Questions to Guide the National Agenda

is a subset of a larger testing issue faced by
the National Toxicology Program.

* 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.

> 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.

76

Biotechnology is currently being regulated
by EPA through the Federal Insecticide,
Fungicide, and Rodenticide Act (FIFRA; 7
U.S.C. 136-136y) 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. 15Oaa-jj) and regulations adopted in
June of 1987 (CFR Part 330).

¢ 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).

¢ Information systems that are especially

useful in epidemiology are specific disease
and injury registries. Often existing cancer
registration data is available from state or

Papers and Proceedings
Research for Agricultural Safety and Health, May 1, 1991

hospital data. Use of these information
systems is an inexpensive and powerful
epidemiologic tool.

Through the State Health Registry of Iowa
at the University of Iowa, we are now able
to register birth defect and cancer inci-
dence. An Alzheimer’s Disease Registry
has also been developed for some counties,
and a Rural Injury Surveillance System is
now under development.

These health effect registries are especially
useful as they allow systematic collection
of large numbers of specific types of birth
defects, cancers, or injuries that can then
be studied quantitatively through the use
of case control studies. This approach has
been used effectively in the assessment of
risk factors for a variety of specific types of
cancer.

The same approach is now being applied
to birth defects, which have an added ad-
vantage of having a much shorter latency
(hence more accessible and valid data). In
the case of injuries, there is no latency and
the circumstances of injury are usually
clear. This will allow the injury registry to
collect more data at the time of the event
and thus reduce the time and cost of case
control studies.

Epidemiological Studies

¢ 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.

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

and birth defect registries. Data on the
sale of certain farm chemicals provide
another type of exposure registry. Another
type may be derived from widespread tes-
ting of drinking water for nitrates and
pesticides.

While these exposure registries usually
provide evidence of exposure to certain
agricultural chemicals, epidemiological
research requires much more detail in
terms of the types and amounts of specific
chemical use, the time-frames of use, the
type of application, and the use (and non-
use) of protective equipment. These types
of data must almost always be collected
retrospectively, but could be collected
prospectively in a small cohort or in a
sample of a larger cohort.

Collection of representative exposure data
is also essential in cross-sectional studies of
injuries and health effects. These data are
necessary in order to derive exposure
response relationships, which are essential
to the development of guidelines for re-
duction of exposures and the prevention of
diseases and injuries.

¢ There are very few trained industrial
hygienists specializing in agriculture. The
need for these skills in the collection and
interpretation of environmental data is
critical to advance agricultural health and
safety research.

Demonstration and Education
Research

Closely related to epidemiological research
is the area of demonstration and education
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

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.

¢ 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 defi-
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
Research for Agricultural Safety and Health, May 1, 1991

and injury incidence, availability of health
care, and related social services

—people living in rural areas have less
favorable statistics than their urban coun-
terparts.’ Especially vulnerable are
migrant agricultural workers who are at
triple jeopardy—poor, rural and uninsured.

« These social service and health-care
delivery factors clearly influence the inci-
dence of rural injuries and diseases and
point up the importance of interaction and
collaboration between those engaged in
agricultural health and safety research with
rural sociologists and those engaged in
rural health care delivery research.

AGRICULTURAL DISEASE AND
INJURY RESEARCH PRIORITIES

Injury Morbidity and Mortality

Available data on the risk of injury and
traumatic death consistently reflect a high-
er injury risk to those living in rural com-
pared to urban areas, with a mortality rate
for unintentional injuries twice that of
urban areas.’ This excess is attributable to
several factors, including increased mor-
tality from motor and non-motor vehicle
deaths arising from higher speeds on
poorer roads, less seat belt use, more use
of high-risk utility vehicles, and poorer
access to trauma care. At particular risk
to rural injury are farmers, their family
members, and hired and migrant laborers.

In addition to the several factors that place
rural residents at increased risk are added
the occupational risks of farming. The
National Safety Council estimated deaths
among farm residents to be 56.2 per
100,000, 30.1 of which were motor-vehicle-
related, 20.1 work-related (18.1 in farm
work), 8.0 home-related, and 4.0 public
non-motor vehicle deaths.’ The trend in

agricultural mortality over the past ten
years has shown relatively little
improvement and remains higher than that
of mining and construction.

