thedell, J. Kammermeyer, Potential Health Hazards to Agricultural Workers in Swine Confinement Buildings. Journal of Occupational Medicine. 19(6):383-387, (1977). 13. K.J. Donham, M. Rubino, T.D. Thedell, J. Kammermeyer. Ambient Levels of Selected Gases Inside Swine Confinement Buildings. American Industrial Hygiene Association Journal. 46:658-661, (1985). 14. JA. Merkel, T.E. Hazen, and J.R. Miner. Identification of Gases in a Confinement Swine Building Environment. Trans. ASAE. 12:310-315 (1969). 15. W.C. Banwart and J.M. Brenner. Identification of Sulfur Gases Evolved from Animal Manures. Journal of Environmental Quaky. 4(3):363-366, (1975). 252 Papers and Proceedings Gases, Vapors, Uquids, and Drugs, May 1, 1991 16. D.L. Morses, MA. Woodbury. Death Caused by Fermenting Manure. Journal of the American Medical Association. 245(1):63-64, (1981). 17. K.J. Donham, L.W. Knapp, R. Monson, K Gustafson. Acute Toxic Exposure to Gases From Liquid Manure. Journal of Occupational Medicine. 24(2):142-145, (1982). 18. S.R. Hagley, D. L. South. Fatal Inhalation Of Liquid Manure Gas. Medical Journal ofAustralia. 2:459- 460, (1983). 19. A. Phelps. The Hidden Hazard. Hog Farm Management. 25(4):38-39, 1988. 20. Anonymous. Fatalities Attributed to Methane Asphyxia in Manure Waste Pits - Ohio, Michigan, 1989. MMWZ, 38(33):j583-586, (1989). 21. H.N. Nigg and J.H. Stamper. Exposure of Spray Applicators and Mixer-Loaders to Chiorobemilate Miticide in Florida Citrus Groves. Arch. Environmental Contamination Toxicology. 12:477-482, (1983). 22. J.M. Devine, G.B. Kinoshita, R.P. Peterson and G. L. Picard. Farm Worker Exposure to Terbufos [phosphorodithioic acid] during Planting Operations of Corn. Arch. Environmental Contamination Toxicology. 15:113-119, (1986). 23. W. Popendorf. Mechanisms of Clothing Exposure and DermaI Dosing during Spray Application. In: Performance of Protective Clothing: Second Symposium. ed. by S.Z. Mandsorf, R. Sager, and A.P. Nielsen. Amer. Sot. for Testing and Materials. Phii. PA, 611624, (1988). 24. W. Popendorf and J.T. Leffmgweh. Regulating OP Pesticide Residues for Farmworker Protection. Residues Reviews. 82X25-201, (1982). 25. H.N. Nigg, J.H. Stamper, R.M. Queen. The Development And Use Of A Universal Model to Predict Tree Crop Harvester Pesticide Exposure. American Industrial Hygiene Associafion Journal. 45(3):182- 186, (1984). 26. J. Maybank, K. Yoskida, and R. Grover. Spray drift from agricultural pesticide applications. J. Air Pollution Control Association. 28:1009-1014, (1978). 27. National Research Council. Regulating Pesticides in Food, National Academy Press, Washington, DC, (1987). 28. D. Fairchild. Ground Water Quality and Agricultural Practices. Lewis Publishers, Inc., Chelsea, MI (1987). 29. J.H. Stamper, H.N. Nigg, W.D. Mahon, A.P. Nielsen, M.D. Royer. Pesticide Exposure to Greenhouse Foggers. Chemosphere. 17(5):1007-1023, (1988). 30. R.L. ZuehIke. Common cutaneous problems in agricultural work. In: Proceedings of Conference on Agricultural Health and Safety. Society of Occupational and Environmental Health, Environmental Sciences Laboratory, 100th Street and Fifth Avenue, NY, pp. 54-67, (1975). 31. F-A. Patty. Industrial Hygiene and Tom'cology. 2nd Edition. Pages 352-354, Interscience Publishers, NY (1958). 32. N.J. Bohinger and R.H. Schutz. Guide to Industrial Respiratory Protection. DHHS (NIOSH) PubI. 87- 116, (1987). Surgeon General's Conference on Agricultural Safety and Health - 1991 253 Research - Chemical and Biological Hazards 33. S. Helmers, F.H. Top, and L.W. Knapp. Ammonia Injuries in Agriculture. J. Iowa Med. Society. 61(5):271-280 (1971). 34. I. Kass, N. Zamel, CA. Dobry, and M. Holzer. Bronchiectasis following ammonia burns of the respiratory tract: A review of two cases. Chest, 62982-285, (1972). 35. D. Hogan and P. Lane. Dermatologic Disorders in Agriculture. Occupational Medicine: State of the Art Reviews, 1:285-300, (1986). 36. C.L. Wand. The Problem of Skin Diseases in Industry. Washington D.C., Office of Occupational Safety and Health Statistics, U.S. Department of Labor, U.S. Government Printing Office, (1978). 37. R.M. Caplan. Cutaneous hazards posed by agricultural chemicals. Journal of the Iowa Medical Society, 59(4):295-299, (1969). 38. D. Burrown. Contact dermatitis in animal feed mill workers. British Journal of Dermatology, 92167-170, (1975). 39. R.D. Peachey. Skin hazards in farming. British Journal of Dermatology, 105(Supp.21):45-50, (1981). 40. W.W. Spink. The Significance of Bacterial Hypersensitivity in Human Bruceliosis; Studies on Infection due to Strain 19. Brucella Abortus. 41861-873, (1957). 41. A.H. Keeney and M.C. Hunter. Human infection with Newcastle virus of fowls. Archives of Opthul- mology. 44:573-580, (1950). 42. U.W. Leavell, Jr., M.S. McNamara, R. Mueliing, et al. Orf-Report of 19 human cases with clinical and pathological observations. JAMA, 204~109-116, (1968). 43. T. Grandin. Animal Handling and Farm Animal Behavior. Veterinary Clinics of North America: Food Animal Practice, 3:324-336, (1987). 44. R.W. Lyons, C.L. Samples, H.N. DeSilva et al. An Epidemic of Resistant Salmonella in a Nursery- Animal-to-Human Spread. JTAMA 243:546-547, (1980). 254 Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 o A National Coalition fix local Action Convened by the National Institute fix Occupational Safety and Health April 30 - May 3, 1997, Des Moines, Iowa MIGRANT WORKERS' PERSPECTIVE By E. Roberta Rydq BA. Executive Director, National Migrant Resource Program, Inc. I am coming to you from Buffalo, New York, where I have been for six days par- ticipating in the National Migrant Con- ference, which is a joint group with migrant education, migrant health, migrant head-start, and migrant labor. So, I am running a little ragged here in my throat, and I ask you to bear with me for just a little while. NATIONAL MIGRANT HEALTH PROGRAM I am going to give you a brief synopsis of the organization that I work with because I think there are some resources there that some of you might be interested in. The National Migrant Resource Program is located in Austin, Texas. It has been there for almost 20 years. We act as a resource not just to migrant health centers but to any other interested parties around the country. We are a private, non-profit corporation. We have a newsletter, a directory, and a number of publications, perhaps the most exciting of which is one that was just completed by Dr. (inaudible) who is an epidemiologist with Mercer University in Georgia. I am going to read you one sentence out of this report. It is an analysis of migrant farmworkers in the midwestern stream. He says, "The results of this study are significant, shocking, and convincing. The findings are based on a sample of migrant and seasonal farmworkers living and working in the U.S., yet their demographic patterns, socioeconomic conditions, lifes- tyle characteristics, and disease categories reflect agrarian third-world conditions rather than those of the most powerful and affluent nation in the world." This monograph is available for all of you if you want to contact me. Our name is listed in the back of the roster of par- ticipants. I come from a farming background. I am the daughter of a farmer, and I am also the ex-wife of a farmer. I have been a health center administrator and worked with migrant farmworkers since I got out of college in 1972. I would also like to let you know that we are doing-if any of you have an interest in it we would like to hear from you-some work with EPA on expert meetings on the topics of children and pesticides and on biological monitoring alternatives. COMMENTS ON PAPERS I am going to go directly to the presen- tations that were made yesterday. I would like to state that of the four, some of them were more directly applicable to migrant farmworkers than others. Even the one that was least directly applicable, i.e., Dr. Popendorfs presentation on gases, liquids, vapors, and veterinary drugs, con- tained significant concepts that are very valuable when applied to the field of mi- Surgeon General's Conference on Agricultural Safety and Health - 1991 255 Research - Chemical and Biological Hazards grant health. I speak particularly of his paradigm of anticipation, recognition, eval- uation, and control. The other concept that he presented was that adverse health effects are the cul- mination of an often complex chain of events beginning with a nebulous source and traveling through a physical pathway. This concept is very important, especially if you think for the moment of the father of a farmworker family, say 50 years old, who comes into a clinic with chronic headaches, gastric problems, or dermatitis. We cannot figure out what the problem is. How do we determine what series of events or exposures led him to this state? After 40 years of exposure, traveling in maybe one or two streams, a multiplicity of states, and working with a range of crops that go from apples to mushrooms to zuc- chini - what kinds of exposures has he had? Certainly the case is complex beyond that of the grower, the farmer, who stays on one farm, one piece of property, over a 40- to 60-year span of time. We do not know what the chronic effects of low-level continuous exposure are, but because we do not know, we sometimes hide our heads in the sand and pretend that they are not problems, much like we did with cigarette smoking 20 years ago. Good judgment and common sense advised us that smoking was not healthy. To touch on Dr. Popendorfs theory, we could anticipate potential problems, we could recognize the questionability of put- ting such a substance in our bodies, but yet for economic and political reasons we got stuck on evaluation before we could move on to control. Are we going to wait until we can prove, irrefutably, that exposure to chemical and biological substances is hazardous to the health of farmworkers, farmers, and consumers before we use this God-given good judgment and anticipate or recognize the danger and take action? You might wonder why I mentioned the consumer here. Those of us who work in migrant health believe that the migrant farmworker and the farmer are, in essence, the "canaries." Do you all know what I mean by that concept? The indicator of risks that are shared with the consumer. I speak here not only of chemical hazards but of biological exposure. A colleague of mine testified before a joint session of the Congress in the early years when we were trying to promulgate the field sanitation regulations which, by the way, were only finally passed in 1987. He said, "Just tell me, sir, exactly what amount of fecal mat- ter present on a strawberry is a tolerable level." All of the presentations touched on issues which are of significant impact to farmworkers. I would like to run through that list briefly with you at this time. We spoke of infectious diseases for which farmworkers are at high risk, because of their working and crowded living con- ditions. TB, STD, HIV, parasites, gastroenteritis, Salmonella, Shigella, hepatitis A, UTI's, and respiratory infec- tions-all of them very clearly problems that we see in the farmworker population. One of the reasons that I referred you to Dr. (inaudible) study is that he does an analysis of the frequency of these diag- noses in this study. Dr. Von Essen spoke to us of airborne dust. Certainly hypersensitivity pneumonitis is less of a problem with the migrant farmworker population, since only 256 Papers and Proceedings The Migrant Workers' Perspective, May 2, 1991 small numbers of them work in dairy or grain operations. I have a foster child who lives with me and is 20 years old. I have known Danny since he was three, and I had him in day care in southwest Michigan. He is the child of a farmworker family that is home-based in the Little Rock or Bates- ville, Arkansas area. When they are not migrating north, they work in the poultry industry. Danny, at the tender age of 20, has chronic bronchitis from having been in and out of the poultry settings and the freezers of the processing plant. This is clearly a problem, but in less significant numbers than the larger portion of the population that works primarily in fruits and vegetables. I would like to draw attention to the fact that for farmworkers, we are talking about chemical and biological exposures, but there are a number of other hazards that people often do not think about as being agriculturally or occupationally related. For example, automobile accidents with farmworkers who are traveling 1,200 miles up and down the stream in cars that I would not drive 200 miles in are signifi- cantly related to occupational employment. I would like to go to Dr. Blair's presen- tation. It is most exciting to me in that it takes a very honest approach to the dif- ficulties in assessing the chronic effects of acute exposure. Certainly clusters of can- cer among farmers which cannot be explained for other reasons are alarming enough to motivate us to anticipate and recognize the problem so that we can then control it. Let us not get bogged down in the assessment, or we will lose all of our canaries. What are the solutions? Certainly there are some laws on the books which need to be fully implemented. I had originally jotted down the word "enforced," and I crossed that out and used the word "implemented," because, quite frankly, our enforcement is not working. We have people here from OSHA. Someone asked me a question just before the conference started as to how things were going with OSHA in Texas. Enforce- ment does not happen. Specifically, the laws that are on the books include such things as field sanitation, use of child safety restraints in automobiles, minimum wage, and re-entry times, but these are not always observed. Then there are other laws that have yet to be promul- gated. I speak specifically here of the loopholes in current laws, which exempt migrant and seasonal farmworkers and farmers from basic worker protection standards afforded to all other workers and child labor laws which do the same. There is movement towards promulgating both of those at this time. One of my colleagues, Dr. Paul Monahan who is sitting in the back row, has information on each of those. The group within migrant health that takes a strong advocacy role is the migrant clinicians' network, and I believe he has copies of the posrtron papers on both of those laws. Currently worker protection standards within the Environmental Protection Agen- cy are bogged down in a political morass where they have been for years. They need to get out of the red border status ' and be promulgated. SWeon General's Conference on Agricultural Safety and Health - 1991 257 Research - Chemical and Biological Hazards Once this is achieved, they merit careful, independent, academic evaluation from professionals like yourself with an eye to modifications. Let us push now to get them on the books because if we try to inject modifications at this time into the political process, I am afraid we will never have the standards. Is it really acceptable that such a large portion of our population be relegated to the edge for the duration of their lives? I Unfortunately, laws alone are not going to improve conditions for farmworkers. I would like to propose to you that farmworkers and farmers are literally in the same field--or boat as you might say-not only when it comes to exposures, but economically and politically. It is very clearly recognized that farm and farmworker families have lived their lives on the edge between survival and des- titution for at least the last 10 years. Many farm families have lost that struggle through suicide and bankruptcy. We do not see, visibly, tangibly, the demise occur- ring in the numbers of the farmworker population because there has always been another family to take the place of one that settles out. So we can not quantify it for farmworkers the way we can for farmers. The theory of the hierarchy of need tells us that safety, shelter, and nourishment are the three basic needs of any human, and that without assurance of them, self-actualization will not occur. Is it really acceptable that such a large portion of our population be relegated to the edge for the duration of their lives? Sometimes the farmworker's plight is er- roneously blamed on the farmer or on the laziness of the farmworker. So who do we blame for the farmer's plight? I blame the ignorance, selfishness and greed of the consumer and all of the mid- dlemen in the food production system. Perhaps where humanitarianism and altruism are not strong enough to create change, consumer self-concern may. We can certainly look at the examples of Alar in the Pacific Northwest, the con- sumer reaction, and the practice of its use among growers. We can look at the European Economic Community and the purchase of beef with steroids. We can look at the safe tuna model for examples of where consumer pressure has certainly brought about change. We know that it is a powerful entity. RECOMMENDATIONS I have 10 recommendations: 1. I would like to suggest that it is very important that we continue to mainstream farmer and farmworker issues, especially in arenas such as these, and I would like to volunteer to be one of several linkages that can help to bring participants- par- ticipation of migrant farmworkers themsel- ves to sit and be a part of your negotiations. Not all farmworkers are monolingual, and several of them are very outspoken in English as well as Spanish. 2. Enforce protection standards where they exist. 3. Promulgate laws where necessary. PaDers and Proceedinas The Migrant Workers' Perspective, May 2, 1991 4. Educate both farmers and farmworkers decide where our values lie and promul- as to the risks that they face. gate and implement legislation accordingly. 5. Educate the consumer and the general public. 6. The academic world needs to feel free to speak out about the risks, even where proof does not exist. Let good judgment prevail. 7. Promote economic market changes that assure that farmers and farmworkers receive a decent wage or profit for their work, because truly it is the economic market that drives the situation. In this manner, both farmers and farmworkers can be pushed back from the edge where they currently teeter. 9. Anticipate that the Free Trade Agreement between the United States and Mexico is going to blow us all out of the water, at least for the first five years, and then recognize that the short-run, political solutions and protections must be put in place in order to protect not only the farmer and the farmworker but the con- sumer, in that we do not control the use of toxic substances in Mexico. 8. Recognize the difference between farm families and huge, multi-level, diversified agribusiness, which is making a profit, and 10. Just as it took Surgeon General Koop's audacity to challenge the economic and political bastions of the tobacco in- dustry and to state that cigarettes smoking is hazardous to our health, so too can Dr. Novello have the audacity, as a pedia- trician and a woman and, I dare say pro- bably a mother, to speak out on behalf of the hazards faced by our farming com- munity.0 QUESTIONS Anonymous: You used the term "blow us out of the water," on the Free Trade Agreement. Could you clarify that? Roberta Ryder: The question is, What do I mean by "blow us out of the water" on the Free Trade Agreement? I have a sense that the long-term benetits of the Free Trade Agreement are going to be of significant value to this country and so, therefore, I personally am not opposed to it, but when you look at the fact that the production of a watermelon, for example, basically costs the same in Mexico as it does in the United States with the exception of the labor factor, what we are going to fmd is that the importation of agriculture into the United States will be far more prevalent than it is right now. We will also find that some of the larger, healthier farms are going to actually move into Mexico, and there will be others who cannot sustain that kind of change that will go under. That is the impact on the farm. For the farmworker, what we are going to find is that there are a number of second-generation agricultural farmworkers that have been here in the United States traveling along all of the streams, that are truly America's working poor. They are not a welfare population, and they are not going to have work. That is going to be a burden on American society just as it is in our inner city areas where we have large welfare populations. I do not think that it is going to have a significant impact on the cost of produce for us as the consumer, but I do think that it will actually cut, pull the rug out from under our feet on, any of the consumer safety Protections that have been put in place to control the use of certain substances because, in Mexico, things Surgeon General's Conference on Agricultural Safety and Health - 1991 259 Research - Chemical and Biological Hazards like DDT are still being used quite frequently without any control at all. We are going to be consuming that produce. Anonymous: To come back to the local level, how do we educate our migrant workers on all these things that are going on... (inaudible). Roberta Ryder: The only way that I know of is through outreach. Our clinics have gone from being very basic, simple, community-level organizations to somewhat more sophisticated-nicer buildings, better trained doctors, and in the process, what we find is that we are not reaching the farmworkers. As our health centers have become more and more a part of the industry and our highly trained physicians sit in the clinic and wait for the patients to come to them, we are reaching smaller and smaller numbers of the total population. We know-and dollar resources are clearly the issue here-that the only way to reach them is through outreach, through use of lay rich people, employment of the best and the brightest of the migrant farmworkers themselves, and through paraprofessionals and mid-level practitioners to go out into the labor camps and the housing, the colonias in the Valley of Texas, and take care of the basic level things. I am speaking in health, because that is the field that I am most familiar with, but I think you can apply that to education whether it is health education or safety education. Anonymous: Can you get that through, say, migrant clinics? Roberta Ryder: You definitely can. Migrant clinics have the expertise and the know-how. They have the models. Right now what they are lacking is the resources, and they are committed to health education and worker protection status. Anonymous: Do you have a list of migrant clinics? Roberta Ryder: The question is, "Do I have a list of migrant clinics ?" I have a directory that is produced out of our office in Austin, Texas, and that is available free of charge. It includes all of the grantees funded through the Federal Department of Health and Human Services and each of their satellites, including names of the health professionals that work in them and the services that are provided. Included in that directory is also a list of pediatricians around the country who are members of the American Academy of Pediatrics who provide services to farmworkers on a volunteer basis. 