Charge to the Conference, May 1, 1991

ries and diseases associated with numerous
chemical, biological, and physical hazards.

Occupational Lung Diseases

In 1988, agriculture had the sixth highest
work-related lung disease rate in this coun-
try. Types of lung diseases ranged from:
allergic, to asthma and acute responses to
toxic or irritating grain fumigants.

Musculoskeletal Disorders

Another disease entity that is prevalent is
degenerative musculoskeletal disorders.
They result form chronic exposure to farm
machinery vibrating, or to repetitive trau-
ma associated with farm work. The most
noticeable for these are reported as low
back pain, hip arthrosis, and degenerative
arthritis of the knee and upper extremities.

Migrant workers are typically involved in
work that involves frequent hand and wrist
movements, awkward working positions,
and a dependence on manual lifting, which
may be conducive to carpel tunnel syn-
drome and low back injuries.

Occupational Cancer

Regarding cancer, epidemiological studies
of farmers have uncovered consistent ex-
cesses of hematologic cancers, including
leukemia, Hodgkin's disease, non-
Hodgkin's lymphoma, and multiple myelo-
ma, as well as cancers of the lip, skin,
stomach, prostate, and brain.

Causative agricultural exposures have not
been conclusively identified, but agents of
concern include nitrates, pesticides, viruses,
antigenic stimulants, and various fuels, oils,
and solvents.

Excess cancers of the lip and skin are
linked to increased exposure to the sun's
ultraviolet radiation.

Severe Traumatic Injuries

Severe occupational traumatic injuries
usually occur suddenly on the job and are
either fatal or require immediate medical
care. These injuries affect, in substantial
numbers, children under the age of 16 and
the elderly 65 and older.

Machinery, especially farm tractors, are a
major cause of death to agricultural work-
ers. Others result from inadequate farm
building design and livestock handling.

Of the estimated 1,500 machinery-related
deaths annually among all occupations,
more than half involve farm equipment.

Cardiovascular Diseases

Another serious disease associated with
agriculture is heat stroke. Agricultural
workers are at the highest risk of devel-
oping this compared to all other workers,
including miners and construction workers.

One associated risk factor is the lack of
available drinking water, which affects at
least one-fifth of labor-intensive farmwork
nationwide.

Reproductive Disorders

Workplace exposures can adversely affect
the male and female reproductive systems,
and as a consequence interfere with fetal
development, and children's health. Pesti-
cides may cause reproductive failure in
either men or women, genetic damage, or
miscarriage.

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

57


Looking Ahead to the Next Century

Moreover, the nature of agricultural work
and the physiological changes of pregnancy
put the pregnant farmworker at increased
risk of health problems for both herself
and her baby.

Neurotoxic Disorders

Neurotoxic disorders present problems for
the farmers as well. Approximately 10,000
people in this country suffer acute poison-
ing by organophosphate insecticides annu-
ally. These pesticides affect the nervous
system, and up to not, the long-term neu-
rologic consequences are known.

Noise-Induced Hearing Loss

Regarding noise, noise-induced hearing
loss is a well-documented result of expo-
sure to farm machinery noise, especially
tractor noise. Approximately 323,000 agri-
cultural workers are exposed to potentially
hazardous noise levels. Such hearing loss
has been found to affect a quarter of youn-
ger farmers and fully one-half of older
ones.

Significant numbers of those affected have
been found to develop a communication
handicap by age 30.

Dermatological Conditions

Epidemiological data indicate that derma-
tological conditions caused by ultraviolet
radiation, plant materials, soils, fertilizers,
pesticides, and agents causing zoonotic
infection are very common among United
States farm workers.

In 1984, these disorders comprised over
two-thirds of the occupational illnesses
among crop production workers.

Skin disorders in this group were over five
times more common than among all pri-
vate sector employees combined, and near-
ly three times that of manufacturing em-
ployees.

Psychological Disorders

Additionally, farmers, farm family mem-
bers, and other rural inhabitants are not
exempted from stress-related psychological
disorders, especially depression.

Some of these psychological disorders
appear to be related to isolation, economic
hardship, weather conditions, or labor
status.

Infectious Diseases

In addition, some infectious diseases,
which are agriculture-related, vary form
one part of the country to another. Some
others, such as those related to poor sani-
tation, like dysentery, hepatitis, typhoid
fever, and intestinal ailments, are common-
ly spread by using the same eating and
drinking utensils, drinking non-potable
water, and from fecal-oral contaminating
due to the lack of toilet and handwashing
facilities.

Others, like parasitic infections - estimat-
ed to be 20 times that of either the general
U.S. population or even other rural or
poor urban populations, are epidemic
among migrant farm workers.

Such is also the case for tuberculosis. For
migrant workers, this is an occupational
problem, and not an imported disease.
The disease is 3,000 times more prevalent
among black migrants than the general
population as a whole.

52

Papers and Proceedings


So now that I have disseminated the infor-
mation, and you are aware of the problem,
what do we do?

First, and most importantly, parents who
farm need to know what the dangers are.
Second, parents must then educate their
children about these dangers. Ignorance-
like knowledge can remain forever.

The country is ready and the time is ripe
to move the national agenda forward re-
garding injury control. The key to any
success we might realize, however, lies in
our ability to come together, first at the
local level, and then at the Federal level.