NIOSH, through its National Traumatic
Occupational Fatalities (NTOF) database,
reports 20.7 deaths per 100,000 agricultural
workers, versus 7.9 deaths per 100,000 for
the general private - sector workforce.’
Results of epidemiological studies and
newly developed surveillance systems sug-
gest these national estimates may sig-
nificantly underestimate both deaths and
farm-related injuries.

The Iowa Department of Public Health
farm injury surveillance program
(SPRAINS) reported 83 deaths for 1990
based on voluntary reports from health-
care providers.” As this was the initial
year of reporting, it is thought that this
number is incomplete; yet this number of
deaths is over 60 percent higher than
previous estimates of farm deaths in Iowa.
Epidemiological studies draw our attention
to the importance of farm machinery in
fatalities and severe injuries, to higher
rates of injury among children and the
aged, and to the substantial numbers of

intentional deaths (suicides and homi-
cides).”

While it is clear that traumatic injuries and
deaths are epidemic on American farms,

we still lack national and state-based
information systems (surveillance), a rea-
sonable understanding of risk factors, and
an adequate characterization of hazards of
farming associated with injury morbidity
and mortality. Therefore, three research
priorities in the area of traumatic injuries
are:

1. Development of national and state-
based information systems, which will

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.’*”

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.

80

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. There 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.

Papers and Proceedings
Research for Agricultural Safety and Health, May 1, 1991

In addition, excesses of lung, stomach and
prostate cancer have been observed in
cohort studies of manufactures and appli-
cators.* Other potential risk factors for
cancer incidence include viruses, and
dietary and other factors as possible
contributors to cancer incidence among
agricultural workers.” A number of
methodological issues pose difficulties in
interpreting these findings and indicate
priorities for research in this area:

1. There is a uniform need for better
environmental characterization of agri-
cultural chemical exposures through the
development of valid and inexpensive
environmental exposure protocols.

2. Use of exposure registries linked with
cancer registries promises to provide
important additional data on cancer risk
among agricultural workers.

3. Improved epidemiological methods to
assess and validate previous agricultural
and other exposures are needed for
adequate analysis and evaluation of
cancer data.

Reproductive Health Effects

Concern about possible adverse
reproductive health effects arises from
toxicological testing showing some agricul-
tural chemicals to be teratogenic, from
widespread use of some of these chemicals,
and from some case reports suggesting as-
sociations between certain adverse repro-
ductive effects and agricultural expo-
sures.'*!7 The reports on dibromochloro-
propane (DBCP) on male reproductive
function have provided an important exam-
ple of the toxic effects of this pesticide, an
exposure, which now continues in some
developing countries.”

Assessment of adverse reproductive effects
has a significant methodological advantage
over assessment of cancer incidence in that
the latency from the time of exposure to
the time of the reproductive effect is much
shorter than that for cancer, which is gen-
erally 20 or more years. The lack of birth
defect information systems has greatly
hampered evaluation of birth defects in
association with environmental exposures.
Priorities for research in this area fall in
two areas:

1. Additional systematic toxicological test-
ing of agricultural chemicals and com-
monly used combinations of chemicals
for adverse reproductive effects.

2. Further development of birth defect
registries and linkage of these infor-
mation systems with exposure registries,
and through the development of case-
control studies with adequate exposure
data.

Neurological Health Effects

Recent reviews of the neurotoxic effects of
pesticide exposure have focused on chronic
neuropsychological sequelae from expo-
sures to organophosphate pesticides.” ”
While the early (immediate and delayed)
neurotoxic effects are well-described for
organophosphate intoxication, until
recently little attention had been given to
evaluation of possible chronic effects.

However, as the result of several case
studies and clusters of adverse behavioral
and neurological findings, the World
Health Organization (WHO) and the
United Nations Development Programme
(UNDP) are coordinating a ten-country
European, prospective epidemiological
study on the neurotoxic effects of low-level
exposure to organophosphorus pesticides.

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.”

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

82

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 farm 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.