260 Papers and Proceedings I do not know whether to say thank you to Kelley Donham or not. This morning I was asked to give a foundation's perspec- tive on the papers and presentations that were made yesterday. As Kelley has sug- gested, it probably is easier for me to give a layperson's perspective. In a sense, I hope to give a community perspective, and quite frankly, a perspec- tive of a young midwestern farm youth and one from my involvement in agriculture as a farmer. In fact, I continue to farm today and had the opportunity in 1989 to pur- chase a farm in Michigan and continue to be involved there. Although my bias and experience and exposure to the issues of agricultural health and safety clearly lie on the safety side, I will talk about that in just a minute. I first want to clear up Kelley's story. As Kelley mentioned, one day while shearing sheep on the farm, I contracted orf virus. Surgeon General's Conference on Agriculturai Safety and Health FARMSAFE 2000 o ? National CoaMon fix Local Action Convened by the National InStitute for Occupational Safety and Health April 30 - May 3, 7991, Des Moines, Iowa A FOUNDATION'S PERSPECTIVE By Gene F. Graham, MS. Assistant Program Director, W.K. Kellogg Foundation Dr. Kelley J. Donham: The next speaker is a person who I had the privilege of meeting just a little over a year ago, he revealed to me this morning that he got an infection once from one of his animals and since that time I think he has become quite a leader and promoter, very much so, in the whole area of agricultural health and safety. Gene Graham was born on a farm. I guess you have to have that stamp of approval, almost, to be here. If we keep this up, we are going to have so many people up here doing this stuff and not farming maybe we will not have to worry about those problems anymore, but . . . we need to keep in mind and perspective who we are working for and what we are trying to do. Anyway, Gene was born on a dairy farm in Michigan, a little ways north of Lansing. His project, perhaps more of a hobby than an actual economic unit on the farm, was pure-bred sheep. Gene went to Michigan State University and got a degree in education and specifically agribusiness and natural resources education and went to work in real life in a high school, in Laingsburg, Michigan, as an agricultural instructor, until 1989. He then went to work for the Kellogg Foundation in Battle Creek. Starting about one year ago, Gene was the stimulant to get an agricultural health and safety initiative going within Kellogg, which has helped to move this whole process along in a very big way. So, without further ado, I would like to introduce Gene Graham: It was the first time that I had come to grips with some of the relationships bet- ween agriculture and health, although I had read about and understood, at least at a very rudimentary level, some of the potential that health issues in agriculture pose. I think, though, that what stirred me more was a series of experiences as I grew up in a very rural community, as Kelley said, not far from Michigan's capital, in Ingham County, Michigan. I think about two very good friends, Ron and Steve, who, in separate tractor accidents, were either killed while working on a farm or while driving a farm tractor down the road. One, in fact, was struck by a car and killed. I also think about Gary, who, as a sophomore in high school, had a full chop- per box roll onto him. He lost his left leg just above the knee. Surgeon General's Conference on Agricultural Safety and Health - 1991 267 Research - Chemical and Biological Hazards I think about Sarah, in probably the most devastating experience that I could ever imagine, who walked too close to a sickle bar mower and lost both her feet. Somehow, in the miracle of what has gone on in health care in this country, Sarah had both feet successfully reattached. As one of the presenters alluded to yesterday, when you are in some of those situations, you do not look up at the doctor and say, "How much is it going to cost?" Also, when I was a graduate student at Michigan State University, I remember very specifically, a good friend got stuck by a needle with animal vaccine, for the third time in his young life, and died within just a few hours of that experience. I think about five members of a family, in an accident that many of you heard about in Michigan's Upper Peninsula, where one after another each individual attempted a rescue from an underground manure pit and all five lost their lives. Just last year, in the school district where I grew up, in a small rural community, the local people went through the pain of one suffocation/asphyxiation in an upright grain silo and a second accident where a young man lost his legs and a big share of his future as the result of a sweep auger in the bottom of a grain bin. So, all of these experiences wear and bear on my mind as I think about these issues and what we heard about yesterday. With respect to a foundation's perspective, the foundation that I represent is not one that is very typical or traditional. It is one that says as its motto, "The application of knowledge to the problems of people." So that does not qualify me very well to stand today and reflect about the presentations that were made yesterday. For the Kellogg Foundation, it is an issue of the complimentary relationship between research and community intervention, where each bears directly on the other. It is a fundamental and naive belief that models and demonstrations can be estab- lished which will, at some point, affect policy even at a very local or regional level. It is the application of knowledge for community intervention. A foundation can only bring limited resources to this or any other important issue. It cannot do work by itself. In fact, foundations have no role except to contribute some pieces to the equation of research, surveillance, education, and inter- vention. For the Kellogg Foundation in Battle Creek, Michigan, this work represents an opportunity to bring financial resources, networking, and an expectation of in- novation. In our particular initiative, the expectations include collaborative, comprehensive, responsive, intensive, con- tinuous, cost-effective (however that can be measured), creative, and effective programs at a community level. COMBINED FACTORS OF RISK As I reflect on the presentations which were made yesterday, I will only talk about where I see some potential next steps in relationship to what I heard. First, I would address an issue that was raised regarding combined factors of risk. The context of this issue could include factors outside of agriculture, such as cigarette smoking, which complicates our understanding of agricultural risk for exposure to the lungs. Another example which was given yester- day was the case of two pesticides and what equations are appropriate, and what 262 Papers and Proceedings A Foundation's Perspective, May 2, 1991 do the results of the equations really mean? Have we got that figured out in a scientific and meaningful way? A final example that I would give, and I think this may be a midwestern perspec- tive, is the combination of wood smoke and a livestock confinement building. These are conditions and circumstances which exist on farms today. These are things at a community level which are very relevant; that young people and adults, in rural communities, who work and live on farms and tend to get exposed to more than one pesticide, to more than one type of animal confinement, to more than one risk must face a combination of oc- cupationally and non-occupationally related risks. ADDITIONAL STUDIES Secondly, I want to comment on the sug- gestion of additional studies. Yesterday Dr. Blair suggested a study of farmers. He said, perhaps a massive study which would be long-term in nature, of 100,000 farmers. I said to myself, Who? Who are we in American agriculture? What 100,000 farmers are we? The question generates out of my concern for a regional and locally diverse agricul- ture. Clearly, American agriculture is a regionally diverse agriculture. We all understand that fact. Moreover, the con- text of any one particular region is based on farming systems and farming practices, which are locally diverse. In fact, as I move to that and think about exposure to risk, farming practices and farming systems come back again to the forefront and cause me to reflect in a second way, by thinking about a reduction of exposure to risk. Certainly our rural neighbors knew 30 years ago that when one generation on the farm grew up severely asthmatic, they had to design and develop different ways to harvest and feed forage on our community dairy farms. These are things at a community level which are very relevant; that young peo- ple and adults, in rural communities, who work and live on farms and tend to get exposed to more than one pesticide, to more than one type of animal con- finement, to more than one risk must face a combination of occupationally and non-occupationally related risks. Today, I think that we need to refocus on those efforts, and how we reduce risk in a meaningful way with respect to forage and grain handling, feeding systems, and milking systems. Why is it that some of us went to milking parlors as opposed to staying with our stall or stanchion barns? The examples, in the context of any regional production system and the diver- sity of local production strategies and production techniques, are all there. ECONOMIC INCENTIVE A third factor, one with which I was especially impressed this morning as I listened and reflected in the plenary ses- sion, is one of economic incentive. As we think about the very traditional models of prevention and assistance in agricultural health and safety, we historically depended on enforcement, education, and en- gineering. I am still convinced, even as I read the policy statements and voluntary equipment standards proposed in this country, that there must be economic in- Surgeon General's Conference on Agricultural Safety and Health - 1991 263 Research - Chemical and Biological Hazards centives in order for agricultural producers to change practice and in order for them to be able to provide leadership for their workers to change practice. ETHNIC AND CULTURAL DIVERSITY The fourth area that I raise as a concern is the ethnic and cultural diversity of the prospective target population. This mor- ning I listened as Dr. Pamela Elkind talked about the worker acceptance levels of yellow gloves versus black gloves. I was saddened, as two of my fellow con- ference participants looked at each other in disbelief as to say, `This is silly," and I said to myself that it does not seem silly to me. On Saturday morning, while I am watching cartoons, I put on my yellow house work gloves and polish my shoes, because I do not want shoe polish all over my hands. The issue of cultural sensitivity is relevant though. I do not wear those yellow gloves in front of anybody else. 1 I want to challenge you all about how it is that we can develop meaningful op- portunities for enfranchisement, access to the institutions of society, and the much needed occupational safety and health interventions for migrant and seasonal workers. It seems to me that there are learning style differences, cultural sensitivities, a need for the reduction of cultural barriers, and need of a more comprehensive understanding of the referent values and attitudes for various cultural populations involved in American agriculture. Traditionally these 264 groups have been, at best, slighted and, at worst, alienated. I am terrifically disap- pointed that with the exception of Bobbi Ryder and a few others who are here, very few migrant and seasonal workers or workers' representatives are present. I am saddened that this meeting was scheduled on top of a national meeting which deals more specifically with the issues of migrant and seasonal labor. I want to challenge you all about how it is that we can develop meaningful oppor- tunities for enfranchisement, access to the institutions of society, and the much needed occupational safety and health interventions for migrant and seasonal workers. At a very philosophical level, in this great American experiment and interesting American fabric, we have a great opportunity. Some would say that we are not up to this challenge, yet we, as Americans, have established so many new ideas and institutions in our desire to find better ways. I would point to the Land Grant system, which established that technical and scientific education was important for the whole populace, as opposed to only the wealthy or the gentry in this country. I would point to the whole system of public school education, which has a fun- damentally different meaning in this country than in others and, in the develop- ment of, and now our transition away from, the one-room schoolhouse. I say to myself and to you, let us not lose our perspective or sight of our opportunity for innovation in this area. In fact, let me restate this challenge dif- ferently. Less than 50 percent of the par- ticipants in this meeting represent those issues concerning non-owner operators, Papers and Proceedings those who either are unpaid workers or who are paid what are clearly substandard wages and live in substandard conditions across the country, then we have done a less than adequate job in identifying the issues. There must be enfranchisement of all people in this country involved in agricultural production, or we will not have addressed the issues of agricultural health and safety in an adequate and meaningful way. LESSONS FROM OTHER INTERVENTIONS Fifth, I would say that there are lessons from other safety and health interventions, lessons which I did not hear referenced enough and which I am still curious about. These include seat belts, child restraints, helmets, and smoking laws, Please do not misunderstand me. I am not an advocate of additional levels of regulation, but I do think that there needs to be a balance between research, regulation, surveillance, education and behavioral change, and improved service delivery. I strongly believe that there are models from the progress made in the areas of cigarette smoking, in helmet use, in seat belt use, and as was raised yester- day by Dr. Popendorf, in the process and sequence of industrial hygiene, and how science can be applied to American agriculture. SURVEILLANCE SYSTEMS Finally, and in closing, a sixth area that I would raise is that of surveillance systems. I continue to be very frustrated about our lack of a comprehensive and unified sur- veillance system. This is especially chal- lenging for someone who is a relatively new entrant, as an individual, into the field A Foundation's Perspective, May 2, 1991 of agricultural safety and health. I have been very frustrated while working with others to conceptualize systems that will eventually serve populations at the local level. It is very clear to me that in a society that is losing its grasp on the availability of resources and on where we should put resources, we will have the opportunity to invest only in those programs and places where we know interventions are effective. Presently, we do not even have a system of baseline surveillance data that is uniformly agreed upon. Even so, I hold out hope. I hold out hope for evolution in the NIOSH or other related programs as was mentioned yester- day, in the surveillance system that is being developed here in Iowa. I hold out hope for what others have done on a state-by- state basis, and for what more traditional safety organizations have done to document injury in agriculture in this country. I am convinced that we have not achieved even the very basic goal of accurate injury and illness data yet. We need to continue to work towards this goal so that we can measure the eventual effectiveness of interventions. Well, that brings me to the closure of my remarks. For me the priority is community intervention. Yesterday was a phenomenal experience for me to again listen as some of the health issues in agriculture were raised, issues which it is difficult to become familiar with, based on their chronic nature as opposed to their traumatic nature. In sharing a closing thought, it seems to me that as a nation we are more con- Surgeon General's Conference on Agricultural Safety and Health - 1991 265 Research - Chemical and Biological Hazards cerned than ever about the protection of the resource base upon which American agriculture is built. As evidenced by some of the speakers in this morning's plenary session, we have developed a greater con- cern for the issues of land and water management as reflected in agriculture. These concerns cross all levels: local, state, regional, and national. As I reflect on the issues of sustainability, and I believe that this renewed importance on the wise use and protection of our resource base is important, I ask myself, can the challenge posed by the greater protection of all workers in American agriculture, and in the prevention of occupationally related injury and illness merit any less attention, as an issue for the sustainability of our great agricultural system? My answer, and hopefully, our common answer must be that the protection of human resources in agriculture is an area of critical impor- tance.0 266 Papers and Proceedings Surgeon General's Conference on Agricultural Safety and Health FARMSAFE 2000 . A National Coalition for Local Action Convened by the National Institute for Occupational Salty and Health April 30 - May 3, 1991, Des Moines, Iowa A CLINICAL PERSPECTIVE By Dean T. Stuelanci, M.D. Medical Director, National Farm Medicine Center I am going to come at this primarily from the point of view of a clinician and with that I would like to make two quick com- ments to Bobbi Ryder. One of the things about someone who spends first six days in Buffalo and then three days here in Des Moines is that she cannot be accused of exactly seeking the garden spots of the country. The second thing is you have a sore throat and headaches. Why do you not take two aspirin? If you take good care of your cold, it will be over in seven days; if you do not, it will last a week. I have three parts to my presentation. The first is some of the difficulties that I believe a clinician in practice experiences when trying to deal with the farming population and, specifically, some issues that were discussed yesterday. Second, I want to look at some of the specific things that were in each of the presentations. Third, I want to make some short recom- mendations. DIFFICULTIES IN CLINICAL PRACTICE As a physician, one of the real issues clear- ly is what I would call a cultural gap bet- ween the clinicians and most of their clients, or patients in this case. We often have to learn, so to speak, a language that is different from what we would ordinarily speak. As an example, I can even report-and it is nice of Kelley to speak as well as he did of the Marshfield Center-but I can give a report of my own colleagues having some