And this is why we are here today-to ex-
plore what is needed to facilitate and pro-
mote this common goal, and work together
in making it a reality.

In order to accomplish this, we need to
return to some of the basic aspects of
public health and management.

o  We must work to raise the conscious-
ness of the public and alert the commu-
nity leaders about critical issues.

.  We must also build coalitions-partner-
ships between health, education, envi-
ronment, labor, and agriculture cornmu-
  nities.

We must begin to disseminate the appro-
priate information, and we must as a con-
sequence of such information, encourage
action to prevent injuries.

Ultimately, my goal is to motivate all of
you to reduce agriculture-related diseases
and injuries, by prevention.

If we are to be successful in this endeavor,
we must tackle the problem head on.

Charge to the Conference, May 1, 1991

My wish is that this Conference will set a
milestone in saving lives and preserving
health. To accomplish this, Dr. Millar and
I hope to convene a follow-up conference
in the near future to develop a national
strategy for the prevention of agricultural-
related diseases and injuries.

But until then I must tell you that it is my
belief that in agricultural safety and health,
prevention begins and ends with the fami-
ly, and so, the family should be one of our
main targets as we fulfill the charge I have
given to this Conference.

The key to any success we might realize,
however, lies in our ability to come to-
gether, first at the local level, and then
at the Federal level.

There was a famous 19th century Puerto
Rican literary figure, Eugenio Maria de
Hostos, who considered the family to be
the cornerstone of society. He said:

. . . as members of a family, we are so
closely bound to it by gratitude that we
recognize its effects from the cradle to
the grave. If we are born, we owe it to
the family; if we grow up, it is through
the protection of the family; if we are
educated, it is the work of the family;
when we are with the family we work for
it, away from it we long for it; we are
happy in the family and for its sake; if
we are unfortunate, we regret it for the
sake of the family; ill, we fear death for
its sake, and in dying, we long for it.

With all this in mind, your deliberations
here will set the stage for the work that
needs to be done in this field. You have
the responsibility of building a firm foun-

Surgeon General's Conference on Agricultural Safety and Health - 1991               53


Looking Ahead to the Next Century

dation for our future actions in the coming
decade. Your networking and coalition
building will set the partnerships that need
to be maintained.

This may be the tenth Surgeon General's
conference on occupational safety and
health, but this is just the beginning of our
work together.

Appropriately enough, today, May lst, is
traditionally viewed in agriculture as a "day
of fertility." Hopefully, today will mark the
day for our National Coalition for Local
Action to grow stronger. I trust that will
be the case.

We know that changes do not come easy-
they take commitment, partnership, and
dedication.

It is apparent to me that this group is
serious about injuries, and their impact on
the lives of all our citizens.

It also seems to me that we know what to
do and how to do it. Now we, together,
must do it.

Only when this is done will this local ac-
tion serve the national purpose. Friends,
this is our "Field of Dreams." If we build
it, they will come. I know we can, I know
we will.

Thank you, and God Bless.0

54

Papers and Proceedings


OPENING REMARKS

of you can probably relate to what I am
talking about.

Good morning, and thank you for that
kind introduction, Dr. Millar.

But, I am from a rural community, and I
can stand up here, as many have, and

It is a pleasure to be here. I have a back-
ground similar to that of many people who
have taken this podium. Senator Harkin
stood up here and said he was from a
small town.

relate to you story after story of my experi-
ences with working with agriculture-the
experiences of discing a loo-acre field at
the age of 10, or planting at the age of 11,
or maybe even driving a grain truck with
7% tons of grain at the age of 14.

Well, I am also from a small town, the
town of Fillmore, Indiana, a rural commu-
nity. Sometimes when I am talking across
the country, in cities such as Los Angeles,
Oklahoma City, Iowa City, talking about a
small town, I say, "You know Fillmore is so
small that when you drive into Fillmore
there is no need for a turn signal because
everybody knows where you are going any-
way."

I will be honest with you: at that point in
my life I did not give it a second thought.

By the same token, most of you involved in
agriculture know that it is a way of life,
and it is a respected way of life. I feel that
the objectives being accomplished here and
the directions that we are heading are
definitely right.

I think it is one of the few places in the   Dr. Millar, you talked about my involve-
country that you can dial the wrong num-   ment in the FFA. The FFA is the nation's
ber and still talk for thirty minutes. Many  largest intercurricular student youth orga-

Surgeon Gefleral's Conference on Agticu/tural Sat&y and Health
FARMWE 2000 9 A National Coalition for Local Action
Convened by the National Institute for Occupational SaWy and Health
April 30 - May 3, 1991, Des Moines, Iowa

REMARKS BY THE NATIONAL FFA PRESIDENT

    By Mark Timm
President, National FFA Organization

Dr. J. Donald Millar: One of the great things about this conference to me is that there are so many
young people here. We are very, very pleased with that aspect, and oftentimes in public health
meetings there are not a lot of young people around.  It seems to me that we have not made
prevention and public health all that attractive to young people. But this is a field that compels the
imagination of youth as well as the rest of us. So it is a great pleasure for;me, at this point in the
conference, to introduce you to a young national leader, Mark Timm, who is the national president,
FFA. Mark is president for 1990-91. He is 19 years old, and he serves over 387,000 FFA members in
over 7,600 local chapters nationwide, including the District of Columbia, Puerto Rico, and the U.S.
Virgin Islands. These FFA members are preparing for careers in the science, business, and
technology of agriculture. Mr. Timm was State FFA president in Indiana last year and is a National
FFA scholarship recipient. He is currently on a one-year leave of absence from Purdue Univer-
sity-my wife and I drove through West Lafayette just two days ago-where he is studying sales and
marketing with sights on working for an agricultural company in the future. During his year as FFA
president, he will travel more than 200,000 miles, making hundreds of appearances on behalf of the
FFA. It is my very great pleasure to introduce Mark to you:

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

55


Questions to Guide the National Agenda

nization-nearly 400,000 FFA members
nationwide. And serving as national presi-
dent is a tremendous honor. It is a great
opportunity, but it is even a greater re-
sponsibility, because, as the speakers have
stood up here and talked abbut the role of
youth in America there are not very many
opportunities for youth to speak out and
speak to adults.

I have been given the chance to represent
a large portion of the youth in America
and the youth in agriculture. It gives me
great delight to see the young people in
our organization out here. I do not know
if you have had the chance to notice, but
there is more than just my jacket running
around here. There are seven chapters
from all across this country.

Dr. Roper talked about leadership. Well,
our organization is based on agriculture.
That is the backbone of this organization.

But, equally important, our students are
interested in developing their leadership,
their personal, and their academic skills,
through agriculture. We are teaching them
not only to be stewards of the land but to
be the future leaders of our communities,
of our state, of our country, and eventually
even of our world.

I would like to share with you some of the
leadership that we are showing in the area
of safety. We have a National Chapter
Safety Award Program.

This year, at our National Conventidn, we
honored over 150 chapters for outstanding
accomplishments in the area of safety.
Thirty-six chapters received gold recogni-
tion, and out of those 36, seven were cho-
sen to attend this conference. Those seven
chapters are going to be putting on poster

56

displays tomorrow afternoon in the poster
display demonstration.

I want to share with you, just to highlight
some of the safety areas that we work on
or that we address as an organization,
because, you see, our primary goal as a
national safety award program is just like
the goal that your theme states. It is a
national coalition for local action.

This year, at our National Convention, we
honored over 150 chapters for outstanding
accomplishments in the area of safety.

It is a national award program centered at
the local level. What we do is assess the
needs of the community. The chapter
assesses the needs of the community, and
some of those needs that we address are
National Farm Safety Week; Farm Safety
for Just Kids, which you have heard about;
chemical safety for farmers; water quality
testing; and all-terrain vehicle (ATV) and
three-wheeler seminars.

Chapters even address areas such as boat-
ing safety; holiday awareness programs
such as the testing of candy on Halloween;
fire-prevention safety; home safety, farm
machinery operations, and hazardous grain
hauling; chain-saw safety; restricted use for
pesticides; CPR classes and substance
abuse awareness. So, we are touching
several areas in safety, focusing primarily
on agriculture, which is our backbone, but
also other areas of safety.

Not only do we have our National Safety
Award Program, but we also are infusing
safety into our curriculum-agricultural
education. We have initiated programs in
areas such as food safety and environmen-

Papers and Proceedings


tal safety. As a matter of fact, one of our
most recent programs was food safety-a   1. Surveillance-Agriculture-related Dis-
                     ease, Injuries, and Hazards.

$300,000 project that business has picked
up and is willing to sponsor, and we plan
to start developing the actual curriculum
this summer.

2. Research-Biological and Chemical
Hazards.

3. Research-Physical and Mechanical

We will be writing the curriculum and will    Hazards.
be spreading it across the country, with 400
workshops, trying to educate our teachers  4. Intervention-Agricultural Workers'
of agriculture education and the home       Protection from Hazards.
economic teachers about food safety, all
the way from the production of food to the  5. Intervention-Safe Behaviors among
processing of the food. So we are covering    Adults and Children.
a wide range, a wide spectrum, of food

safety. We will educate teachers on food
safety, then they will educate the people
that make it count, and that is the young

A presentation panel will deliver talks on a
variety of issues. Tomorrow, after a morn-
ing plenary session, a concurrent session

people in America.

will reconvene to hear discussion panels
comment on today's presentations. The

I would like to close on my statements    concurrent session will reconvene again
about the FFA and our role in safety by   after lunch tomorrow, to hear public com-
quoting what one of the chapters that are   ment and to address the points to be re-
represented here-the Stockton Chapter of  ported back to the full conference on Fri-
Missouri-said in their safety award appli-  day morning.
cation:

Health is not everything,
but you're dead without it.

[REMARKS AT THE CONCLUSION
OF THE SESSION]

[REMARKS AFTER THE
FIRST SPEAKER]

Before we conclude, I would like to thank
them for giving me the opportunity to
come here, and I would also like to say
that, as the population of the rural com-

The rest of this session will frame the work  munity declines, so does our membership
of the conference around three activities:   in the FFA, the organization that I repre-
surveillance, research, and intervention.    sent. However, our urban membership has
Each of the three following speakers will   drastically increased, so we are involving a
pose questions related to each of these    much more diverse group of young people
activities, which will be addressed by five   interested in agriculture.
concurrent sessions.