Papers and Proceedings
Research for Agricultural Safety and Health, May 1, 1991

3. Development and evaluation of inter-
vention programs to prevent dermatitis
among farm workers are further re-
search needs.

Noise-Induced Hearing Loss

Several studies have now reported bilateral
high-frequency hearing loss to be quite
prevalent among farmers.” Of particular
concern is the frequency with which this
abnormality is observed among farmers
under the age of 30. This strongly suggests
that noise is the cause of this injury. In-
deed, farm machinery and chain saws are
known to generate noise levels above
recommended limits. A further finding has
been that relatively few farmers use
hearing protection. Therefore, research
priorities here include:

1. Systematic industrial hygiene surveys to
characterize farming operations where
noise levels exceed recommended lev-
els.

2. Development and evaluation of inter-
vention programs to provide adequate
hearing protection to those engaged in
these farming operations.

THE NATIONAL AGRICULTURAL AND
ENVIRONMENTAL HEALTH INITIATIVE

Since the publication of Agriculture At
Risk: A Report to the Nation, which sum-
marized the recommendations arising from
the national public policy conference, "Ag-
ricultural Occupational and Environmental
Health: Policy Strategies for the Future,"
and the dissemination activities of the
NCASH, there is a new level of awareness
of the magnitude and severity of disease
and injury among American agricultural
workers. Significant credit for initiation of
and support for this effort is due to several

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
of the U.S. Congress and several state
legislatures.

As a result, and for the first time, a
healthy dialogue has involved all parties to
these important issues. Significant resourc-
es are now available through federal ap-
propriations and some state appropriations
to mount this national research and inter-
vention initiative. This research effort is
just beginning. The challenge ahead is to
maintain this momentum and build upon
these gains.

CONCLUSIONS

1. The high risk of disease and injury
arising from agricultural exposures has
now been recognized and has now been
placed on the national public health
agenda.

2. Adequate resources and incentives have
been provided to address the multiple
research priorities. These resources
must be maintained and cultivated.

3. A healthy dialogue has promoted the
involvement of most parties. Greater
efforts are needed to involve full
representation of children, women,
migrants, and the rural poor.

4. The challenge ahead is to prioritize,
implement, and publish research fin-
dings and translate this research into
meaningful prevention and health deliv-
ery programs.0

Surgeon General’s Conference on Agricultural Safety and Health - 1991 83
Questions to Guide the National Agenda

REFERENCES

1,

10.

11.

12.

13.

14.

15.

16.

17.

18.

84

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.

Fassinger PAD and Schwarzseller HK. The Work of Farm Women: A Midwestern Study, Research in
Rural Sociology and Development. (1):37-60, 1984.

Ungar RL. Farm Women at Risk: Work Roles and Agricultural Exposures. Thesis, Department of
Preventive Medicine and Environmental Health, The University of Iowa, 1990.

National Safety Council. Accident Facts, 1988 Edition. National Safety Council, Chicago, Ill, 1988.

Glass DJ. Agricultural Biotechnology: Occupational Health and Regulatory Issues in Occupational
Medicine: State of the Art Reviews. 6(2):301-309, 1991.

Dosman JA. Technical Workshop Report: Working Group I: Occupational Health and Safety Strategies
for Agriculture, American Journal of Industrial Medicine. 18:353-356, 1990.

Summer L, Limited Access: Health Care for the Rural Poor. Center on Budget and Policy Priorities,
Washington D.C., 1991.

Baker SP, O’Neill B. and Karpf R. The Injury Fact Book. Lexington, Mass.: Lexington Books, 1984.

Myers JR. National Surveillance of Occupational Fatalities in Agriculture, American Journal of Industrial
Medicine. 18(2):163-168, 1990.

Currier R. Iowa Department of Public Health, Personal Communication, 1991.

Stallones L. Surveillance of Fatal and Non-Fatal Farm Injuries in Kentucky, American Joumal of
Industrial Medicine. 18(2):223-234, 1990.

Merchant JA. Agricultural Respiratory Diseases, Seminars in Respiratory Medicine. Thieme, Inc., No.3,
7:211-224, New York, 1986.