difficulty in confusing silo gas ex- posure-that is, nitrogen dioxide-from organic toxic dust syndrome or hypersen- sitivity pneumonitis. The point, of course, as was pointed out well yesterday, is they occur at two completely different times. They both can occur in silos. They have different settings. Prognostically they are worlds apart. But, in point of fact, when a physician sees someone short of breath who has just been in a silo, he says, "Well, I suspect this is silo gas exposure," when, of course, especially if it is in the spring, it is not. The same thing might go on when we get to talk about more specific exposures. I know one of the things that we think we should do is encourage patients, that is the farmers in this case, to know the exposures that they have endured and be able to speak to them with some intelligence, and I think that is very good. On the other hand, I can tell you as a practicing clinician, everybody has all kinds of strange exposures which they believe they have incurred, and it is often difficult to sort out fact and fancy. Although these are worthwhile recommendations, it just is not as easy as it may seem. Surgeon General's Conference on Agricultural Safety and Health - 1991 267 Research - Chemical and Biological Hazards Another thing we often talk about is the age of machinery and its poor repair. But we need to recognize that change in far- ming practices actually occurs quite rapidly and so those of us who left the farm at say 18 or 20 have to recognize that things are being done significantly differently now than they were then. This is especially true if we deal with the issue of chemicals. I think if you look at, for example, the information on the back of a pesticide bag and so on, it is all there. It strikes me about as useless as a PDR and nobody gives you any idea what is important and what is unimportant; the information is basically confusing, Finally, I want to point out that I think there is some sort of a feeling that farmer and farm groups are in some sense not particularly cooperative. I think we all recognize they want to work and want to get back to work. There is always a tendency in any society to blame the victim, and that is clearly the case here as well-and especially, as we've pointed out already, certain sub-groups are especially difficult in the sense of not being able to communicate to us well. For example, migrant families have already been spoken of, and likewise certain secluded groups that tend to be in agricul- ture. Locally we have such groups as Amish; obviously they speak English with us. For example, as was pointed out in Dr. Currier's discussion, they may not have the simple vaccinations that we expect most people to have had. Second, I want to speak about difficulties, for the physician, in some of the diagnostic methods. When you go through, for example, some infectious disease, you will see references to serologic methods. Serologic studies are very good in telling you what has transformed from previously negative to positive and they give you some indication of what is occurring in the population, but in terms of a specific patient, you usually only get a diagnosis after the fact. So if we can develop diag- nostic studies that are more specific to disease, we certainly can aid the clinician a great deal. In that regard, I would like to comment on the issue of pesticides and viruses and the relationship to cancers that are well recog- nized. There is probably not a great deal of difference from a clinician's point of view as to the etiology of the cancer, un- less we know something about preclinical diagnosis or screening methods and can make recommendations in that regard. Clearly, recommendations with regard to screening at least certain populations have been fairly effective. If we can make those sorts of recommendations-that is, who should be screened, how often, and by what method, or if there are some preclinical diagnostic methods, who is at risk-1 think we have come a long way. As I have said, the diagnosis of the cancer probably is not a particularly difficult issue for the clinician, as treatment protocols are well publicized. The issue of preclinical diagnosis remains an issue which may have social as well as medical implications. Third, I think you have to recognize that most practicing clinicians do not have a great deal of public health or preventive medicine orientation. We are taught, and I probably more than most as I practice primarily emergency medicine, how to deal 268 Papers and Proceedings A Clinical Perspective, May 2, 1991 with things on an acute basis. We have a very strong fii in terms of how to treat and the need to treat. That is a real problem. It is relevant, for example, if you look at such things as control of hypertension or control of cholesterol. Here you have a number and an intervention that you can follow. It fits very well into the treatment model because you can pick a disease by definition, have an effective treatment, and perhaps alter the patient's risk. But for most of these things that we are talking about, that is not true. The issues then with regard to prevention and exposure are sometimes dissatisfying to both the physician and the patient who find that there is no delivery of what they consider to be health care even though treatment may be very effective. In that regard, I would just like to say a couple of words about surveillance. I think that many times it is useful to have clinical cooperation with surveillance methods. I want to just suggest that there are three things that one needs to recognize in terms of deriving cooperation from physicians in surveillance methods. b First, we clinicians are very good at saying we are busy. Believe it! If you do not believe it, just ask our families. So, you have got to come on-even if it isn't true-and say, "I understand you are busy." b Second, it is looked at as an intrusion. Since there is a perception that there is already too much intrusion, you need to make the point that that is not the intent. ' Third, if you point out that this is likely to be useful, then it is going to go a long way. Of course, in point of fact, I think most clinicians are verv interested in providing very good uskful information to providing very good uskful information to help prevent problems. I think most help prevent problems. I think most clinicians are found to be fairly clinicians are found to be fairly cooperative. cooperative. b Fourth is the issue of knowledge base. It is important to remember that when we talk about medical practice, we emphasize the word "practice." Over a period of time one develops a skill of being able to recog- nize and do certain things particularly well and other things less well. Even with a well-developed left brain, there is only a certain amount of infor- mation that can stay anywhere near the forefront. Even in a rural practice, the agricultural illnesses are going to be only a small portion of the overall practice. So something needs to be done to keep that information in the forefront. We had here yesterday four very good experts who spoke very well, and very clearly, and very lucidly to the issues that were raised. But for a particular physician in a typical family practice, these are all going to be blurred together and have to be dealt with simultaneously. There need to be some ways to get this information to the clinician in ways that are more pala- table. One of the things people talk a great deal about are data and information banks. I have not particularly observed that my colleagues are very quick in researching those for care of a specific patient. As an example, I just want to talk briefly about the issue of cellulitis related to needle sticks or puncture wounds, which may occur in barns or areas where an- tibiotics are used frequently. There are Surgeon General's Conference on Agricultural Safety and Health - 1991 269 Research - Chemical and Biological Hazards several people who will speak to the obser- vation that the bacteria that are con- taminating those wounds, when they develop infection, are multiply resis- tant-much different from the usual bac- teria that clinicians have been told to ex- pect in a skin infection. As far as I can see, we do not yet have a science to pre- dict what those bacteria are going to be nor what antibiotics should be given to treat such an infection. Finally, in terms of problems, it makes no sense to speak to the issue of agricultural problems in medical practice without speaking to the issue of the whole rural health care delivery problem, itself. Clear- ly, at the present time, the infrastructure is being challenged in many ways. As was alluded to yesterday, rural hospitals are being significantly threatened. Someone suggested that 25 percent are in difficult straits. That is after 10 percent have already left the practice. Although we understand the need to reformat and downsize, I think it is also important to remember that at the present time, and I want to emphasize "the present time," hospitals are usually the key to the medical community. Hospitals do not necessarily have to be the basis for a rural medical community, but that does mean we are going to talk about a different model. The rural health practitioner generally feels that he has a lack of support, that he has difficulty probably with his professional life and education, and that the working poor are a particularly difficult problem in terms of finances. Rural populations in general have more than their share of working poor, as has already been pointed out in this session. Agricultural groups probably have even a higher represen- tation. ISSUES RAISED IN THE PRESENTATIONS Next, I would like to speak to specific issues that I think were raised in each of the four talks, and hope here I will be a bit more provocative. The first difficulty is talking about the differentiation between hypersensitivity pneumonitis and toxic organic dust syndrome. The differential diagnosis is clearly important prognostically and per- haps even clinically, but it is actually, I think, much more difficult than it appears. If one knows a specific allergen that is expected in a specific region, then a very useful test, of course, is the presence or absence of that precipitant. At least that tells you whether that specific patient is at risk. On the other hand, the differentiations based on a chest x-ray, which I think many times can be clinically quite subtle, or arterial blood gases which usually are bor- derline, can be very difficult. So, when you are trying to tell the patient whether this is an important exposure or not, whether the prognosis is difficult or not, I find is not as easy as it would appear. I guess I would appreciate it if Dr. Von Essen could speak to that a little bit at the end. There is also an issue of acute and chronic bronchitis. Although we recognize that such things as buildings, particularly con- finement buildings, are a risk, it is unclear to me what difference that makes in terms of clinical practice except from prevention. I am unsure if you know of specific an- tibiotics or specific treatment or prevention protocols that would apply in a particular exposure. 270 Papers and Proceedings Finally, I agree with the point that there seems to be a relationship between organic toxic dust syndrome and asthma; at least many people seem to feel that is true from an empirical or episodic point-of-view, but I am not sure if there is exactly science or statistics to support that, and I am not sure if that is a clinically relevant issue or not. Next I want to speak to some of the infec- tious disease issues. First, I want to com- mend Dr. Currier for stressing the problem of the migrant farmworker who has the whole family at risk because of living con- ditions. I might point out that it would be unwise to speak of sexually transmitted disease as occupational exposure. But that does stress the importance of recognizing the whole family and the environment as part of the agricultural business. The risks are not just that of work but also of the living environment. This, of course, applies in a large measure to the non-migrant farmer as well. I believe food-borne illnesses are primarily an issue in the rural environment in general. I think it is an increasing problem, and I am not sure if you have specific suggestions in that regard or not. Clearly one issue is knowledge. For example, the physician assistant with whom I work can regularly diagnose giardiasis because we see it so frequently. Again, it is not necessarily an agricultural problem; it seems to be rural in general. 1 also appreciate the emphasis on populations at risk, especially the elderly and the children. I want to emphasize with regard to the infectious diseases that the new practices lead to new problems, or sometimes resurfacing of old problems. It is good to keep before the clinician how A Clinical Perspective, May 2, 1991 things are changing in agricultural practice, because it is going to change in their prac- tice as well. Next, I want to discuss pesticides. It is probably appropriate that the discussion of acute pesticide exposure was largely ig- nored because it is probably better recog- nized in practice anyway. At any rate, it is actually, from a statistical point of view, not a big part of anyone's particular prac- tice; I am not making any points about that. With regards to chronic effects, I would like to ask for more information. First is in regard to neurologic symptoms. It seems to me that in a clinical practice, one hears this issue asked about a great deal, not only by the agricultural worker or family but the people across the fence from them. Please remember that even in the most rural of communities, close to half of the people are just rural dwellers and not agricultural farmers or workers. Neurologic symptoms tend to be vague. They tend to be similar, whatever the cause. There seem to be ineffective inter- ventions, and the prognosis seems to be very difficult to ascertain. So any further information that we can get in that regard, and especially good diagnostic studies, I think would be very helpful. With regard to cancer, I concur with by Dr. Blair, also alluded to earlier, that the farmer may well be the "canary" or the test animal for cancer in our society. We are seeing an increase in many cancers, and so this is very relevant information. I think the idea of synergism between chemicals is basically a given. For example, there is the farming practice of Surgeon General's Conference on Agricultura! Safety and Health - 1991 271 Research - Chemical and Biological Hazards applying two herbicides for a specific weed where it is recognized that plants are developing resistance. If they need to use synergism against the pests, I suspect that synergism applies to the unfortunate vic- tims as well. Finally, looking at the issue of gases and vapors, one of the difficulties that I have as a clinician is obtaining good, adequate measurements. That is not necessarily because of the fact that there are not good industrial hygiene methods, but we have to appeal to people like those in Iowa to turn out these people much more quickly and with an agricultural background. Clearly we need that kind of consultation. 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. I A specific problem is the allergic responses to some of these substances such as pes- ticides, antibiotics, or whatever chemical you wish. Both farmers and clinicians need to recognize that many of these are sensitizers, so the chemical that has not been a problem in the past may become one in the future; at least clinically that appears to be the case. Otherwise, the farmer and clinician tend to dismiss the idea that a particular chemical may be the problem. Second, I want to speak to the issue of antibiotics again. My bias is that a big part of the problem with feeding an- tibiotics to animals is not residual an- tibiotics in the animal, but the change of the local environment in which the animal is present. Perhaps these antibiotics may be an allergen, especially for the farmer, and not necessarily for the person ingesting the food. I think it is good that Dr. Popendorf pointed out that the manure gas is, for example, something that needs to be understood much better by clinicians. For example, the case in the Upper Peninsula of Michigan to which Mr. Graham referred was reported in some sources as methane poisoning. Although methane was undoub- tedly present, I agree with Dr. Popendorf that the most likely agent was hydrogen sulfide. The relevance is in emergency medical practice. Hydrogen sulfide, if you are going to treat it, should be treated with the nitrates in the cyanide kit; whereas if you are dealing with methane, it is primarily an issue of oxygenation and ventilation, which does not necessarily need specific treat- ment. RECOMMENDATIONS Finally, I would like to close with just five recommendations. 1. We need to work to help the clinician and, therefore, the farmer on specific diag- nostic methods and treatment methods for agricultural problems. If there are specific treatments that should be different for different types of agricultural exposure, we need to know those. 2. We need to look much better at the issue of promulgation of this information as reference works. 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. Because of the distance typically between 272 Papers and Proceedings A Clinical Perspective, May 2, 1991 the clinician and the farmer, that will not happen without specific efforts. 3. We need to increase the status of such entities as state and local health departments and industrial hygiene and provide adequate resources for them to respond to the clinical needs of farmers. 4. We need to deal with the issue of the rural medical infrastructure in general. If the rural medical infrastructure is in dif- ficulty, then these agricultural health problems cannot be addressed well. 5. One of the things that I find personally important-and I think many of my col- leagues would agree-is the positive aspects of medical practice in the rural, and especially agricultural, communities. The patients generally are very appreciative of the care they get. They are very willing to go into rehabilitation. In fact, most clinicians complain that rural patients want to go back to work before they are well.