                   I get the chance, as I travel across the
One session will address surveillance; two  country, to represent youth in agriculture,
will address research; and two will address  and I want to share with you one quick
intervention. These five concurrent ses-
sions will convene this afternoon. The five  story before we conclude. That is, a spe-

sessions are:              cial place that I have found off the coast of

Questions to Guide the National Agenda, May 1, 1991

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

57


Questions to Guide the National Agenda

Alaska. It is a special place called the
Diomede Islands.

Why it is so special is because the Intema-
tional Date Line is found to run right
down between the Diomede Islands. Not
only that, but one side of the islands is
owned by the Soviet Union and the other
side is owned by the United States.

Not only does America need its young,
but young people need your help, support,
guidance, and leadership.  I

So you can sit on one side of the island
and look across and it would be the 28th
of the month, and on the other side of the
island it would be the 29th. On a clear
day, when you look across these islands,
not only would you see another perspective
on life, since the Soviets value the posses-

sions they have and we as Americans value
freedom-but on a clear day you can even
see tomorrow.

If you really think about that-the ability to
see into the future-1 wish I had the ability
to see in the future right now because, let
me tell you, I see a tremendously bright
future in this industry of agriculture.

I am proud to say that I am a part of agri-
culture and proud to be here representing
this organization, representing youth in
agriculture. With that, I would like to
leave you with one final statement on
behalf of the youth, and that is that Ameri-
ca needs youth because youth represents
the future of the state of this country and
of the existence of everybody. Not only
does America need its young, but young
people need your help, support, guidance,
and leadership.0

58

Papers and Proceedings


Surgeon General's Conference on Agricultural Sakty and Health
FARM&FE 2000 . A National Coalition for Local Action
Convened by the National Institute for Occupational Satkty and Heatth
April 30 - May 3, 1991, Des Moines, Iowa

THE ROLE OF PUBLIC POLICY IN
AGRICULTURAL SAFE7Y AND HEALTH

     Joseph A. Enney, M.P.A.
Executive Director, National Safe Workplace Institute

Mr. Mark Timm: Our first speaker this morning is Mr. Joseph A. Kinney, Executive Director of the
National Safe Workplace Institute, located in Chicago. Mr. Kinney spent his youth and entire
professional career closely linked to agriculture. He grew up in Kansas working on farms and
ranches and was deeply involved in breeding Charlette cattle when he was a college student at
Illinois State University. Mr. Kinney holds a Purple Heart from service in Vietnam. He later spent five
years working on agriculture in the United States Senate, and an additional five years as staff director
for the committee on agriculture in the National Governor's Association. He spent a significant
amount of time living and working with farm families in several states, including Idaho, North Carolina,
Minnesota, Alaska, and California. He holds graduate degrees from the Maximal School of Citizen-
ship and Public Affairs, and from the University of Pennsylvania. In 1987, Mr. Kinney founded the
National Safe Workplace Institute, which is a not-for-profit organization devoted to making oc-
cupational safety and health a higher priority for the private and public sectors. Both Mr. Kinney's
background and his interest in safety uniquely qualifies him to speak on the topic, The Role of
Public Policy in Agricultural Safety and Health. Mr. Kinney:

Good morning. It is really a privilege for
me to be here today to address the Sur-
geon General's Conference and to discuss
the role of public policy in agricultural
safety and health.

As you have just heard, I have had two
careers. My first career was in agriculture.
In fact, about 10 years ago or so I had the
opportunity to address an agribusiness
audience in Dallas, and one of the old
ranchers in the audience got up and made
a little speech and at the end of it he said,
"And son, how long you been involved in
agriculture?" I said, "Sir, 30 years. Next
question, please." So, you know, I feel like
I've been around it a fair bit of my life,
since I was about 32 when I spoke in Dal-
las.

Throughout my life, I have developed a
deep appreciation for the role that our
farmers and ranchers play in the produc-
tion of the food and fiber of this country.
They clearly are our backbone. Without

them, we would have nothing. In fact, if
you look at our economies and compare
them with many of the economies in the
industrialized world, one of the real
strengths we have is our efficiency in food
and fiber production. It is because of
people like Mark. We all really owe them
a lot.

As Mark said, I spent a lot of time living
and learning from farmers and ranchers. I
have cured tobacco in Harnett County,
North Carolina. I used to be involved in
all aspects of grain and livestock produc-
tion in Illinois. Certainly I have baled my
share of hay in Kansas. I have tended
ranges in Wind River, in Wyoming.

My least favorite job was culling potatoes
in Idaho. But I took those jobs because
working in Washington, you tend to be sort
of isolated and insulated from reality, and
so when I would meet an interesting farm-
er I would ask him, "Well, can I come and

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

59


Questions to Guide the National Agenda

work for you for a week and learn what
you do?" That is how I did it.

I actually was injured once. I had a very
severe laceration to my left leg and was
stitched by a "vet." When we design our
surveillance systems, it is clear that we
have got to include veterinarians because I
was stitched by a vet. I have got a lot of
ugly scars, but it is the ugliest. But it was
a very valuable experience because it
taught me that farmers like to rely on their
own community. I would be very surprised
if there is not some resistance to NIOSH.

b Certainly one of the things that I learned
in my years in Washington was that the
agricultural community is strongly resis-
tant to OSHA. I think that will have to
change. Clearly, farmers are a unique
group. Farmers tend to work until the job
is done. They do not know a g-to-5 day.
But it is also clear that agriculture defies
easy generalization.