Merchant JA. Agricultural Exposures of Organic Dusts. Occupational Medicine: State of the Art Reviews.
2(23) April-June:409-425, 1987.

Blair A and Zahm SH. Herbicides and Cancer: A Review and Discussion of Methodologic Issues, Recent
Results in Cancer Research, 120:132-145, 1991.

Pearce N and Reif JS. Epidemiologic Studies of Cancer in Agricultural Workers, American Journal of
Industrial Medicine. 18(2):133-148, 1990.

Schwartz DA and LoGerfo JP. Limb Reduction Defects in the Agricultural Setting, American Journal of
Public Health. 78:654-659, 1988.

Gordon JE and Shy CM. Agricultural Chemical Use and Congenital Cleft Lip and/or Palate, Archives
Environmental Health. 36(5):213-221, 1981.

Whorton D. Dibromochloropropane Health Effects, Chapter 48 in Environmental and Occupational
Medicine. WN Rom (Ed), Little, Brown and Company, Boston, 1983.

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19. Rosenstock L, Daniell W, Barnhart S., Schwartz D, and Demers PA. Chronic Neuropsychological
Sequelae of Occupational Exposure to Organophosphate Insecticides, American Joumal 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.

2. Schenker MB and McCurdy SA. Occupational Health Among Migrant and Seasonal Farmworkers: The
Specific Case of Dermatitis, American Journal of Industrial Medicine. 18(2):345-352, 1990.

23. May JJ, Marvel M, Regan M, Marvel 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 Conference on Agricultural Safety and Health
FARMSAFE 2000 ¢ A National Coalition for Local Action

Convened by the National Institute for Occupational Safety and Health
April 30 ~- May 3, 1991, Des Moines, lowa

INTERVENTION FOR AGRICULTURAL SAFETY AND HEALTH

Myron D. Johnsrud, 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 U.S. Department of Agriculture’s Extension Service. In this 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 Intervention for Agricultural Safety and Health.

Dr. Johnsrud:

 

 

INTRODUCTION

"The health of the people is really 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

are in protecting agricultural workers and
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—does it stop at the farm gate or
timber mill? Or, does it include many
segments of food, feed, and fiber
processing?

Papers and Proceedings
Intervention for Agricultural Safety and Health, May 1, 1991

These are just a few of the questions con-
fronting us today in the important issue of
agricultural safety and health. This morn-
ing I want first to present a brief history
and the current status of intervention ef-
forts. Second, I will pose questions to
guide the concurrent session on developing
intervention strategies for various targeted
audiences, approaches to intervention, and
the need for collaboration. Third, I will
suggest some areas that I see as the pres-
sure points, injuries, and fatalities of high-
est priority and the places where we have
the best chance to intervene successfully.

CURRENT STATUS OF INTERVENTION

Voluntary safety efforts have had much
success. Agriculture has the most exten-
sive community of voluntary safety profes-
sionals of any industry in the United
States. What was probably the first farm
safety effort began in 1933, when the Sixth
Annual Rock River Valley Safety Confer-
ence meeting at Fort Atkinson, Wisconsin
organized a farm safety section.

In 1937 the National Safety Council held a
meeting of an agricultural section. Its first
farm conference took place in 1947. An
organized professional effort to prevent
farm accidents began in the Cooperative
Extension system early in the 1940’s with
appointment of a full-time Extension farm
safety specialist by the University of Wis-
consin.

A coalition of farm safety professionals
representing agricultural equipment
manufacturers, the Farm Bureau, insurance
companies, and the Cooperative Extension
System chartered the National Institute for
Farm Safety in 1961 to provide a forum for
the exchange of research results, surveil-
lance data, and effective intervention met-
hods. Much of the success in reducing the

occupational injuries experienced by agri-
culture over the past 50 years is due to the
accomplishments of these professionals
working cooperatively through or-
ganizations such as the National Institute
for Farm Safety and the safety committees
and standards committees of the American
Society of Agricultural Engineers (ASAE).