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 273 Surgeon General's Conference on Agricultural Safety 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, 1991, Des Moines, Iowa FARM MACHINERY AND VEHICLES By Thomas L. Bean, Ph.D. Safety Leader, Ohio Cooperative Extension Service Ohio State University Preparation for this presentation included the review of literature, accident reports, unintentional injury data, and technical and professional papers from the United States and foreign countries. One of the earliest was a 1931 study by J.R. Jewel1 from the Cooperative Extension Service, University of Nebraska. After such an extensive review, it is appropriate to pro- vide a broad, general brush to this topic and indicate the most significant items that stood out as general findings, which seemed to run as a thread or recurring theme in much of the literature. volving" tractors were the most common type of machinery-related trauma. Tractor over-turns, it appeared, were in- volved in the majority of agricultural fatali- ties. Many studies indicated that youth and the elderly were most often associated as an at-risk population. The studies varied, though, when you com- pared those using statistics from govern- ment agencies that were not gathering the appropriate and associated data with youth. AGRICULTURE, A HAZARDOUS OCCUPATION The most obvious finding was that agricul- ture, based upon statistical studies, was usually classified as a hazardous industry or occupation. Most early studies concen- trated on on-farm injuries as occupational in nature. In either case, the majority of studies indicated that farm equipment was the single factor most associated with on- farm injury. Farm equipment accounted for 40 to 60 percent of deaths and injuries in the ma- jority of studies, followed very closely by livestock injuries and falls. Numerous types of farm machinery have been im- plicated in all studies, Since the majority of farm machinery is associated with trac- tors, it stands to reason that injuries "in- In either case, the majority of studies indicated that farm equipment was the single factor most associated with on-farm injury. I Injury data for youth under a certain age was often excluded from the data base. Many studies conducted by those of us in the field have included unintentional inju- ries, which have occurred in the lower-age group, and recognize the associated prob- lems. GENERAL DUTY The opportunity presents itself to include some homespun theory. This happens to be a theory of mine: on family farms, older tractors and equipment are often reserved for general duty while newer 274 Papers and Proceedings 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 is often done by the youth or the elderly. The typical farm- er, 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 doing field-related operations. As a result, when you combine the inexperience of youth and the dimin- ished capacity that comes with aging (be- cause the elderly or youth usually do this general duty) with the inherent danger of the equipment, you have an increased potential for trauma. HIGHWAY HAZARDS Few studies have centered on farm ma- chinery and the hazards associated with highway travel. This is an area that needs additional study. A recent study by Farm Journal surveyed 100 of their readers. Those readers indi- cated that traveling on roads to reach the field was one of their primary safety con- cerns. Of concern to these readers were faded slow-moving-vehicle (SMV) em- blems, implements without brakes or lights, no turn signals, no clear differentiation between the turn signal and the flashers, and no stops or pins to hold the equipment in transport. Some equipment is held in transport by the hydraulics. There is also a problem of farm vehicles being exempted from state motor vehicle laws. These exemptions are based on agriculture being a protected class, similar to the farm exemption by OSHA. The Farm Machinery and Vehicles, May 1, 1991 protection agriculture is given as a protect- ed class varies from state to state. A review of state laws will reveal that a farm tractor is usually well-defined, which means that many state legislatures can recognize a farm tractor. However, when you explore legislative definition of imple- ments of husbandry, farm machinery, farm wagons, farm trailers, or special vehicles (another term in many state laws for such farm equipment), you discover a gray area. The typical legislature fails to define them. Exemptions are set by definition or the lack of definition. This is the problem. It is a learning activity that needs to be con- ducted with state legislatures. Farm vehicles-varying, again, from state to state-may be exempt from registration. They may be exempt from any kind of inspection, adequate lighting requirements, braking requirements, or other require- ments, which are normally associated with other types of vehicles. As an example, if you study the West Vir- ginia laws, you will find that farm vehicles may be exempt from braking requirements. If you do not have to have brakes, you are exempt. As for a driver's license, most states exempt agricultural vehicles and, therefore, the people that run them, from any kind of licensing requirement. Age or physical condition does not make any difference. They are exempt by defini- tion. It is a problem. An eight-year-old can operate a farm vehi- cle on roadways. Yet all other drivers may need a driver's license to operate motorcy- cles, cars, buses, trucks, etc. This is not so for farm machinery. This is a sample of Swwm General's Conference on Agricultural Safety and Health - 1991 275 Research - Mechanlcal and Physical Hazards the many other exemptions caused because agriculture is a protected class. STUDIES IN OHIO Some of the studies that we are doing in Ohio, I will briefly present to you. We have a project now with a special agricul- tural population, the Amish. Buggy Safety If you were to view Ohio highway safety statistics, you would find there are three classes of agricultural highway accidents. One is tractors, the second one is farm machinery, and the third one is buggy accidents. Are buggy accidents part of the agricultural problem? The answer is probably, because the Amish really only use buggies for two things: 1. To do some activity concerning the farm. 2. To go to church. So buggies can be a potential agricultural problem. We are embarking now on an effort to work with Amish youth in their schools on safe buggy operation. Highway Safety We are conducting a second project in cooperation with our Highway Safety Of- fice. In the fall, we will be conducting a survey of 1,200 farms in an effort to get the farmers' perceptions of the hazards of operating agricultural equipment on the state and county highways in Ohio: 1. What type of equipment is actually being operated on the roadways? 2. What are the conditions under which farm machinery is moved on the road- ways? 3. What are the major problems with op- erating farm equipment on roadways? 4. What is the road worthiness of farm equipment? RECOMMENDATIONS Although there are many that could be made, the following are some recommen- dations for research and action, 1. We need to continue efforts in research on human sensors and automatic shut-offs. If a person is too close to the tractor in a given situation, it should not start or con- tinue to operate. 2. Research on roll-over protection on older tractors should continue. 3. There should be aggressive inclusion of safety in all of ASAE and other standards. 4. There should be research conducted on the lighting and marking of agricultural equipment. 5. There should be some consideration for a uniform motor vehicle code on farm tractors and machinery used on the high- ways, including set definitions of types of agricultural equipment. This would pro- vide a model for states to consider in fu- ture legislation. 6. There should be continued studies on agricultural safety educational techniques that work.0 276 Papers and Proceedings Farm Machinery and Vehicles, May 1, 1991 REFERENCES 1. Jewell, JR; Farm and Home Accidents: Their Cause and Prevention. Extension Circular 5578, University of Nebraska (1931). 2. Ottey, Audra and Charlene Finch; "Farm Journal Survey Shows Road Travel Tops List of Safety Concerns." Farm Journal, Volume 115, Number 3, February 1991. QUESTIONS John Hahn: I am with the Iowa Division of Labor. Regarding the ROPS, the rollover protection on the tractors, I have heard no mention about the need to use a seat belt or a safety harness to keep from being thrown out of the tractor on to the ground where you can be crushed by the crush-proof cage as it rolls over. Dr. Thomas Bean: Deftitely that is a problem. We-1 say we-a lot of us know that that is a problem. I can go to any farming group, and I ask how many have rollover protective structures-&her cabs or poles-and get a good many hands. Then I ask the next question, "How many use their seat belt?" You will probably find zero or very few. We realize that it needs to be addressed as a behavioral problem. Farmers tell me the reason is because they get off and on their tractor so many times. Something has to be designed or implemented or there has to be education about what is acceptable to that group as far as belting them in on the tractor. Often I try to use the example of highway safety and ask them, "Do you use it when you ride on the highway, at least ?" Still the answer is very, very low. John Hahn: With seat belts on things like tractors-I once looked into seat belts on forklifts, and there is a big controversy on forklifts, and there is something that they call the fly swatter effect. That is, when you fall off an elevation on a forklift, is it better to be fastened in there so that when you hit, your head goes bump, bump, bump against the pavement, or is it better to be unrestrained ? There probably is some of that in agriculture also. (inaudible): I am back. One thing on your comment on the forklift. Generally, other construction equipment works with a seat belt. What some companies have done to keep the guy's head from being pounded into the ground is just to take metal screening or expanded metal and put it on the side and that way he can just cut his head up once against the screening when he goes. John Hahn: I was talking about forklifts. I just might add, I know that there are a lot of problems on the issue of seat belts, when you put a screen or that type of thing on. I know it is more of an issue in logging than it is, maybe, in farming, but the idea is that once you put that screen in, you have now taken that person, and if he has the seat belt on, he can become a human pincushion. The point I was trying to make is, this whole issue of seat belts is a very tough one because, depending on what industry you are working in, there were a lot of complaints when NIOSH talked to OSHA and recommended seat belts on skidders in logging. The main complaint we had was you had screening devices on those skidders to provide something like a cage for that person whiie he is in the skidder. When it rolls or rolls over or while he is moving through the woods, if sticks, and that kind of thing comes in through that mesh, he cannot get out of the way if he has his seat belt on. I have not heard that complaint yet from farmers, but at the same time, these are the types of issues that you have to learn to resolve when you start talkiig about the use of seat belts on this type of equipment. There are other factors that we have to be aware of and we cannot make just a blanket statement that seat belts are the best until we start getting some good information and look at some of the other types of alternatives, such as possibly a seat bar. We are not sure what is going to work. (inaudible): I just have a comment on the seat bar versus seat belts. In Canada, log skidders are being equipped with seat bars, and it looks like they are getting very popular. Surgeon General's Conference on Agricultural Safety and Health - 1991 277 Surgeon General's Conference on Agricultural SaMy and Health FMMSAFE 2000 o A Nafional Coalition for Local Action Convened by the National Institute for Occupational Safety and He&h April 30 - May 3, 1991, Des Moines, Iowa MUSCULOSKELETAL HAZARDS By David Cochmn, Ph.D. Industrial Engineer, U.S. Occupational Safety and Health Administration Good afternoon. I feel a little out of wa- ter in that my specialty is not in agricul- ture. I have been asked to talk about ergonomics, musculoskeletal disorders, and agriculture. As I started thinking about the agricultural environment, I realized that I see it as a hostile environment. It is about as hostile an environment as we have in this country. We have chemical and dust hazards, ma- chines that can take your bodily parts rather easily, slips and falls, amputations, death, noise, and temperature hazards, including cold stress and heat stress. We also have whole body and segmental or limb vibration, explosions, and infectious diseases. Lastly, on my list, we have musculoskeletal hazards. Quite honestly, I think most of you and most people in agriculture do not consider musculoskeletal disorders or musculoskele- tal hazards very much. If you do, you think of back injuries. Back injuries prob- ably are far and away the biggest problem that my discipline, which is ergonomics, deals with. There are, however, cumulative trauma disorders of other sorts. I consider back injuries cumulative trauma. In many cases it is a one-instance injury, but in most cases we strongly believe that they are cumulative. The more times you lift exces- sive weight, the more times you stress your back or strain it, the more likely it is that 278 you will have a back injury. It is a cumula- tive problem. In addition, we have problems of the up- per extremities. I am going to go into that in a minute. I thought, that problem is probably not present in agriculture. I was talking to a friend of mine, Barbara Silverstein, who was with the University of Michigan and is now in the state of Wash- ington. She was telling me that the top oc- cupational category suffering from tendini- tis in the state of Washington is farmworkers. They do not have the foggi- est idea why or where it is occurring. Ergonomics and cumulative trauma do exist in agriculture, and probably a lot more than we realize. CUMULATIVE TRAUMA DISORDERS Now, being a professor I have to educate a bit, just in case you do not know some of the things that I think are important. I am going to talk about some of the cumulative trauma disorders. These can be of the upper extremity or the lower extremity-not necessarily concentrating on the back. Tendon-related Disorders First, tendon-related disorders usually occur by overuse of, or stretching of, or excessive forces exerted by these tendons. The most common is tendinitis, inflamma- tion of the tendon tissues. Another very Papers and Proceedings common illness is tenosynovitis, separate or concomitant inflammation of the tendon and its sheath. I normally think of it as the sheath. I do not know how good your anatomy is, but we have tendons. Tendons really are ca- bles in the body. Around those, in strate- gic locations, we have soft tissue that pro- tects the tendons, called sheaths. They are a lubricated tissue. As the tendon slides around a corner or moves past bones, it is protected by the tendon sheath. When the sheath becomes inflamed, it is normally called synovitis. Sometimes when the tendon is involved it is tenosynovitis. This is common in normal manufacturing operations. It probably is common in farming or in agriculture, but we do not have much data. Carpal Tunnel Syndrome Second, carpal tunnel syndrome gets all the press. It is a problem in the wrist. One of the nice things about this one is that all the reporters are suffering from this. Since they are suffering from it, they write about it. There is nothing like hav- ing an interest in your own preservation. Carpal tunnel syndrome is indicated by a numbness or tingling on the palm side of the first two fingers, part of the third fin- ger, and the thumb. It is the damage to the median nerve that goes through the carpal tunnel. The carpal tunnel is in the wrist. It is bordered on three sides by bones and on the fourth side by a strong ligament. None of these give very much. So when you use your tendons a lot, you get tendinitis or tenosynovitis. swell. When you do that, things Musculoskeletal Hazards, May 1, 1991 When they swell in a confined space, they compress on each other. You get a circu- lar problem in that the more they swell, the more they are damaged, the more they want to swell, the more they are damaged, and it keeps going around and around. It gets worse and worse. The best thing to do is quit doing whatever you were doing that made it happen. It is like the dentist I went to one day. I said, "You know, my teeth hurt when I do like this," and he said, "Well, do not do that." It is the same way with carpal tunnel syn- drome and all of these things. If you back off and do not do whatever is causing it as much, frequently it goes away, and you do not have to end up in very expensive surgery. You do not have to end up disabled. Raynaud's Syndrome Third, Raynaud's syndrome, or occupation- al white finger, is a shut-down of the circu- latory system. It is caused by exposure to vibration in the hands. I am not familiar with this disorder in the feet, but it might happen there. So segmental vibration or arm and hand vibration can bring this on. I have not driven many tractors, but the ones I have driven vibrate. Old tractors are the only ones I have ever driven, be- cause I do that kind of work you are talk- ing about. I have a farm. I am a city boy, but I bought a farm. I have an old Ford tractor, and it does vibrate. There is a lot of vibration out there. There is also non-occupationally caused Raynaud's syndrome. Some people get if without being exposed to vibration; mostly it is women who acquire it this way. Surgeon General's Conference on Agricultural Safety and Health - 1991 279 Research - Mechanical and Physical Hazards Let me go back-there are just a few of the agriculture-related cumulative trauma disorders. There are twenty-some repeti- tive motion related disorders of the upper extremities. There is rotator cuff, pronator teres syndrome, cubital tunnel syndrome, and epicondylitis. These are just examples. Do not get the idea that there are just a few of these disorders. What do you do about cumulative trauma? First, I am getting the cart before the horse, but you have got to work on what is causing it, and so you work on the tools and the work station. Normally I deal with a fixed work station, and in agriculture that is not necessarily true. So the problem is more difficult to deal with. We work on the methods: how people do their job, how they do the tasks. I put training and monitoring in there. It is hard to deal with changing behavior; because I do not have a lot of faith in training if it is easier to do something one way than the other. I do not think we have a problem with work pace in agriculture, certainly not in the farming part of agriculture, maybe in other places. I am going to skip idle time; that is production-line-oriented. RISK FACTORS There are six risk factors that we look for in cumulative trauma. Repetition First is repetition, high repetition. If you are doing something highly repetitive over and over again, it tends to cause these problems. Repetition is rampant in things like processing of fish, meat packing, and luggage making. Is high repetition present in farming? I do not know. I do not think anybody knows. My guess is that repetition is not where the major problem is. At the other side of the curve, statically maintaining muscles causes problems. Statically loading muscles causes them to be exerted. They build up metabolic by-products. A lot of the time the circula- tion is cut off so that nutrients are brought into the muscles and the by-products are not carried off and you get rapid fatigue. Very static operations are a problem and very dynamic or repetitive operations are a problem. High Force The next factor, high force, is probably present in spades in agriculture, especially in maintenance-type things. Farmers and agricultural workers are notorious for ig- noring good sense and picking up things they should not pick up. They exert high forces. Things that require pinch grasp go along with that. Anytime you start using the tips of your fingers to exert force, you are not mechanically effective. It puts the body at a bigger disadvantage than normal. So we have pinch grasp, we have static grasp, and what I call a press grasp, any- time you are pressing with hands. In in- dustry when you are boxing things or when you are folding boxes or you are pressing down on tape, you start getting incidences of carpal tunnel syndrome. Those motions tend to be highly repetitive and with a press at the end of them. Gloves cause problems. Gloves cause people to overexert for two reasons: they interfere with the grasp, and they interfere 280 Papers and Proceedings with the feedback, so people tend to over- grasp. Gloves are worn a lot in agricultur- al work. Posture First, let us talk about shoulder posture. Anytime you are reaching down and be- hind or you are putting your elbow up in the air, you are doing something that a meatpacking company I have dealt with calls winging of the elbows. When they look at any kind of a task, they look for that. That causes problems with the ten- dons and the nerves. Repeated inward and outward rotations, especially when you are going from the maximum of one to the other, is called pronation and supination. Inward and outward. Think about rotating the fore- arm. If you do that frequently, it causes problems such as cumulative trauma disorders. When tasks are highly repetitive or are highly forceful and involve bending the wrist, they cause the tendons to wrap around a corner. They are pressing against those soft tissues that are supposed to lubricate their movement. Sometimes they press against the median nerve and do damage. We want to keep the wrist in a neutral posture as much as possible. Mechanical Stress Concentrations Anywhere on the Skin If you have somebody who has to maintain a pressure on the hand or anywhere else, it is a problem. Resting their arms on sharp edges or lack of a good armrest can cause nerve damage. It can cause circulatory or circulation damage. Musculoskeletal Hazards, May 1, 1991 If they use their hand as a hammer, like banging hubcaps on, banging things loose with the palm of their hand or the base of their hand, this causes nerve and circula- tion damage. Mechanical stress concentra- tions anywhere on the skin can cause prob- lems. A lot of the tools we use-pliers, screwdriv- ers, things like that-press right in the palm of the hand where you have the tendons and the nerves running, and they do dam- age. Vibration There are probably people in this audience who know a lot more about vibration than I do. We have whole-body vibration, and we have segmental vibration. Dealing with each is different. The frequencies that cause problems are different. As far as I can tell in reading the literature, there is no good number as to what is excessive and what is not. There are some guidelines. NIOSH put out a publication on this with- in the last year.' It is pretty good, but as far as I could tell there is no magic num- ber that says, "When you start exceeding this number, you have got problems." Cold Now, when you throw in cold with any of these other factors, it accentuates it. When you throw in vibration with any of these other factors, it accentuates it. If you put cold in the environment and you get cold hands or cold muscles and ten- dons, it accentuates the problem. If you are doing some of these things and your body is vibrating, it accentuates the prob- lem. Surgeon General's Conference on Agricultural Safety and Health - 1991 281 Research - Mechanical and Physical Hazards If any of you are familiar with industrial hygiene or familiar with chemical hazards, you know that OSHA sets permissible exposure limits (PEL's). Those are based on single-chemical exposures or single-agent exposures. She was telling me that the top occupational category suffering from tendinitis in the state of Washington is I farmworkers. No one knows what the combined pres- ence of toluene, gasoline, and carbon mon- oxide does to you and at what concentra- tions that combination is a problem. WORK DESIGN It seems to me in agriculture that we have a problem of work design. We have the task that people are doing. We have the machinery and equipment they are using. We have the products that they are pro- ducing and the products that they are us- ing. All of these combine to be potential problems. One of the things that I am interested in is packaging. Things that people use on the farm are packaged in anywhere from 5- to loo-pound quantities. I have seen people picking up 50-pound containers or loo-pound containers and standing in pre- carious situations and pouring them into hoppers or whatever. The same thing in ergonomics occurs. We have repetition here. We have force. We It is no surprise that we have back injuries. have posture. We have mechanical stress- It is no surprise that we have slips, trips, es. We have cold and vibration. All of and falls. In fact, if these were in regular these things combine in some way to cause industry-if I were not working for OSHA problems. at the moment-I would say, "OSHA might shut them down." It is hazardous. One of the main questions I get is, "How many repetitions are too many reps? How much force is too much force?" We do not know because the problem is almost al- ways in combination with something else. You cannot isolate them. We know that almost no force is required if the repeti- tions are high enough, because we have people that sign for the deaf that get car- pal tunnel syndrome. This is far and away the easiest to read and best book on cumulative trauma of the upper extremity.2 It was originally put out by NIOSH, and it is now available from Taylor and Francis for about $23. There is an 800 number. They are located in Phila- delphia. RESEARCH NEEDS I could not find data or anybody who knew of any data out there relating to cumula- tive trauma disorders, and there is not much relating to back injuries in agricul- ture, which I see as the number one re- search need. We have a dearth of data. My understanding is NIOSH is beginning to act on this and that there are several programs. I think there are about three programs that may start to collect more data. I will admit that I may be ignorant of some of the data that has already been collected. 