Throughout my life, and I am 42 now,
there have been two consistent themes.
The first is that our farms and ranches
tend to grow in size, almost year by year.
The little house on the prairie, near where
I grew up in Kansas, now looks a lot more
like Dallas.

b The second theme is that we are spen-
ding a lot of money-a significant amount
of money-on supporting farm incomes
from the Federal treasury. I think that is
very important to understand, because I
know farmers-and we will talk a little bit
about this today-want to resist any kind of
intrusions by external forces. But what
farmers need to understand-and rural
people need to understand-is that there is
a significant public investment in what they
do and, therefore, there is a significant

Frankly, there would be more public in-
volvement if it were not for the farm lob-
by. Having met with many farm organiza-
tions, I can tell you that at least in the past
they have resisted involvement. I think
that is going to change. In fact, I think we
will begin to see more public involvement
in these issues in the near future. I mean
involvement beyond the sort of touchy-
feely things of education and beyond
research issues. There are any number of
areas that we could see develop.

public interest in their health and
well-being.

My interest in occupational safety and
health stemmed from the death of my
brother, Paul, from a scaffold collapse in
Colorado. Since I have been involved, I
have had a peripheral interest in agricul-
tural safety. At the Institute, we have
written about it. We have talked about it
a little bit. We are doing a rather compre-
hensive analysis of options for public invol-
vement on job safety. I will touch a little
bit on that today.

Frankly, there would be more public
involvement if it were not for the farm
lobby.    I

You have heard plenty about the size and
magnitude of this problem. You know, the
National Safety Council puts out data and,
based on this data, agriculture has had
persistently high levels of injury relative to
other regulated areas. I guess the lesson
we could learn from that is that the free
market and, perhaps, many educational
approaches are not working. We need to
look more aggressively to other approach-
es.

60

Papers and Proceedings


The Role of Public Policy in Agricultural Safety and Health, May 1, 1991

I would like to show you a couple of trans-
parencies that I put together here so we
can get a sense of who is involved and
what is involved. Farmers like to talk
about target prices. People in public
health like to talk about target groups.

When we look at this issue, we need to
understand that there is more involved
than the men and women who own and
operate farm enterprises. There are chil-
dren. There are farmworkers. There are
all different categories of people.

Sector
Agriculture
Mining Workers
Covered by OSHA

Dollars Spent
Per Worker
    $0.30
  $181.68
    $4.34

U.S. Department of Agriculture's Commitment to
Agricultural Safety and Health, FY 1991:
b Extension Service-distributed on
a formula basis with $19,000 to
  each state:              $970,000
c Competitive Grant Program:    $1 ,ooo,ooo
      Source: Prof. William Field, Purdue University.
                                         1

Ygure 1. Federal Dollars (Fiscal Year 1987) Spent
on Occupational Safety and Health.

Now, potentially there are all sorts of laws
that could be applied in this area-child
labor laws, criminal prosecutions for not
only fatalities and homicides, but batteries
and injuries. There is obviously the possi-
bility of citations. Right now there is a
rider on the appropriations bill that keeps
OSHA from inspecting injuries or fatalities
on farms. Of course, there is Workers'
Compensation, and, finally, there are injury
lawsuits.

To this point the public involvement has
largely been limited to research and educa-
tion migrant protection, and health servic-

es. Of course, there is the sanitation stan-
dard. But the involvement of both states
and the Federal Government has been
quite limited.

1. Surveillance            $5,745,816
. Farm Family Health and Hazard Survey.
. Occupational Health and Safety
Surveillance Through Health Departments.

2. Research             $6,217,817
b Applied Preventive Research.
w Education and Training Programs.

3. intervention            $6,676,367
. Cooperative Agreement Program for
Agricultural Health Promotion Systems.
b Demonstration Cancer Control Projects for
  Farmers.
                       Source: NIOSH.

Figure 2. National institute for Occupational Safety
and Health-Agricultural Safety and Health Program.

In fact, if we look at Figure 1, we can see
that these data are a little old; but, I am
told by the producer of it, Bill Field of
Purdue University, that the data really
have not changed that much. As you can
see, occupational safety and health expen-
ditures equal about thirty cents per farmer.
Perhaps that is what they think their lives
are worth, but we spend a substantial
amount of money, for miners, and a small
amount of money for regular industrial
workers.

The Agriculture Department's commitment
is now essentially limited to a $975,000
fund distributed equally to states. Perhaps
we are going to hear that the U.S. Depart-
ment of Agriculture (USDA) is also going
to spend a million dollars in competitive
grants that will be committed by the end of
this fiscal year.

Surgeon General's Conference on Agricultural Safety and Health - 1991                61


Questions to Guide the National Agenda

Figure 2 shows NIOSH programs that are
multi-year programs. It looks like a lot of
money. NIOSH spends $X3-$19 million
dollars. In reality, it is quite little.

In Figure 3 what we wanted to measure,
in terms of budgetary expenditures, is the
commitment that we have to occupational
safety and health in America. Total feder-
al workplace health spending involves the
budgets for NIOSH, for the Occupational
Safety and Health Administration (OSHA),
and for the Mine Safety and Health Ad-
ministration (MSHA).

In 1981, we spent one dollar out of each
$1,579 of the Federal budget for these
programs-not very much. By 1991, that
amount of money had dropped to just a
one dollar out of each $2,408.

