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

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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

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