1. From my point of view, we need to determine the nature and the extent of the 282 Papers and Proceedings Musculoskeletal Hazards, May 1, 1991 problem. We also need reporting. It is my understanding that most farmers have never heard of an OSHA-200 log. 2. We are going to need epidemiological studies. 3. We are going to need studies on pack- aging and how to repackage things. 4. We need studies of what are the high- incidence tasks out there. Now some of them you know, but I would venture to say that if we ever arrive at cumulative data, if it is out there, we will find some tasks we do not know about now. 5. We also need to research what can be done in machine and equipment design to minimize cumulative trauma disorders, if that is what is causing them. 6. We need to figure out what the costs and the benefits are. 7. Lastly, and not necessarily least impor- tant, we have to come up with things that are acceptable to the people doing the work. You know as well as I do that there is no more independent group than farmers. Maybe truck drivers challenge them, but farmers are very independent. You put guards on machinery, you do things that are supposed to be for their benefit, and they blow it off. We have to come up with solutions that are acceptable to this com- munity.0 REFERENCE Putz-Anderson, Vern; Cumulative Trauma Disorders: A Manual for Musculoskeletal Diseases of the Upper Limbs. New York: Taylor & Francis, 1988. QUESTIONS Ronald Schuler: I am from the University of Wisconsin, Madison. Dr. Co&ran, have you heard of milker's knee, and is that a cumulative disorder? Dr. David Cochran: I have heard of it. I am not familiar with it. My guess is yes, but I do not know. Tom, do you know? Dr. Thomas Bean: It is very similar to miner's knee. It is a bursitis, an inflammation of the bursa of the joints, because of the constant bending, and the repetition, and the force as you are kneeling against the ground. Dr. Wesley F. Buchele: I am Wes Buchele from Iowa State University, retired. Dr. Co&ran gave a list of things you ought to conduct research on. I would like to add to that list, if I might, putting a screen over a wagon to permit people from sinking in the grain when they happen to be on grain. I happen to be one that thinks we should put extra seats on the tractor, with seat belts, because people are going to ride tractors and are going to have more than one person on the tractor. Therefore, we ought to start taking care of the problem as they do in Europe. I also think that we should think about putting floor boards on tractors to eliminate people being run over by tractors, which they are from time to time-run over by either a front wheel or a back wheel. We no longer put planters and cultivators in that area. I think we also ought to put a seat bar like on a ferris wheel or on forklifts. They have taken care of the forklift problem by putting a Surgeon General's Conference on Agricultural Safety and Health - 1991 283 Research - Mechanical and Physical Hazards seat bar on the skid steer loaders. We should have seat bars on tractors. We should also promote the use of guards by retrofitting. I think that we need to retrofit roll bars on tractors, guards on power take-off shafts, and guards on augers. Mark Veazie: I am from the Johns Hopkins Injury Prevention Center. Dr. Co&ran, have you done or are you aware of any assessments that have been done on cumulative trauma risk with manual harvesting typical of migrant and seasonal farm work? Dr. David Co&ran: I am not aware of any, but there may be. 284 Papers and Proceedings Surgeon General's Confrmnce on Agricultural Safety and Health FARMSAFE 2000 9 A National Coalition for Local Action Conumed by the National Institute for Occupational Saristy and Health April 30 - May 3, 1991, Des Moines, Iowa ELECTRICAL POWER By Robert McLymore Extension Safety Specialist, North Carollna State University Dr. Glen Hetzel contributed a lot to this presentation, as well as some of my other colleagues. In the event that I did not call you to get some background information, do not feel bad. When they have the pan- el presentation tomorrow, you can answer some questions. Electrical safety areas of concern are elec- trical wire components, electrical wiring systems, overcurrent protection, ground- fault interrupters, and grounding. These terms may not be important to you now. Maybe as you think in terms of what you do at your home, these terms can have some significance. ELECTRICAL WIRING SYSTEM The reason why I am talking about electri- cal wiring components is that we need to know where power is coming in on an operation. We know that it is coming in several plac- es-at the service entry riser and the meter. You may have a meter on your home. Think about it. There are meters on farms. Farming is not like that picture that you saw-that poster-where you see them out in the fields smiling, laughing, carrying on, and having fun. It is much more. There is power somewhere on that farm: overhead power; there is underground power coming to that farm. It all has to go through a certain code. Figure 1. An Example of a Wiring Box. For these components, you should only have licensed electricians install that elec- tric wiring, and it has to be inspected. This may be what one of those wiring boxes looks like (Figure 1). You have never opened one up, have you? You have never opened your fuse box up Surgeon General's Conference on Agricultural Safety and Health - 1991 285 Research - Mechanical and Physical Hazards at home, have you ? It does not look like that. It has circuit breakers in it, has it not? This assures that the wiring will meet the requirements of the National Electric Code (NEC), as well as local safety codes, which may be in your home or in your state. There are requirements for agricultural buildings in Article 547 of the NEC that specifies the type of materials to use for safety and protection is the environment in which this wire is contained. Dusty or damp conditions exist in agricultural build- ings, which may create explosive atmo- spheres or corrosive conditions for electri- cal metal fixtures and equipment. Did you ever think about that? These things, in themselves, may be explosive. That explosion may be in the form of a fire. That is what those conditions may be. Figure 2. The Atmosphere of a Chicken Barn. How many of you know about poultry. You ate it today at lunchtime. Was it good? Those are dusty, damp, dirty condi- tions-if you did not catch it in the last slide, that is what dust looks like when it is in suspension in the air (Figure 2). This is what dust looks like when it is coming out of that vent that is adding air into that house (Figure 3). It is collecting particulate matter. Will that dust bum? Is it truly just dirt, or is there partially dry material in with that material? OVERCURRENT PROTECTION The next part is overcurrent protection. There are specific types of overcurrent devices. You have the plug, the cartridge fuses, and the breakers. Figure 3. Dust on an air vent from a Chicken Barn. Fuses This is what they look like (Figure 4). There is the fuse (right, center in Figure 4). You have seen this type at home be- fore, a screw-in fuses. That is another type of cartridge fuse (also in Figure 4). Some are delayed so that when a surge of power goes through them-too much electricity-they are de- layed. They protect the conducting wire. You are probably more familiar with breakers in a box at home (Figure 5). The fuses and breakers are installed to protect the circuit, not the appliance. 286 Papers and Proceedings Figure 4. Examples of Fuses. Figure 5. Examples of Breakers. There are special fuses that are available to protect the electrical equipment, and it is important that we realize that overcurrent devices are sized to carry no more current than the circuit wire is rated to carry. Is that important to you? Is it important to that farmer? Yes, it is important because he has some expensive equipment that he is using, and overcurrent protection is needed to protect it. What about for his own personal life? Electrical Power, May 1, 1991 Think about you and the overcurrent de- vices that may be in your home. You have wires like this that are made to carry a specific amount of electricity. If contact is made with a live part, will the overcurrent device trip and protect human life? No. Well, I used to work at a funeral home, so I have seen it, too. The human body will receive a lethal shock if the current that flows through the body is 0.01 amperes or greater. A fuse or breaker will not provide protection to the human body. The wire protected by the proper size of the fuse or breaker will not allow the temperature of the wire to exceed safe operating condi- tions and cause what we have on some farms-explosions in bins and fires where material may be stored, like hay or dry feed. GROUND-FAULT INTERRUPTER The ground-fault circuit interrupter (GFCI). Are you familiar with that term? Do you know about it? You have seen it a lot? You buy devices, appliances, that have GFCI's on them. It is the most re- cent device that is used and designed to protect human life from shock. It is designed to detect minute amounts of current, 0.005 amperes or greater leakage, from the circuit. It is supposed to trip the circuit off. The overcurrent power and the conven- tional tripper turn the circuit off when there is a current flow that is in excess of the rated value of the breaker. The GFCI may be a separate device or it may be incorporated within a breaker. It is de- signed to give protection from that lethal Surgeon General's Conference on Agricultural Safety and Health - 1991 287 Research - Mechanical and Physical Hazards shock in a fraction of a second. It can be used on any 120-volt circuit. It is also required in places at home by NEC. These places are in the kitchen, in the bathroom, in the garage, and exterior sockets on the house. How many of you use extension cords outside to, perhaps, vacuum the car? Has the circuit ever tripped off for you when you were outside ? Be thankful that they invented the GFCI. You would not be here at this conference without its protec- tion. Think about farmers. Are they always in dry locations when they are utilizing some of their appliances, some of their tools, like a skill saw or maybe a hand grinder? There is one particular person who was using his welder when it was raining. He could not work outside, but he had some welding work that he needed to do. He did not want to use the welder inside his shop because it was too small, too tight of an area, and there would be too many welding fumes. He laid down a piece of sheet metal; he pulled out the piece of equipment he was going to do some weld- ing on, and he hooked it up to the welder. The coroner tells us what happened to him next. He was shocked and killed. It was raining. There was the metal. There was the electrical appliance, with the electrical source coming in through the welder, and the welder was not properly grounded. There are three types of and locations for these devices. We will find that these GFCI' scan be at a distribution box to protect the entire circuit or they can be at a receptacle box. They can also be in an extension cord. GROUNDING Do you see the third leg (Figure 6)? These are designed to give you continuity, to give you the grounding so that you do have a proper ground in that extension cord. That term "third-wire" ground and bonding should be understood for safety. Electrical bonding means to connect all metal parts in the building together and that this be connected to the system of the ground. The proper grounding of the system helps prevent stray voltage, which is a term that a lot of my colleagues know about. It is not voltage that wanders around aimlessly saying, "I am looking for a victim." It is voltage in itself that is not going to a prop- er ground. It provides a low resistance path for the neutral current to go to the ground. That third-wire ground is the conductor in the wiring system that extends from the ground to the main distribution panel to the electric device and looks similar to that (shown in Figure 6). That is what is plugged in for your hot side and cold side. That is the ground that goes in. This is what it looks like on the other side, on the male side. That is the female receptacle and the male receptacle (Figure 7). That is why bonding is so important-I talk about it twice be- cause a lot of injuries and deaths could be avoided if the electrical bonding process was followed. The last slides I have are getting more back to the topic of what to do from an 288 Papers and Proceedings Electrical Power, May 1, 1991 Figure 6. Example of Three-wire Receptacles. Figure 7. Male and Female Receptacles. agricultural perspective, or even from just regular people's perspective. GENERIC PROBLEMS When you start thinking about your uses of electricity, there are generic problems I see that may arise on the farm. Wire Damage One is damaged wire resulting from crush- ing or cutting incidences where wire can be enclosed in a conduit material or exposed. In Figure 8, you see wire that is encased - either a metal case-like conduit or in the hard rubber, plastic, or the other material that you have that wire comes in. When you are working around a farmplace, you are using a lot of equip- ment. Farmers are using equipment that backs onto it. Two-Prong Adapters These are what I call pseudo-outlets (Fig- ure 9). These are two-prong plugs. The significance of these two-pronged plugs is that there are two-prong adapters being used with various equipment that requires that third wire ground; that third leg, so they can properly ground the electricity that is flowing through. Figure 8. Examples of Wiring. How many of you have remodeled your homes lately, or done anything inside the home where you changed a light fixture or maybe have changed a wall socket? They sell what I would term pseudo-outlets for you. They were originally designed for two wire and replaced with a cover for a third wire Surgeon General's Conference on Agricultural Safety and Health - 1991 289 Research - Mechanical and Physical Hazards Figure 9. Two-prong Plug and Adaptor. ground. It looks like it is grounded prop- erly, but it is not. This is what it may look like (Figure 10). You have them there. Who is to say that has just been put into a two-prong outlet or through the wall sock- et. Assume it is not grounded unless you look behind it. I f. i Figure 10. A Three-prong Receptacle. Wire Nuts Do you know whether or not it has been grounded properly ? Can you tell? Can you walk up to and look at the socket and tell that it has been grounded? Some people, when they replace their wire nuts, do not necessarily use the wire cover on the nuts (Figure 11). They may use plastic. They may use tape. They may squeeze them together. But it may call for the wire cover, the wire nut, the yellow cap That is why those 250 fatalities occur. Some of them did it before, some of them did not. This is a term which is not a scientific term, but I like it. Have you heard of a term called "shade tree mechan- ics?" This is what I call the "jack-leg" wire mechanic. That means that he is not fol- lowing codes for the types of materials he uses. This is a faulty method of installa- tion. There is a hot wire that goes through the wire. There is a hot side and there is a cold side. You can hook the hot side through the switch and the cold side through the switch so the wire is running through the white side. When you shut if off,. the switch goes off, but it is still hot. You start working on that socket. You start taking it out of the wall to repair it; it is still connected. The power is still flowing through it. Was it installed using NEC codes? Figure 11. A Wire Nut. 290 Papers and Proceedings to go over that wire where that connection has been made. A lot of jack-leg wiring will go on like this. You have a conduit box there designed to carry only so many connectors inside. They are rated because of the amount of heat that is given off by each connector. They build up additional heat inside. This situation is an excellent point for a fire to occur, unsuspectedly, for the wiring itself to degrade from the heat, causing it to touch the metal casing and the metal conduit around it. A person could then touch it and die. Overhead Wires I would be remiss without talking about what we traditionally think about on the farm where we have equipment that is being pulled around: getting in contact with overhead wires. There are labels. There are safety shields and warnings in place to help people to avoid that situa- tion. Most people, farmers and agriculture workers, do try to obey this. Sometimes, however, they get too busy, and they forget for a few moments. That moment of care- lessness may end up with that piece of equipment getting in contact &th that line. We know how electricity kills. It is going to go through what is grounded the most. A cartoon character can live through it. The human body cannot. CONCLUSION Inspections Need to be Made In conclusion, I would like to offer the following. Inspections need to be made on Electrical Power, May 1, 1991 the farm. They need to be made on a scheduled basis and immediately when things are damaged. These inspections will reveal problems before they become life- threatening situations. Those conduits, if they are bent, need to be checked. How many times have you put down an electric cord and said, "Well, I am only going to use this temporarily here; get some power to do this little func- tion." NEC Codes Should be Followed Five years later you still have that same electric cord in place. Think about it at home. You have an electric cord you have been using someplace, have you not? That moment of carelessness may end up with that piece of equipment getting in contact with that line. We know how electricity kills. The NEC should be followed. It helps everyone on that farmstead or that place. They can have some assurance that there is some safety, that they know that it is supposed to be working like this. You know what kills a lot of people-things that "were supposed to be," (and were not) and sometimes we do not find out until after the fact. Safety Procedures Adopted There are safety procedures that should be