I

`igure 3. Workplace Safety and Health Regulatory,

       Total       Amount   How Many Federal
    Workplace   Required to   Dollars Spent for
Fiscal    Health    Keep Pace Each Dollar Spent on
Year   Spending with Inflation'  Workplace Health'
Gil   $4,294     n/a    $1,579
1983   $4,165    $4,854    $1,941
1985   $4,356    $5,234    $2,172
1987   $4,524    $5,493     $2,219
1989   $4,807     $987    $2,212
1991'   $5,447    $6,512    $2,408
o Estimate.
' Inflation data based on calendar years; 7997 figure is an
estimate.
' Another way of expressing this statistic: Number of federal
dollars spent for every sing/e dollar spent on the combined
budgets of OSHA, MSHA, and NIOSH.
     Sources: Inflation Data-Bureau of Labor Statistics,
   Budget Figures-Cffice of Management and Budget.
    Compiled by the National Safe Workplace Institute.

Research, and Education Spending-Adjusted for
inflation and as a Share of Federal Budget, Selected
Years (in millions).

What this chart represents to me is a di-
minished and decreasing commitment to
workplace safety relative to other budget

priorities. There is no way around that.
We have also looked at this and you know,
we have looked at occupational health
versus EPA, we have looked at this versus
the National Institutes of Health and a lot
of other measurements. Clearly, our com-
mitment to occupational health in this
country-workplace health-is going down.

Now in Figure 4, we looked at workplace
health compared to the national defense.

        Total
Fiscal   Workplace    National
Year    Health*     Defense     &tiJ
1981     $429.4    $157,513     366.9
1983      416.5     209,903     504.0
1985      435.6     252,748     580.2
1987       452.4     281,999     623.3
1989      480.7     290,361      604.0
1991'.      544.7    298,910 o **   548.8
*includes combined budgets of the Occupational Safety and
Health Administration, Mine Safety and Health Administration,
and National Institute for Occupational Safety and Health.
`*Estimate
`**Pts-Desert Storm
      Source: Cffice of Management and Budget.
   Compiled by the National Safe Workplace Institute.

:igure 4. Comparison of Total Workplace Heait
Spending Versus National Defense Spending,
Selected YE!XS (in hundreds of millions of dollars).

In 1981, as you can see, we valued our
national defense 367 times more than we
valued the health and safety of workers in
America. That is what these data say to
me. By 1987, the ratio had grown to 623
times. In 1991, it dropped to 548 times.
But, of course, that was before Desert
Storm. No one seems to know what is
going to happen to the defense budget. I
think we are going to have to add some-
where in the neighborhood of $40 billion
plus. So, the 548 times figure will be much
closer to 600 and something.

62

Papers and Proceedings


In fact, if you look on Figure 5, at work-   extension friends and they were telling me
place health spending compared to farm   how poorly the USDA agriculture research
income stabilization, in 1981 we supported  budget has been doing. My friends, you
farm income 23 times more than we sup-   have been doing much better than NIOSH,
ported workplace health.          OSHA, and MSHA, as you can clearly see
                    in this Figure 6.
Please do not misunderstand what I am
saying, I have worked hard on the farm   What these figures suggest to me, at least
bills of 1973, 1977, and 1981, and I certain-  at a superficial level, is that there may be
ly know all the arguments for target prices  more room to do more things at USDA.
and price support loans and all the various
USDA programs.             Of course, that raises a significant question
        I think they are very   I hope will be worked out in the next year
valuable. These are income transfers to   or two. The question is how we might best
farmers. Clearly, the dollar amounts fluc-  coordinate and work together. I think
tuate up and down depending on what    there is room for both agencies to be in-
commodity prices are doing, but never-    volved in this area. In fact, I think they al-
theless it is interesting to compare price   ready are. The Extension Safety programs
supports and workplace health spending.   go back a hundred years-a long, long time.

        Total       Farm                   Total     Agriculture
Fiscal   Workplace     income           Fiscal   Workplace    Research &
yri%TJ    Health*    Stabilization   &l&l   yeaJ   Health'      Services    Ratio
1981     $429.4     $ 9,783      22.8    1981     $429.4      $1,540       3.6
1983       416.5      14,344      34.4    1983     $416.5      $1,578      3.8
1985      435.6      21,323      49.0    1985     $435.6      $1,813       4.2
1987      452.4      29,606      65.4    1987     $452.4     $1,864      4.1
1989      480.7      14,817      30.8    1989    $480.7     $1,964       4.1
1991 o *     544.7      9,761       17.9   1991 o *    $544.7     $2,404       4.4
&ludes combined budoets of the Occuoationai Safety and   *includes combined budgets of the Occupational Safety and
Health Administration, Mine Safety and Health Administration,   Health Administration, Mine Safety and Health Administration,
and National institute for Occupational Safety and Health.     and National Institute for Occupational Safety and Health.
-Estimate.                         "Estimate.
       Source: Office of Management and Budget.          Source: Office of Management and Budget.
    Compiled by the National Safe Workplace Institute.       Compiled by the National Safe Workplace institute.