We cannot ignore the fact, however, that
the rate of decline in agricultural fatalities
and injuries is much slower than that expe-
rienced by mining and construction, the
other two most hazardous industries in this
nation. Except for this fact, we would not
be here today. Because of it and the ef-
forts of such organizations as NCASH, the
Congress has recognized the need to com-
mit additional resources to research, sur-
veillance, education, and intervention pro-
grams.

Most of the new programs are being ad-
ministered by NIOSH. In administering
these programs, NIOSH has recognized the
value of supporting existing programs. An
example of this is NIOSH’s intervention
program Agricultural Safety and Health
Promotion Systems, which is providing
funding to enhance educational safety
programs through the Cooperative Exten-
sion System in 15 states.

Two new NIOSH programs crucial to de-
veloping intervention include establishing
two new centers in Iowa and California for
agricultural research and education and
supporting occupational health and safety
nurses in agricultural communities. These
programs exemplify, too, the key questions
we must ask ourselves in developing
strategies for intervention programs.

1. How do we implement promising and
innovative new programs such as nur-
sing services in agricultural communities

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.

88

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-

Papers and Proceedings
Intervention for Agricultural Safety and Health, May 1, 1991

workers, while acknowledging the need for
health and safety, did not have time to
attend meetings.

Radio, general farm magazines, and con-
versations with others are prime informa-
tion sources. The Cooperative Extension
Service received a very high rating as a
source of health and safety information.

A sizable share of the farm population is
children. Accidents are the primary cause
of death among children less than 15 years
old in the United States as a whole and in
farming. About 23,000 farm children are
injured on farms each year. Why are these
injuries occurring?

Partly, it is the generally risky nature of
the farm environment and the fact that it
is both home and office for farmers and
for their spouses and children. Often, the
economic realities of farming create a
dependence on children for labor. Fre-
quently, either there is no adequate child
care for them off the farm or it is too
costly for farm families. These problems
exist for both the farm-operator family and
the migrant-labor family.

In a recent national survey, farmers
reported that they allowed their young
children (aged 6-9 years) to ride on a trac-
tor, and as many as 29 percent of 7-9 year-
olds were driving the tractor. Between
ages 7 and 15, farm children were per-
forming a wide range of farm operations
with tractors.

When asked about risks of such behavior,
farm parents surveyed saw a low accident-
risk level for their children when they were
riding on a tractor the parent was operat-
ing or when the children were operating
the tractor. As great as a 40 percent
reduction in the farm fatalities to children

 

may be possible if children do not ride on
tractors.

 

Studies of the cognitive physical

limitations of children at various stages up
through 15 years of age indicate that they

are being put at risk through farm ac-
tivities that they are asked to perform.

I have yet to see a farm safety awareness
or education program that did not stress
the danger of extra riders on tractors. This
poses some important questions that need
to be applied to all agricultural safety and
health problems.

Why are our safety warnings going un-
heeded? Are we reaching and involving
our targeted audiences sufficiently to
develop effective education and awareness
programs that change behavior? What will
be the most effective combination of en-
gineering controls, awareness, education,
regulation, and enforcement to find
solutions to each problem?

Studies of the cognitive physical limitations
of children at various stages up through 15
years of age indicate that they are being
put at risk through farm activities that they
are asked to perform. Their parents do
not understand that risk potential. How
do we direct our educational efforts at
these target populations? Helping farmers
understand the developmental limitations
of their children could significantly reduce
child accidents and deaths on farms.

Another target population is the estimated
3 million migrant and seasonal farmwork-
ers from many different ethnic groups.
Children are about one-third of this popu-
lation.

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.

Extension agents, disability experts, rural
professionals, and volunteers will offer

90

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? How do we educate
to achieve behavioral changes toward bet-
ter agricultural safety and health? Many
educational programs are in place.

Papers and Proceedings
Intervention for Agricultural Safety and Health, May 1, 1991

We have our own, ranging from training of
persons who will be using restricted-use
pesticides to courses that instruct youth
(14-15 years old) in operating tractors safe-
ly. Of the more than 23,000 Nebraska
youth that have completed the tractor
certification training program conducted by
the University of Nebraska Cooperative
Extension Service, only two have died in
tractor-related accidents.