adopted. First, if you are going to do your own work, you need to have someone there who can check it over before you start using it. What happens with people Surgeon General's Conference on Agricultural Safety and Health - 1991 291 Research - Mechanical and Physical Hazards doing their own work is that they are al- ways trying to save on budgets. Other problems are putting things up and not checking to make sure that they have been wired or that they have been ground- ed properly. Maybe someone cut down on the materials that are being used because he or she is just going to add some power to a particular room or building on the farm. I have seen places where you have wires extended over here, hanging down-a light bulb extended hanging down from the rafter. That in itself is an accident waiting to happen. They can be avoided. We are trying to get codes followed, in- spections made, and safety procedures adopted. When you work with electricity outside, make sure that you do not use equipment unless it has been properly grounded with that third wire. Make sure that everything has been bonded together so that it is properly grounded. Only then can we address this problem effectively.0 292 Papers and Proceedings Surgeon General's Confetmce on Agticuttural Safety and Health FAR&&FE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safefy and Health April 30 - May 3, 1991, Des Moines, Iowa NOISE AND STRESS By Matthew Marvel, M.D. Attending Physician, Oneonta Health Center It is indeed a privilege to speak to this dedicated and distinguished group. I ap- preciate being invited to speak here. The topic of my talk today is noise and stress. Let me preview a little bit what I am going to talk about. In a few words, I am going to be talking about noise and its potential to cause stress. I am not going to talk about stress to any great extent. Most of my expertise is in the area of noise and noise-induced hearing loss in farmers. I am going to discuss those topics. For those of you who are not familiar with the subject, I am going to define noise and what constitutes dangerous noise. I will be reviewing OSHA guidelines gov- erning noise exposure, show some sample farm-equipment sound levels, and review the characteristics of noise-induced hearing loss. I am going to give an overview of studies that examined hearing loss in farm- ers and finish with suggestions for future research. NOISE AND STRESS First, a few words about noise and stress. Can noise cause stress? Yes. For exam- ple, if this microphone were to start having feedback, I think both you and I would start to have stress after a little while. There are ample studies in animals that have documented the ability of noise to cause stress-related physiological changes. In humans, noisy jobs have been associated with higher rates of various diseases. Noise can cause stress by interfering with communication, disturbing concentration, and acting as a noxious stimulus leading to activation of neurohumoral mechanisms. Noise results in elevated blood pressure, heart rate, and respiratory rate, as well as affecting other systems. All these contrib- ute to increased levels of fatigue and, ulti- mately, injuries. DANGEROUS NOISE Noise is loosely defined as an undesirable sound. It is a subjective definition and one that is a matter of taste. For example, one man's noise is another man's music. Potentially hazardous noise, on the other hand, can be simply defined as something greater than 85 decibels and is indepen- dent of the source. It is a function of the intensity, as measured in decibels, and of the duration of the sound. This governs industrial workers and not, for the most part, farmworkers. It can be used as a guideline and should be used for farmworkers. After all, a hundred decibels in a factory is no different than a hundred decibels in a barn or in a field. Surgeon General's Conference on Agricultural Safety and Health - 1991 293 Research - Mechanical and Physical Hazards Where I am from, Ostego County in New York. Various types of equipment operate above this 85-decibel level. A cab added to a tractor can have a protective effect, on lowering the exposure to sound. Chain saws are loud. Some people might find surprising their including chain saws on this slide, but in my part of the country particularly they are widely used on the farms, in wooded areas for clearing and for cutting firewood. We have heard, at various times in the talks this week, how engineering is improv- ing things for farmers. That is true in the area of sound production as well. Newer equipment is engineered to be quieter, but there is a lot of older equipment still in use. A survey of upstate New York found that the average age of tractors in use on farms is about 20 years. There is quite a bit of equipment out there being used that has not benefitted from this improved engineering. NOISE-INDUCED HEARING LOSS Noise-induced hearing loss can be either permanent (PTS stands for permanent threshold shift) or temporary (TTS refers to temporary threshold shift). Established noise-induced hearing loss is permanent, but moderate exposures to noise may cause temporary threshold shifts. Repeated temporary threshold shifts may become permanent. Noise-induced hear- ing loss is sensorineural. In noise-induced loss, opposed to conductive types of losses that are due to middle ear disease, there is actual damage to the neurological struc- tures of the inner ear. It tends to be bilat- eral but may often be directional, as some of the studies have shown. In addition noise-induced hearing loss presents &ally at higher frequencies, with a characteristic loss that occurs at 4?000 Hz. This is com- monly called the noise notch. This has implications for hearing conserva- tion measures as well. Noise-induced hearing loss develops more rapidly at the higher frequencies, and speech comprehen- sion is affected. Consonants are heard at the higher frequencies, whereas vowels tend to be in the lower frequencies. It once was thought that speech was mostly a phenomenon that occurred between 500 and 3,000 Hz. The work of Alice Suter and others, however, has shown that accu- rate speech comprehension requires the perception of higher frequencies and that we need to be looking at those as well.' STUDIES OF HEARING LOSS I would like to now turn to the overview of some of the studies on hearing loss in farmers. It is not a large body of evidence at this point, compared to a lot of other fields. Again, I am going to give an overview of the different published studies from the scientific literature covering hearing loss in farmers. The first reported study was by Glorig in 1957, who reported the results of hearing tests done on visitors to the 1954 Wisconsin State Fair.2 He found that farmers aged 50 to 69 had significantly more hearing loss in the 2,000 to 6,000 Hz range than office workers of the same ages. The frequencies affected pointed to noise-induced hearing loss as the culprit. Lierle and Reger reported, in 1958, on the adverse effects of tractor noise on the hearing of farmers.' 294 Papers and Proceedings The next reports did not appear until the mid-1970's, when Karlovich tested the hearing of an unselected rural population in Wisconsin', and Townsend studied a similar group in rural central Michigan. Townsend used a mobile van to visit rural communities over an g-week period and tested over 1,300 adults. The purpose of the study was to depict a profile of hearing sensitivity of rural mid- western adults. His findings were that, on the average, hearing loss was greater than could be expected by aging alone. There was no significant difference in hearing, however, between those with a history of industrial work and those with- out. He concluded that in addition to occupational noise exposure another noise exposure, perhaps recreational such as one gets during hunting, boating, or the use of snowmobiles, seemed to be a prime con- tributor. Thelin re-examined what Glorig had found from the 1954 study to see if the discrep- ancy between the hearing of older farmers and office workers could still be shown and if there had been a change, and to deter- mine if younger farmers were also at risk. The sites were the 1979 Missouri Farmer's Association Agri-Fair and the 1982 Shelter Insurance Health Fair." He tested 161 farmers and 75 non-farmers at the Agri-Fair and 130 office workers. His findings were that older farmers were still at risk for high-frequency hearing loss as were younger farmers, which Glorig had not found. Like Townsend, however, he also found a higher rate of hearing loss in non-farmers at the Agri-Fair. The non-farmers' hearing was not as bad as the farmers' but was worse than the office workers. Noise and Stress, May 1, 1991 Karlovich, in 1988, published reports of his testing of 812 visitors over a 5-year period to the Wisconsin Farm Progress Days.' The purpose of this study was to re-evaluate the prevalence and characteris- tics of noise-induced hearing loss in a rural population. The findings were similar to the overall trends that Glorig had found in the 1950's. Males continued to acquire noise-induced hearing loss sufficient to affect their ability to commumcate. It was seen as early as age 20. One out of four of the males had the beginnings of a communication handi- cap by age 30; one-half of them had a communication handicap by the age of 50. Again, both farmers and non-farmers dem- onstrated noise-induced hearing loss, sug- gesting a non-occupational source of noise like firearms use. Only 25 percent of noise-exposed males reported consistent use of hearing-protective devices. Broste, et al., in a 1989 publication, exam- ined an even younger group for evidence of noise-induced hearing loss.8 He studied 872 high school students from Wisconsin to determine whether students engaged in farming had evidence for more hearing loss than their non-farming peers. He found that about twice as many students involved in farming had evidence of early noise-induced hearing loss as compared to non-farmers. Less than one out of ten of the students, however, used hearing protection. The left ear was more severely affected, and for the first time in this series of studies, precau- tions were taken to exclude or to try to control for temporary threshold shifts. I have a study that is due for publication this year. It will be appearing in the Arner- Surgeon General's Conference on Agricultural Safety and Health - 1991 295 Research - Mechanical and Physical Hazards ican Journal of Industrial Medicine.' We tested 49 randomly selected, full-time dairy farmers from Ostego County, New York. Ours is the first study to examine a ran- dom selection like this. We also tested 49 age- and sex-matched rural non-farmers. The purpose of our study was to assess the prevalence and nature of hearing loss in this population. Like Broste, we controlled for temporary threshold shifts, but we used hospital-based equipment. We found an alarming rate of hearing loss in the farmers, while the non-farmers had losses not far from what one might see due to the effects of aging alone. High-frequency ranges (HFA), is an average of the frequencies at 3,000, 4,000, and 6,000 Hz. Sixty-seven percent of the farmers had abnormal hearing as opposed to 37 percent of the non-farmers, at the high-frequency ranges. The PTA4, which measured the mid-frequency ranges of 500, 1000, 2000 and 3,000 Hz, showed somewhat lower levels, but still a big difference. The farm- ers had a 37 percent rate of hearing loss, whereas the non-farmers had 12 percent. As to the results of the subjects who were younger than the mean age of 43 years. At the higher frequencies, where we would expect to find noise-induced hearing loss, we saw lower average thresholds for the farmers. We also found that the left ear was more severely affected, as did Broste. Through correlation regression analysis of the data, we were able to support our hypothesis that the differences found were due to farm noise exposure. I am aware of one other study that is going to be published this year. The preliminary reports were presented at a hearing con- servation conference in San Antonio. This is by {;alle, who is from northern Iowa." Looking at the troubles that some of the studies have had in separating occupational noise exposure from recreational, he sought to select a group of 30 farmers who had only occupational noise exposure. He compared them to a group of age-matched non-farmers who had no significant noise exposure. There were three groupings-age 30, age 40, and age 50. The 30-year-olds had no significant differ- ence at any of the frequencies tested. The 40-year-olds had significant differences in the 3,000 to 8,000 Hz range, again where you might expect noise exposure to start showing. The 50-year-old group had signif- icant differences at all frequencies tested. I was pleased to find that his audiometric data looked similar to what I showed you on those two graphs. Our results look similar. The cumulative summary of the findings, then, showed that farmers have higher-than-expected rates of hearing loss. This is true in all studies. The rates exceed those of the general population, and loss starts in the teen years or before. Farm noise appears to be a major factor. In addition, non-occupational noise may be contributing, as Thelin, Karlovich, and Townsend have reported. This is also something very important to recognize and address. If you are only working on occu- pational noise exposure and people are still losing their hearing while hunting, you are not gaining much. 296 Papers and Proceedings That summarizes the studies that have been done to date. Despite the evidence, some people still have not heard the mes- sage. Therefore, more work needs to be done. FUTURE RESEARCH What are the areas for future research? First of all, we have barely scratched the surface of this problem. There is plenty of room for more research. The number of studies so far is still small, and it is a large and diverse industry with many different risks. We also might find some high- technology solutions like using sound cancellation. I We ought to be testing other regions of the country, other types of farming practices, and other types of farmers. Research should be done for more effec- tive methods of hearing conservation and education. We should be doing dosimetry studies to better define noise risks. I was pleased in looking through the pamphlet showing the poster sessions. It looks like somebody is presenting something on that. Noise and Stress, May 1, 1991 We need more research on the possible synergistic effects between noise and cer- tain agents like carbon monoxide. We need some more research into engineering advancements, greater developments for quieter equipment at the source, ways to improve baq-iers to sound transmission like tractor cabs. This is needed not only for improved new ones, but perhaps more economical ones that farmers could retro- fit. We also might find some high-technology solutions like using sound cancellation. Improvements could be made in hearing protective devices, to improve the fit, the comfort and convenience and, consequent- ly, the likelihood that farmers would wear them. It would be nice to be able to better pre- dict the risk of noise-induced hearing loss from noise exposure levels and early au- diometric changes. Naturally, it would be good to see more basic science research into the anatomic, physiologic, and genetic bases for presbycusis and noise-induced hearing loss. In conclusion, through research, let us continue to look for ways to better de- scribe the nature of the problem so that through the spread of this knowledge those at risk for noise-induced hearing loss may see the ways to prevent it.0 REFERENCES 1. Suter, Lempert B and J Franks; "Real-ear Attenuation of Earmuffs in Normal-hearing and Hearing- impaired Individuals." Journal of the Acoustical Society of America. 87 (5): 2114-2117, 1990. 2. Glorig, A; "Some medical implications of the 1954 Wisconsin state fair hearing survey." Trans American Academy Ophthalmology Otolatyngology 61:160-171, 1957. 3. Lierle, DM and SN Reger; "The effect of tractor noise on the auditory sensitivity of tractor operators." Ann Otol Rhinoi Laryngol 67:372-388, 1958. Surgeon General's Conference on Agricultural Safety and Health - 1991 297 Research - Mechanical and Physical Hazards 4. Karlovich, RS, and TL Wiley; "Spectral and Temporal Parameters of Contralateral Signals Altering Temporary Threshold Shift." Journal of Speech and Hearing Research, Vol. 17, No. 1, pp. 41-50, 1974. 5. Townsend, TH, FH Bess, and WA Fishbeck; "Hearing Sensitivity in Rural Michigan." American Industrial Hygiene Association Journal, Vol. 36, No. 1, pp. 63-68. 6. Thelin, JW, DJ Johseph, WE David, DE Baker, MC Hosokawa; "High frequency hearing loss in male farmers of Missouri." Public Health Rep 98:268-273, 1983. 7. Karlovich RS, TL Wiley, T Tweed, DV Jensen; "Hearing Sensitivity in Farmers." Public Health Reports, Vol. 103, No. 1, pp. 61-71, 1988. 8. Broste, SK, DA Hansen, RL Strand, DT Stueland; "Hearing loss among high school farm students." American Journal Public Health. May: 79(5): 619-22, 1989. 9. Marvel, ME, DS Pratt DS, LH Marvel, M Regan, JJ May; "Occupational hearing loss in New York dairy farmers." American Journal of Industrial Medicine, 20(4): 517-31, 1991. 10. Plakke, BL, and E Dare; "Occupational hearing loss in farmers." Public Health Rep 107:188-192, 1992. 298 Papers and Proceedings Surgeon General's ConRmnce on Agricultural Sakty and Heatth FARMSAFE 2000 o A National Coalition br Local Action Convened by the National Institute for Occupational Safety and Heatth April 30 - May 3, 1991, Des Moines, Iowa TECHNOLOGY TRANSFER By Mumy M&en Product Safety Engineer for Agricultural Equipment Deere and Company There are opportunities for inventions, discoveries, innovations, and improvements that will help reduce the traumatic and acute injuries that occur in agriculture. These opportunities exist in both hardware and software technology, and I contend their impact can be achieved more fully and in a more timely manner through better technology transfer. I will explain that as we go. o By hardware, I mean the sheet metal, machines, parts, and gears. o By software, I mean the safety signs, safety messages and operator's manuals, promotional brochures, posters, human factors interfaced with the machine, and much more. o By technology transfer I am talking about not only what moves the infor- mation going from here to there, but also the process that drives it, how the information gets delivered from point A to point B. We are engaged in this conference to help protect the men, women, and children who come in contact with agriculture. I am especially interested, of course, in that part of agriculture that relates to agricultural machinery such as farm tractors. 