Ygure 5. Comparison of Total Workplace Healt   :igure 6. Comparison of Total Workplace Health
Spending Versus Farm Income Stabilization Spen-  Spending Versus Agriculture Research and Services,
ding, Selected Years (in hundreds of millions of dollars).   Selected Y&V.S (in hundreds of millions of dollars).
Figure 6 compares total workplace health  The next figure, Figure 7, is what my four-
spending to agricultural research and ser-  year-old son would call a "big nasty."
vices of selected years, basically every    These are the kinds of public sanctions
other year from 1981 to 1991.       that can be taken against job-safety viola-
                            tors.
As you can see, the agricultural research
and services budget is growing at a faster   b First, if you look at the economic
rate than workplace health. I was having   literature, the most costly part of OSHA's
breakfast this morning with some of my    involvement with business is not in fines,

The Role of Public Policy in Agricultural Safety and Health, May 1, 1991

Surgeon General's Conference on Agricultural Safety and Health - 1991                63


Questions to Guide the National Agenda

but clearly in the inspection process.
There are many studies on that.

b Second, there are civil penalties, and
they were recently increased by a
substantial magnitude.

b Third, there are criminal penalties.
There is legislation in the Congress now to
increase the amount of time we can spend
in jail for knowingly and willfully tolerating
workplace conditions that result in the
death of a worker. The government has
recently put one person in jail, under the
OSHA Act. It was a South Dakota con-
tractor and the incident involved excava-
tion fatalities. I have no idea how many
people die in excavation fatalities on farms
and ranches, but I am sure it is a substan-
tial number.

b Fourth is Workers' Compensation premi-
um increases.

b Fifth is a seldom-used tool, un-
fortunately. Hopefully, it will be used
more in the future. It is simply an injunc-
tion to stop people from doing what they
are doing.

b Sixth is the loss of eligibility to partici-
pate in public programs. The most recent
example is that of a construction company
called S.A. Healey, a Chicago company
that had a bad safety record with many
violations.

So far, they have lost a $78 million con-
tract in Los Angeles on which they are the
low bidder in, because of their safety re-
cord. They lost a $37 million contract in
Milwaukee, where they were the low bid-
der, because of their safety record. They
are the low bidder in an approximately
$200 million contract in another New Eng-

64

land state where my organization is active-
ly trying to knock them out.

I. Potential target groups:
b Farmers.

b Farm Families (spouse, children).
b Farm Children engaged in farm work.
b Farm Workers, Permanent, Full-Time,
  Year-Round.

b Farm Workers, Permanent, Part-Time,
  Year-Round.

b Farm Workers, Seasonal,
  Part- or Full-Time.
t Migrants.

2. Applicable laws:
b Child labor laws.
b Federal criminal prosecution: homicide,
  willful violation.

> State homicide or battery prosecution.
b Citations for violations by the
Occupational Safety and Health
Administration or corresponding state
  agency.

b Workers' Compensation.
b Injury law suits.

- Compiled by the National Safe Workplace Institute.

?gure 7. Target Groups and Laws that Could Be
Used To Regulate Agriculture Safety and Health.

One of the possibilities that we could see,
frankly, in the agricultural area, is the
possibility of cross-compliance. One of the
models that we might look at in terms of
public intervention and farm safety would
be a farm safety audit.

If farmers did not pass their audits or
make corrections within a specified period
of time, they could lose eligibility for price
support programs, soil-conservation pro-
grams, farm loan programs, farmers' home
programs-whatever programs exist, and
there are plenty of them.

Papers and Proceedings


The Role of Public Policy in Agricultural Safety and Health, May 1, 1991

Another area where I think we will see
some intervention, very soon, of a criminal
nature is children on farm equipment.
Mark Timm talked about his involvement
as a youth.

I could tell the same stories. One is a
recent event; a 21-month-old was killed
while helping his father when he fell under
the wheel of a tractor that his six-year-old
sister was driving. According to Bill Field,
at Purdue, the fact that 300 kids die each
year on farms-kids below the age of 15-is
supported by a similar study at the Univer-
sity of Tennessee.

In recent years, we have documented
three-year-olds who were killed in Nebras-
ka and Texas who were actually classified
as industrial deaths. Let me say one thing.
This 300 number may be substantially
larger in proportion to population than the
numbers of 15-year-olds who are
killed-murdered-in big cities because of
drugs. If that does not make your blood
boil, I think you should go out and have
your temperature checked.

There is no way that anybody with half a
conscience, looking at these numbers and
looking at these stories, can sit and not say
that this is not potential child labor abuse.
We have been responding to increasing
inquiries from prosecutors in various cities
who have been looking into bringing child
labor abuse charges in farm accidents. It
has not happened, but I am certain that it
will happen in the next few years.

Sunday there was a story on CNN-maybe
many of you saw it-about a guy named
Dominguez in Miami who is going to jail
because his kid did not have a seat belt
fastened. In fact, the kid was sitting in his
mamma's lap, if I remember the story cor-
rectly. They had a crash, and the kid was

killed. So the father is being prosecuted.
Frankly, there is not a dime's worth of
difference, in my view, between the
Dominguez in Miami and the man in
Visalia, California.

The last area where I think there is going
to be some involvement, as shown in Fig-
ure 8, has always been a dynamic area.
There are only 12 states in the United
States where farmworkers are recognized
as workers under workers' compensation.