 

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.

 

How do we educate people to change
accident-causing or otherwise risky
behavior? Simple identification of a public
problem such as agricultural safety and
health is not enough to allow the design
and development of successful remedial
programs.

Building meaningful people-involvement
into problem identification, program
development, and program delivery is
essential. Failure to involve the real
stakeholders (the farmers and
farmworkers) dooms even the most out-
standing programs to failure. The era of
unshared decisionmaking is generally be-
hind us.

Need for Collaboration

What is required? The attention, effort,
and cooperation of individuals and organi-
zations at every level of society, from this
conference to our offices at home. Should
there be a national coalition to plan and to
coordinate intervention programs? A

national strategy could rest on the belief
that the most effective preventive efforts
will emerge from a process that emphasiz-
es identifying and characterizing problem
areas and populations at risk.

The collaborative efforts of engineers,
ergonomists, safety professionals, industrial
hygienists, and experts in biomechanics and
the behavioral sciences are needed to
address the most compelling problem areas
by studying what makes up workplace
systems and the process, tasks, and tools
involved. They must identify potential
causal mechanisms, opportunities for inter-
vention, and possible prevention strategies.

How will automatic ("passive") protection
be used more in agriculture? Passive pro-
tection is generally more effective than
"active" measures requiring effort by each
worker.

Engineering controls are available for
many known hazards but have not been
systematically applied and evaluated.
"Passive" measures of prevention could
involve worker protective-system ventures
into the realm of intelligent microenviron-
ments that feature sensors, microproces-
sors, adaptive protective mechanisms, and
display and imaging technology to protect,
inform, and warn workers for hazardous
conditions at their onset.

How do we ensure that the safety and
health of the agricultural worker is not
sacrificed for the sake of other issues? In
considering common issues, such as selec-
tive harvesting versus clearcutting in the
forests, we need to be aware that selective
harvesting may be better for the environ-
ment but that it places the logger at a
greater risk of injury than occurs in clearc-
utting using modern equipment. Can we
engineer machines that allow selective

Surgeon General's Conference on Agricultural Safety and Health - 1991 97
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.

92

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.O

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 Safety and Health

April 30 - May 3, 1991, Des Moines, lowa

RURAL HEALTH POLICY

By Jeffrey Human, M.A.
Director, Office of Rural Health Policy
U.S. Public Health Service

 

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, Taxi, Mean
Streets, and Escape from New York." I
think there is more hope in the country.

This morning’s Des Moines Register ran a
nice story on Dr. Novello’s speech, which I
thought was a high point of the meeting.
What an anachronism to call her the "Sur-
geon General."

Her message makes it clear that she is
both the "Pediatrician General" and the
"Family Medicine General." And that is
what we need in rural health. Yesterday,
everybody had a different ranking for agri-
culture as a dangerous occupation. It was
first, second, third, and fourth within an
our.

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 Agriculture 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 *orma-
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 Health
Association; a coalition whose work at

Surgeon General’s Conference on Agricultural Safety and Health - 1991 93
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
Towa 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.

94

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.

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 1-
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 Willie. That is 1-800-
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 Policy, 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.

 

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

96

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 1-800-633-7701, and they will have us
send you one.O

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 Safety and Health

April 30 - May 3, 1991, Des Moines, lowa

MEDICAL INTERVENTION PROBLEMS AND OPPORTUNITIES
IN RURAL AREAS

By Governor Robert D. Ray
Chairman, National Advisory Committee on Rural Health Policy

 

 

of America’s great leaders, Robert D. Ray:

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 lowa, and
then found a life after politics on his own. He did not lose an election—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 rana
successful insurance company, and now he is president of Blue Cross and Blue Shield of lowa, 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 | 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 |
have ever met. He knows more about health care than most of us. It is a pleasure to introduce one

 

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 Willie; and you have talked
to us about me. I am here to tell you that

Surgeon General's Conference on Agricultural Safety and Health - 1991

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.

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-
tain things.

You cannot just provide more access for
everybody without affecting costs and qual-

98

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.

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 to
do that.

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 chef’s 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.

 

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

7100

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

Papers and Proceedings