1 am also talking about the things that plow the fields and turn the soil. I am going to run through some of these quite rapidly to give you a flavor for modern production agricultural equipment. They are the plows that turn the soil; the plant- ers and tractors, combines and other har- vesters; the mowers; the windrowers; the loaders; the manure spreaders, wagons, and much more. That is a grain drill, a minimum-till grain drill, and a corn planter. You might notice there (on the planter) the dry chemical transfer system Deere and Company devel- oped with American Cyanamid, the "lock and load" system. That is a spectrum of some agricultural tractors, one at closer range. A combine is shown in wheat as well as corn. There is a cotton picker, for those of you from the south and west, and you from Arkansas may be more familiar with cotton strippers. You see a self-propelled forage harvester, a rotary cutter, a rotary mower or mower conditioner, a windrower, and front-end loader with a large, round bale. There is a product that probably no one stands behind, a manure spreader. You see a cotton stripper, hay equipment, all-materials transport utility hauler (which distinguishes it from an ATV or all-terrain vehicle), self-propelled high-cycle sprayer, and a blank slide that gets me on to the important part of my conversation with you today. Surgeon General's Conference on Agricultural Safety and Health - 1991 299 Research - Mechanical and Physical Hazards I have a very strong preference for preven- tion before injuries happen, for the lever- age of design over safe practice control. I recognize, however, the need for a compat- ible blend. I am delighted that you are here. I wish that more people could be. I am also extremely impressed with the attendance at this conference and encouraged about the steep learning curve that all of us are on for these few days that we are together. My plan is to move from the broad per- spectives to suggestions for improved tech- nology transfer. I plan to give you some kinds of research that I believe are appro- priate and necessary. I will close with three general directions. BROAD PERSPECTIVES You have all seen the FFA signposts that declare, "Agriculture is more than farm- ing." It is technically farms, dairies, nurser- ies, orchards, vineyards, cranberry bogs, hatcheries, and more, that produce crops from artichokes to zucchini and livestock from Angus to zebra. Agriculture is done in fields, buildings, and under water. It in- cludes agricultural services such as veteri- nary care, farm management, landscaping, tillage, and crop protection. Agriculture includes tree farms, tracts, nurseries, and those engaged in gathering forest products. And it includes commer- cial fishing, hatcheries, preserves, and commercial hunting and trapping. While our typical "mind's eye" picture may run to the serene dairy in Delaware or to the cotton of California, that is only part of the real picture. Yes, there are household products used on farms. There are hand tools, grinders, welders, saws, drills, motors, mills, and much more. There are ATV's, trucks, crawler tractors, and punch presses. My remarks focus on agricultural field and farmstead or farmyard equipment, typically on wheels or mounted to tractors that have wheels. Many farms have a full line of modem production machinery. Others use tractors and machines that are 50 or more years old. Sometimes equipment is in mint condition; other times it is not, or modi- fied, or built from scratch in a local shop. In all cases, new equipment must be com- patible with the old. A great deal has been accomplished through the voluntary standard system, such as the American Society of Agricultural Engineers (ASAE), to achieve the essential level of inter- changeability and compatibility. Each day technology and our understand- ing of it-how to use it; how product users will interface with it-increases. It leads to improved products-products with greater productivity, products with less cost, and products with improved safety. All of those are happening now. We are on the brink of future technology that will dwarf the revolutions of the 20th century. Semiconductors and the associat- ed inventions have led to innovative new products, like computers, and to improve- ments in others, like radios. Mechaniza- tion, electronics, and biotechnology must be considered the technological revolutions of this century. Perhaps photo&s, the gathering and processing of information transmitted by means of light, will join them. I wish that I had the ability to predict what the next inventions will be. But who 300 Papers and Proceedings knows what they will be or where they will come from? Perhaps one can only do it in a somewhat Buck Rogers' fashion. Most likely we would be in error in timing or content, but we will do some of that for a little fun as we go. We have seen innovations in agricultural equipment, the modern sound-guard body with its noise reduction, its vibration isola- tion, and its fatigue-reducing aspects. We have also seen roll-over protective struc- ture (ROPS) development and the recent development of retractable or foldable ROPS for those essential applications where you must go into a building that is shorter - not as tall as your tractor's ROPS. While some may tend to associate technol- ogy transfer only with hardware, it is also appropriate to realize that technology exists in product safety software as well. That includes the safety signs, the safety messages, the human factor. Most often there is the need to deliver a compatible blend of both hardware and software. I do not, in any way, intend to imply that we should stop doing or not do research that discovers why things work and new information. I think that is a valuable aspect of learning that we should never lose. I also believe that there will be safe- ty impacts of any research that is not spe- cifically aimed at safety. I would also say to those of you who won- der about ROPS that since 1985 virtually every tractor produced has 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 1960. For example, reduced through-put combine harvesters may reduce the entanglement potential and keep the operator away from moving machinery parts. Improved moni- toring and sensing may keep the operator in the relatively protected environs of the operator station instead of out where he or she is more vulnerable. In addition, we have open-throat designs Essentially everyone who is on the receiv- on large round balers. We have service ing end of new information about a tech- tether systems on cotton pickers for doing nology is participating in technology trans- the essential maintenance and cleaning fer. It is not only the "what" but the "how," functions that are appropriate for that the product and the process, the deliver- machine. able and how it is delivered. Improvements have been prevalent as we talk about modem implement-to-tractor driveline guarding; the controls, the steer- ing, and the brake systems; the guarding on the exterior for thrown objects and blade contact; and improvements in the area of lighting and marking. Not revolu- tionary, perhaps innovative, all of these changes have made an improvement in the level of safety that is being provided, and we are, indeed, making the best better. The Technology Transfer Process We need to do more to improve the tech- nology transfer process. U.S. government, universities, non-profit research organiza- tions, industries, and others encompass an astonishing array of research capabilities. To be of greatest value, technology must be put to use. To measure its value, we must look at how well we ultimately trans- fer it. Technology Transfer, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 307 Research - Mechanical and Physical Hazards Not since the Smith-Lever Act of 1914, which established the Cooperative Exten- sion Service, has there been such interest in increasing technology transfer. It is obviously not a one-way proposition limit- ed to dialogue between industry and the Federal government research community. It is more than that, and it is not a simple task. It seems to me that one of the things we ought to do is understand who is doing what in the area of safety research in vari- ous parts and regions of this country. Sometimes equipment is in mint condi- tion; other times it is not, or modified, or built from scratch in a local shop. I Many companies supplement their research and development on a scale not seen in the past and establish aggressive links and liaisons with the external environment. All of this serves to unite the research com- munity with those who really must deliver a product that is attractive to the user. Research and development expenditures are expected to be $155 billion for 1991, according to a Battelle Report. About half of that is being spent by industry and the other half, slightly less, being spent by Federal government. Industry will focus on electronics, composite materials, com- munications, advanced machinery, and energy-efficient products. Defense, Energy, and Health and Human Services will dominate Federal research and development with over 90 percent of their half of the total. The same Battelle Report suggests that all agencies will be improving and enhancing their technology transfer effort. Interest in agriculture is building. The funding looks like it is there. We are here. Our ability to transfer the technology, to transfer the research, to transfer the infor- mation needs to be built. One part of that will be the need to deliver technology, which "understands" the needs and the application. So I direct the next portion of my remarks to the needs. The Needs Much has been said about the National Safety Council (NSC) injury statistics. We need representative data that can be dis- sected and provided in a meaningful way. That needs to be on the national agenda. The now-outdated NSC Farm Accidents surveys, conducted overlapping both ends of the 1970's decade, encompassed 127,000 farm family members and 57,000 full- and part-time workers. The rough conclusion from those surveys still used today is an estimate that one-third of the agricultural injuries can be associated with machinery. A parallel kind of estimate is that roughly half of the agri- cultural fatalities are associated with ma- chinery. Looking at some other data, the seven state surveys that were done with support and help of NIOSH delivered a 60 percent response rate and 5,079 returns. On ag- gregate, approximately 11 percent of those returns reported an accident during the past 12 months. If one looks at the composite information from these surveys, tractors and machinery total about 30 percent or one-third. Ani- mals are second at 16.9 percent, and fol- lowing that are falls on surfaces. 302 Papers and Proceedings A 1985 study in Arkansas showed farm machinery to be involved in about 38 per- cent of all injuries and about 80 percent were to farm family members. Here is something you should note: three of ten, 30 percent occurred while working off the farm. Based on narrative descriptions for the most recent injuries, these ten narratives describe roughly 80 percent of the experi- ence reported in those NIOSH- supported and state-run surveys. Livestock handling topped the list at 19.4 percent, machinery at 13.4 percent, and falls or slips from ladders, equipment, elevated platforms, at 12.2 percent. This information gives you a feel for the severity and kind of injuries that are being experienced. The most frequent injuries, all of the types that we have seen in this kind of survey, have severity toward the lesser severity end of the scale. On the other end of the scale are the fatalities. NSC estimates work deaths, and divides them among agriculture and the other seven standard industrial classifications. NIOSH, BLS, and NCHS also monitor fatal occupational injuries. There is con- siderable disparity in the numbers as well as in how to categorize them. The 1980 to 1985 average for non-transport fatalities on farms puts machinery at 45.6 percent of those fatalities and firearms and drownings a distant second and third at around 12 percent each. As noted in virtually any discussion of farm fatalities, tractors are associated with about two-thirds of the machinery-related deaths or about one-third of the deaths in agricul- ture. The dominant tractor accident sce- nario is an overturn, which may contribute to over 50 percent of the tractor fatalities. Technology Transfer, May 1, 1991 Thus, tractor overturns are about one-half of two-thirds of one-half the agricultural- related deaths, approximately 15 percent of all agricultural deaths. Another 25 percent are related to deaths when someone falls into the path of a tractor. Sometimes operators fall while the tractor is in motion, or they get off before it stops, or they start it in gear from the ground, or one of the riders falls off. It is unacceptable to have a rider on a tractor with or without a cab. About 5 percent of tractor deaths are reported to involve the power take-off (PTO). This category is somewhat suspect since, pre- sumably, there is a PTO-driven piece of equipment attached to it at the time. In addition to overturns, and runovers, PTO entanglements, and the other things, the "other" category for tractors includes things like contact with overhead electrical powerlines and road transport collisions. Imagine yourself driving down the rural country roads of Iowa, perhaps just recent- ly attending the Surgeon General's Confer- ence in Des Moines, "tooling" down a farm-to-market road-perhaps graveled-at your regular road traffic speed then crest- ing a knoll behind a tractor-implement combination. The results can be startling. In some cases it does not make a differ- ence whether there are lights on that equipment or not. In other cases such as in turns, or when there is good visibility ahead, or at night, better lighting and marking could and should be developed. There is a potential for research in trac- tors. When we talk about cresting-the-knoll, perhaps there is room for over-the-horizon detection or for mom Surgeon General's Conference on Agricultural Safety and Health - 1991 303 Research - Mechanical and Physical Hazards toring from above that can deliver the kinds of warnings necessary to avoid colli- sions. We want to make sure in all of this that we are addressing the right problem. For example, is it really the lack of lights, or the lack of good enough lights, or the lack of the right color, or the right position? Maybe more effort should be devoted to improving the connections so that they are more likely to get connected. Consider a product which is hooked and unhooked dozens of times a day. Will it get reconnected? Will it get reconnected on products that never, or seldom, venture onto a roadway? When they do, will it still work? Research may discover a way to multiplex information, control signals, and control power so that it is no extra effort to get the safety value at the same time that you get the desired productivity. The lighting and marking issue is still an open one and some of you may be inter- ested in pursuing in more detail the kind of research that is being launched at Ohio State University on lighting and marking for equipment. Research is necessary in some cases. In other places we need to apply more of what we know. We just looked at the more frequent yet less severe farm machin- ery injury picture, and we looked at the most severe injury death. It is likely there are similar kinds of injuries in between-in the middle ground. It is also likely that there are more severe, but less frequent kinds of injuries in that middle ground. We would generally call them entanglements. Entanglements occur in the belts, chains, and gears that run auxiliary drive systems like cooling fans for engines. They occur as we transfer power from one part of the machine to another part of the machine: 1. In the crop gathering, or picking, or intake mechanisms. 2. In the parts that thresh, or transfer, or clean the material that is flowing through the machine. 3. In the discharge. 4. At the tractor PTO. 5. Along the PTO drive line. Professionals like those in the NSC Agri- culture Division and the National Institute for Farm Safety would likely divide these kinds of entanglements into three major categories of concern: those areas where we gather the crop, those where we are transferring power around the machine, and those where we are processing the crop. A proposed revision to the ASAE standard for agricultural equipment includes a speci- fication for an automatic means to stop the crop-gathering mechanisms and the intake mechanisms of self-propelled agricultural machines. This would be before potential entanglement of the operator, not after. Typical applications have been an operator-presence seat switch on combines and the service tether system that I showed you earlier on cotton pickers. In responding to suggestions for those kinds of systems, the Ontario Implementa- tion Committee rejected the usefulness of interlocking safety cut-off switches as a means for accident prevention. This com- 304 Papers and Proceedings mittee claimed to be aware that some accidents have occurred because of the presence of those kinds of systems. When investigating emergency stop systems for that PTO drive line, they could not resolve the differences between the "invitation" for many to risk entanglement and the poten- tial to lessen the severity of some acci- dents. Research may discover the way to protect maintenance personnel and bystanders from that programmed, unmanned ma- chine that swarms through the wheat field and vacuums up heads of wheat, flowing centimeters off the ground. We may also find a way to detect and respond to the presence of a person who should not be in a protected zone. Per- haps the beginnings for that have already been laid at the University of Illinois with work on the capacitance of discharge sys- tems. Maybe it starts with the radar, ob- stacle avoidance work in the auto industry. Part of why we are here at this conference includes this kind of visioning. What is needed relative to nanotechnology where those micromachines with engines one-third the width of a human hair will be released to swarm across the field and devour preselected bugs from a population of pests? Perhaps we need a more sophisticated ability to anticipate and successfully avoid tractor overturns, like the work at Penn State University, or to alter collision cours- es. Clearly, an early understanding of the application will lead to research that is more readily available. Having identified some needs, it is impor- tant to also consider how those needs will be met in the real world where the opera- Technology Transfer, May 1, 1991 tor must interface with the machine; where human factors become the field of exper- tise; where work, the man, the environ- ment, and the machine come together surrounding the task. We must be cognizant of the somewhat limited ability we have to modify the man successfully; the relative leverage of chang- ing the machine, if that is possible and appropriate; and not forget the ability to adjust the task. Some would say that accidents can be attributed to unsafe actions of operators. Therefore, we ought to focus our research on those behaviors and how to modify or eliminate them. Others would say that the machine's design dictates how the operator will behave. Therefore, we ought to design the machine to not allow errors, to make it difficult to err, to not invite unsafe behaviors or to not accommodate unsafe behaviors, and to encourage safe ones. There are, more likely, opportunities in between than at either end of these polar- ized points of view. I believe it is impor- tant to understand that those possibilities exist and not to forget the option of modi- fying the task. Research is needed to accommodate the physical and behavioral aspects of the people in and around farm machines. I do not, however, advocate identifying any of what you might call generic or typical operator safety behaviors. Identifying new concepts in education and solidifying those guiding principles for educational training, in general, seems to be fertile ground. It may relate to the positioning of incen- tives. It may also relate to cognitive risk Surgeon General's Conference on Agricultural Safety and Health - 1991 305 Research - Mechanical and Physical Hazards avoidance versus situations where the re- wards are greater for risk-taking. Perhaps it springboards from some of the work on injury control strategies and farmworker behavior which will be pub- lished by ASAE between Penn State and the University of Illinois. Where do we go when the weight of what is being published today questions the ability of safety signs to alter-to measurably alter-behavior? I want to express a few things of impor- tance to you, somewhat slowly and careful- ly, because a good friend of mine asked me to do it that way. If you will breathe deeply with me and reflect a moment-the current engineering design community, myself included, as well as students and teachers needs capabilities and tools to better incorporate human factors into what we do. Research on how to build those capabili- ties and the tools themselves are needed for our organization's development and for curriculums. How does safety become the cultural value that permeates all that each of us does? After all, are we not safer than the people out there? What are the skills needed to excel in hazard recognition during the earliest stages of design? Can such skills be learned? What is a capable process for identifying and communicating safety research issues? How do we rationally evaluate alternatives, none of which are without safety risks? What is the measure of safety improve- ment at a stage when we are comparing conceptual alternatives, when we have no injury experience? We are learning more each day about the attractiveness of safety in the user's mind and in the user's perspective. How do we keep the momentum going? How do we tap that latent potential demand? How do we serve those safety needs and wants of our customers? All this could benefit from more research. Consider, for example, how to convince the owner of a 30-year-old tractor worth, at most, $1,000, to put a $500 ROPS on it. The University of Illinois, NIOSH, and the University of Iowa are doing research to help find some of those kinds of answers. A ROPS that provides protection and still meets the needs of users under limbs, vines, and rafters holds promise. It is likely that this kind of roll over pro- tection will produce more acceptable de- signs for the user. Perhaps it may not produce as much protection as users have become accustomed to with larger or more conventional roll over protective structures. Is there an opportunity for validating ac- ceptable ROPS for more compact tractors? In general, research has evolved from centers isolated from commercial consider- ations to centers in touch with the applica- tion, in touch with the network, and with the people who must deliver. My final comment is about better technology trans- fer. It is for the researchers to participate in the safety network or, as Dr. Roper called it, the infrastructure. Researchers must learn the needs, find the funding, know what is being done, share the findings, gain application insights, gath- er and synthesize information, learn, estab- lish contacts, and establish conduits. All of these help prdmote tHe results of the re- search, to participate in sustained improve- ment with those engaged in agriculture. 306 Papers and Proceedings Technology Transfer, May 1, 1991 GENERAL DIRECTIONS I hope to have whetted your research ap- petite and to have given you perspectives. Now to boil my sense for direction down to three points: 1. Overturn protection, refurbished guarding, and proven effective educational training relative to products in use. 2. Integrated approaches to hazard con- trol, primarily aimed at entanglements, which blend the latest injury prevention hardware and software, particularly soft- ware as it relates to behaviors. 3. New technologies for sensing, antici- pating, and responding to the potential for an injury. This is not only in the sense of hardware. I mean it in the sense of the users and their abilities. And I mean it in the sense of those who are striving to pre- vent the first or the next injury from hap- pening.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 307 Sumeon Qmstai'8 Cmhmncr on Agticultml Saibty and Hmith FARMSAFE 2000 o A National Coalition hbr local Action Conwned by the Nat/one/ InrtlMu Ibr Occupationa/ Sahty and Health April 30 - May 3, 7997, Des Molnrs, Iowa THE MANUFACTURERS PERSPECTWE By Mr. John HI Cmwky, M.BA Director of Safety Programs, Equipment Manufacturers Institute The Equipment Manufacturers Institute, or "EMI," is the nrincinal association in the USA `for manufacturers of farm My remarks will be in two parts. equipment. o First, I will give an overview of farm machinery safety research needs as identified by EM1 member companies. o Second, I will address some of the points raised yesterday in the plenary sessions, particularly the questions that Dr. Myron Johnsrud suggested for dis- cussion in these sessions. One on these was "Where do we focus our resources to be of most success?" Allow me to preface my remarks with a word on the role of surveillance as it re- lates to injuries involving farm equipment. Surveillance is said to be important to provide the foundation and direction for both research and intervention. Manufacturers already know quite a lot about how accidents involving their prod- ucts happen from information available to them. They have a good sense of the relative magnitude of product-related acci- dents in terms of the frequency and severi- ty of injury that can result from them. Nevertheless, better injury data, expressed quantitatively, which should be forthcom- ing from the current NIOSH-sponsored initiative, are needed to identify problems at the regional and national levels, to es- tablish prioritized objectives, and to mea- 308 sure progress. Manufacturers need better data on the association, if any, between machinery and cumulative trauma disorder, noise-induced hearing loss, and illness related to the handling and application of pesticides. RESEARCH NEEDS The industry has identified several areas for additional safety and ergonomic re- search. Two years ago, EMI's Agricultural Safety Committee looked at the accident and injury data base, the product-related safety standards, and the innovative work that Murray Madsen described in his pres- entation that individual companies are doing. The committee developed a ques- tionnaire to survey equipment manufactur- ers throughout the industry to find out where they thought additional research was needed. The responses fell into two groupings. One was safety-related research that was thought to be appropriate for public sup- port. The other concerned items for which in- dustry concluded it had the necessary ex- pertise itself to carry out. I would like to revisit the results of this survey with you. The survey identified eight areas that were deemed to merit public support. I will present them in no particular order. Papers and Proceedings Behavloral Research Not surprisingly, in view of much that has already been said by others at this confer- ence, the industry identified a need for research into behavior of equipment users. Manufacturers' experience based on in- depth evaluations of numerous accidents indicated that the manner of use of equip- ment was a significant factor in accidental injury. The equipment manufacturer's view is that there is a need for basic re- search aimed at developing a better under- standing of behavior with respect to safety and risk-taking in the agricultural environ- ment. Behavioral research is needed to guide engineers on how equipment can be de- signed for safer operation and mainte- nance. It must also be designed for devel- oping effective educational and training programs and other measures aimed at inducing fundamental, lasting behavioral changes. Behavioral research is needed to guide engineers on how equipment can be de- signed for safer operation and mainte- nance. I EM1 was familiar at the time of the survey with the work of Dr. Dennis Murphy of The Pennsylvania State University and Dr. Robert Aherin of the University of Illinois in examining attitudes, underlying cultural beliefs, and other factors as possi- ble determinants of behavior. J.I. Case, a member of EMI, has sponsored a literature review, which is being done by Drs. Murphy and Aherin. This work is nearly complete, and the results will be The Manufacturers' Perspective, May 2, 1991 provided to J. I. Case in a few weeks. Case has asked the American Society of Agricultural Engineers (ASAE) to publish the results. We understand that publica- tion may occur by the end of July, 1991. The study will look into four elements: 1. A review of the characteristics of farm- ing and farm-accident statistics. 2. Injury- control strategies. 3. Approaches to modifying safety behav- iors. 4. Effective ways of communicating the safety message. EM1 has received proposals from several organizations in response to a Request for Proposal (RFP) it issued to do additional work in the area of behavior. The propos- als are being evaluated, and EM1 will seek other sponsors to help fund this particular research project. Broad sponsorship by both private- and public-sector entities is being encouraged. Injury Data Collection The second area identified for public sup- port was agricultural injury data collection. The industry strongly supports the work of NIOSH to develop a uniform national reporting system and database. For our purposes, better data is needed on the relationship of machinery characteris- tics to such things as hearing loss, effects of whole-body vibration, and the signifi- cance of such factors as age, fatigue, and environmental variables. EM1 encourages public-sector research in these areas. Surgeon General's Conference on Agricultural Safety and Health - 1991 309 Research - Mechanical and Physical Hazards Lighting and Marking of Equipment The third area is the lighting and the marking of agricultural field equipment. Dr. Thomas Bean of Ohio State University spoke on this subject. We concur in his view that additional work of a research nature is needed. EM1 has issued a RFP for research on the effectiveness of current lighting and marking systems for agricultur- al equipment. Five responses were received. These have been evaluated and a study contractor selected. The study contractor will look at alternative ways of effectively identifying slow-moving vehicles, extremity lighting and marking of equipment that travels on roads and highways, and turning indica- tions. The system now in use in agriculture to indicate turning is somewhat different than the system for motor vehicles. The signifi- cance, if any, of the differences will be evaluated. The study will also look at the adequacy and effectiveness of the slow-moving vehi- cle emblem and reflectors as specified in the standards of the ASAE. The project will include both simulation and field eval- uation using subjects. There is a need for additional funding for the lighting and marking research study. The cost of the study is about $220,000. It is 75 percent funded now and we are look- ing for additional sponsors for the remain- ing 25 percent. Protection During Chemical Handling The fourth area identified in the industry survey concerned protection when handling agricultural chemicals. The focus is on equipment for handling and mixing and transfer of chemicals from original contain- ers to field application machinery. Development of a standardized "closed' system for the mixing and transfer of pesti- cides would provide increased worker protection, guard against damage to the environment from accidental spills and possibly eliminate the need to dispose of excess mixture. EMI and the National Agricultural Chemical Association have undertaken a joint effort to develop such a system. We are not sure that additional research is needed at this particular point. It appears to be more a question of engi- neering development and standardization. Air Filtration Systems The fifth area is air filtration systems that can effectively reduce the hazard of expo- sure to pesticide vapors, dusts, and aero- sols. Tractor cabs now have effective fil- tration systems for most particulate matter. Additional research is required to deter- mine whether a reliable system is feasible to reduce to acceptable levels concentra- tions of fine pesticide dusts, aerosols, va- pors, and gases. ASAE has begun a study on this question. It is also being looked at by the Interna- tional Organization for Standards (ISO). EM.I is participating in both the ASAE and IS0 initiatives. Whole Body Vibration Reduction Sixth, the industry identified improving tractor seat design to limit whole-body vibration as important. The industry has not done any work in this area through EMI. However, some individual compa- nies are looking at it. Manufacturers look 310 Papers and Proceedings to human factors specialists for guidance here. Hazardous Atmospheres Detectors Seventh, devices to detect hazardous atmo- spheres are needed. Reports abound con- cerning suffocations and toxic exposures in confined space environments such as ma- nure reception pits and silos. There is a need for a reliable, inexpensive, and easy- to-use device for on-farm use in confined spaces where oxygen deficiency or toxic gases are present. EM1 looks to the public health sector, which has the expertise and the funding, to take the lead in addressing this research need. Broaden Research Sponsorship Lastly, "research" could be conducted to identify effective ways to gain the interest and support of entities outside the agricul- tural health and safety community to help sponsor the eight kinds of research that I have just described. INDUSTRY-BASED RESEARCH Next, I will discuss certain safety-related areas identified in the EM1 survey that the industry believes it can do either through the Institute or as individual manufactur- ers. These are areas for which industry believes it has sufficient expertise and resources to do the work itself, with some exceptions. There were three such areas identified by the survey: 1. Small tractor roll-over protection struc- tures (ROPS) and seat belts. 2. Safety systems and devices. 3. Product safety signs. The Manufacturers' Perspective, May 2, 1991 ROPS for Small Tractors The first of these was ROPS for small farm tractors. In the late 1950's and early 1960's, extensive research and development work was done by the industry to establish the efficacy of ROPS designs for the kinds of tractor overturns that can occur in nor- mal farming and road transport. Manufacturers began supplying ROPS commercially in the late 1960's. The expe- rience in both the United States and Europe has proven ROPS to be an effec- tive safety device. There is a need for additional research on small tractors' ROPS. The standard "pro- tective zone" around the tractor operator, which controls the size of the ROPS enve- lope, was defined on the basis of the ergo- nomic data that existed in the 1950's and 1960's. The zone remains essentially un- changed today. EM1 sponsored a literature review of the different protective zones used for the design of several kinds of vehicles, includ- ing aircraft, automobiles, racing cars, farm equipment, construction equipment, and mining equipment. This study, which was performed by Triodyne, Inc. of Skokie, Illinois, has been completed. Publication will be through both the Society of Auto- motive Engineers (SAE) and ASAP before the end of 1991. The basic conclusion of the Triodyne study was that it did not appear, from the kinds 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 small tractors. Small tractors are often used in low overhead clearance Surgeon General's Conference on Agricultural Safety and Health - 1991 377 Research - Mechanical and Physical Hazards settings-in vineyards, orchards, storage buildings, and machine sheds. 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 poten- tial 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 pre- sentation, 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 today. Industry's research capabilities concerning ROPS are limited to mechanical and struc- tural aspects. There is little more to be done there with the exception of the small tractor ROPS. Accident data identify tractor roll-overs as the leading cause of machinery-related death on the farm. 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 trac- tors. EM1 believes that behavioral research in this area holds promise of effecting a sub- stantial 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 them. The question should be asked how these farmers arrived at their decision to equip the tractors with ROPS. Was it because of the OSHA rule? Was it because manufac- turers were able to package the ROPS in a cab that was noise-insulated and isolated from vibration of the tractor? 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 trac- tors that do not now have them may in- deed be found by examining the factors in the decisions of the approximately one million farmers who did decide to equip their tractors with ROPS. Safety Systems and Devices The second area identified for further industry research was safety systems and devices. There was some discussion about safety systems and devices yesterday, spe- cifically, the concepts of interlocks for barrier-type guards and operator restraint devices. I would like to identify the criteria that manufacturers use for evaluating concepts or proposals for safety systems and devices, or for that matter most engineering design concepts. There are five such criteria. 1. The first criterion is that a design con- cept must be technologically feasible. The archives of the U.S. Patent Office contain millions of concepts, inventions, and ideas. 372 Papers and Proceedings Many have proven to be successful. Many others have not. Much more is needed than mere technological feasibility as dem- onstrated by the existence of a patent. This is where the other criteria come in. 2. The second criterion is effectiveness. A safety device or system must be effective. There are two necessary qualities for effec- tiveness. b First, the system or device must substan- tially reduce or eliminate the hazard. The tractor ROPS is incontrovertibly effective in this respect. In contrast, there is a type of device with which most of us probably are familiar, the ubiquitous, audible back- up alarm used on heavy equipment. OSHA requires back-up alarms on con- struction equipment such as front-end loaders, forklifts, and dump trucks that have bi-directional movement while work- ing. The alarms "beep" every time the machine goes backward. There is much evidence that workers quickly become desensitized to the audible back-up alarm. They hear it going on and off all the time. If there are several pieces of construction equipment with back-up alarms working on a site it can become difficult to distinguish the back-up alarm of one machine from that of another. The effectiveness of audi- ble back-up alarms is generally recognized to be questionable. Alternative approach- es to addressing the hazard of moving machinery in the presence of workers are being investigated. b The other necessary element for effec- tiveness is that a device be reliable when called upon to perform its function. I will ask rhetorically, how many of us would buy an automobile if the dealer said: "The The Manufacturers' Perspective, May 2, 1991 brakes will perform 999 times out of 1,000 when you apply them, but one time out of a thousand they are not going to work." A type of device that has been proposed for use in agriculture is the electrical-prox- imity-warning indicator. This is an elec- tronic device that is supposed to sense electromagnetic field or capacitance around energized overhead power lines. It either signals an alarm or deactivates a mobile machine before it gets too close to the lines. Tests sponsored by the U.S. Mine Safety and Health Administration (MSHA) re- vealed that when such a device was in- stalled on cranes it gave both false positive and false negative indications. No one has yet been able to perfect a device that will accurately and reliably detect a hazardous electrical field when one is present and will activate only under the hazardous condition. EM1 encourages further re- search and would welcome the discovery of an effective electrical proximity warning device that could be used on tall farm equipment such as portable grain augers. b The third essential criterion is that a safety device must not by its presence, introduce different risks 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 existed several years ago when OSHA, with all good intent, promulgated its ROPS rule for agriculture. As it turned out, there were some small tractors that had backhoes mounted to the three-point hitch, with a separate seat for the operator af- fixed to the backhoe frame behind the tractor. Surgeon General's Conference on Agricultural Safety and Health - 1991 373 Research - Mechanical and Physical Hazards 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 combina- tion of these measures was implemented through various field rework programs to eliminate the hazard. v The fourth requirement is for a safety system or device to be economically feasi- ble. As we have heard from others at this conference, there are strong economic disincentives to safety in American agricul- ture. In the mid-1970's, when OSHA promulgat- ed the tractor ROPS and the guarding and shielding regulations, both original equip- ment manufacturers and independent sup- pliers of these safety devices produced them in large quantities in the expectation that there would be a substantial increase in demand. Unfortunately, the demand was not there. On the other hand, as I have mentioned, the ROPS-equipped tractor cab was attrac- tive to the purchaser. Companies do at- tempt to establish the economic feasibility or salability of products and safety devices before putting them on the market; this is not always easy to do. b Lastly, a purported safety system or device must be functionally practical. Even if the other requirements I have mentioned are met, the safety device can- not unduly interfere with the basic function of the machinery. This requirement is found in the ASAE Safety Standards and in the OSHA safety rule for agriculture. Consider the intake guard of the portable grain auger. The function of a portable grain auger is to move grain from ground level to the top of a grain storage structure and dump it in. The bottom end of the auger, into which the grain flows, has a guard around the inlet opening, that is in the form of a rigid wire mesh cage or screen. Portable grain auger manufacturers, based on the results of extensive experiments with various kinds of grain, determined the optimum size of the wire mesh openings. The size of the openings in the guard is specified in an ASAE standard. In determining the optimum size, industry engineers were aware that if the openings were made too small the guards would plug up. The auger would no longer move grain. If that were to happen, farmers would be inclined to take off the guards, thereby totally exposing the very hazard that the guard was intended to cover. It was known when the standard was writ- ten that the openings were not small enough to prevent passage of a small hand or foot through them and into the moving machinery. Thus, it was found to be nec- essary to have a portable grain auger in- take guard that struck a balance between the compelling need to preserve function and safety. In doing this, the intake guard necessarily provided less-than-perfect pro- tection. There is evidence of a predisposition on the part of people to be unwilling to ac- cept inconvenience in the interest of safety. Recall the 1974 automobiles with the man- 314 Papers and Proceedings datory interlocking seat belts. The cars could be started only if the seat belts had been fastened. A political decision was made to drop the requirement because many consumers became enraged when they found that the safety feature caused inconvenience and sometimes interfered with function. One can conjecture that, to the extent that awareness on a