Coveraae    States
Same as other
Workers . . . . . Arizona, California, Colorado,
Connecticut, Hawaii, Louisiana, Massachusetts,
Montana, New Hampshire, New Jersey, Ohio,
and Oregon (12).
Voluntary . . . . Alabama, Arkansas, Idaho,
Indiana, Kansas, Kentucky, Mississippi,
Nebraska, Nevada, New Mexico,
North Dakota, Rhode Island, South Carolina,
and Tennessee (14).
Limited . . . . . Alaska, Delaware, Florida,
Georgia, Illinois, Iowa, Maine, Maryland,
Michigan, Minnesota, Missouri, New York,
North Carolina, Oklahoma, Pennsylvania,
South Dakota, Texas, Utah, Vermont, Virginia,
Washington, West Virginia, Wisconsin, and
Wyoming (24)

-Compiled by the National Safe Workplace Institute
with the Assistance of the Farmworker Justice Fund.

:igure 6.  Workers' Compensation Coverage c
Agricultural Workers.

Workers' compensation is a no-fault injury
program. When you create workers' com-
pensation programs, you can not sue your
employer for injury. Voluntary really
means no program. I am sure-1 do not
have any studies but I am sure-that the
vast majority of farmers in those states
have no workers' compensation insurance.
Are there any studies on this subject that
you know of?

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

65


Questions to Guide the National Agenda

About how many farmers have workers'
compensation insurance in the states where
it is voluntary ? It would be a good study
to do. In these other states-24 states-it is
limited, like in Georgia. Farmers who
work for the Department of Corrections
are covered, but all other farmers are
excluded. There are all sorts of different
restrictions. We have all the data. We
have analyzed the laws. That is the story!

Let me say that what we are now
recommending to farmworkers who are
injured, especially in the states with volun-
tary programs where there is no compensa-
tion coverage, is to sue. Sue the living
"Bejesus" out of the farmer for whom you
work.

This is the only way that we are going to
get the attention of people in states where
workers compensation is limited and farm-
ers are not covered-sue. It is only
recourse the injured have.

What has happened historically? To use
the terms of economists, the economics of
these injuries have been externalized.
Who pays for injury in the case of the
farmworker or migrant?

I can tell you who pays for it. It is the
families. It is the local public charities. It
is the public hospitals. It is not the farmer.
And, of course, if the farmer can external

ize the cost and risk to other forces in
society, it is rational for that farmer to do
so.

I am not going to sit up here and just tell
you exactly what is going to happen when
and where. I do not know. But, believe
me, it is moving toward public interven-
tions. I hope what that says to each and
every one of you out here is that you need
to begin to get realistic about how you
would like to see these issues addressed.

Our country spends more per capita for
the education of the young than any other
nation, save Switzerland. We spend lots of
money to prepare young people for life.
Cities help educate farm kids.

There is also public investment in human
lives, and we need to do more to protect
those lives in agriculture. I am sorry if
some of you people feel, as my son proba-
bly would feel, that I have come and been
the "big nasty" here today, but I think that
it is time that we begin to look at this and
realize that we have got to do something
about farm safety.0

66

Papers and Proceedings


Public health surveillance is central to the
process of disease prevention. Surveillance
systems are vital tools in targeting the
resources of the public health system and
in evaluating program effectiveness.

The Institute of Medicine report The Fu-
ture @Public Health' found the core
functions of public health to be as-
sessment, policy development, and assur-
ance of the availability of services. Sur-
veillance is intrinsic to the assessment
function and essential for proper policy
development and assurance of service
availability.

An ongoing national dialogue is needed on
the role of public health education in trai-
ning future public health professionals;
graduates of schools of public health are
acknowledging the need for more books
and course materials designed to prepare
students for public health practice. State
and local public health agencies, in partic-
ular, have recognized this need as they
recruit and hire new professional staff.
There is growing recognition of the role of
surveillance conducted by agencies of

Surgeon General's Conference on Agricultural SaWy and Health
FARM&FE 2000 o A National Coalition for Local Action
Convened by the National institute for Occupational Safety and Health
April 30 - May 3, 7991, Des Moines, lowa

SURVEILLANCE FOR AGRICULTURAL SAFETY AND HEALTH

           William E. Halperin, M.D.

National Institute for Occupational Safety and Health

Mr. Mark Timm: Our next speaker is Dr. William Halperin. He is the Associate Director for Surveil-
lance, Division of Surveillance, Hazard Evaluation, and Technical Assistance, at NIOSH in Cincinnati.
Dr. Halperin received his Master's in Public Health and M.D. from Harvard. In 1975 he became an
Epidemic Intelligence Officer at the Centers for Disease Control. In 1979 he became the Chief of
Industrywide Studies Branch at NIOSH. Dr. Halperin has served on numerous professional and
expert committees. He currently serves on the Committee on Risk Assessment Methodology at the
National Research Council. Dr. Halperin has published over 100 scientific papers, editorials, and
letters to editors. His epidemiological investigations include herbicides, dioxin, and biotechnology.
He was a co-author on perhaps the most popular paper in occupational health in the last 10
years-the Sentinel Health Event A Framework for Occupational Health Surveillance and
Education.  That leads to Dr. William Halperin's topic today, Surveillance for Agricultural Safety
and Health. Dr. Halperin:

government as well as by industry and
labor to advance the mission of public
health-"to fulfill society's interest in assur-
ing conditions in which people can be
healthy."'

Although surveillance is an essential ele-
ment of the practice of public health, the
subject is rarely taught in schools of public
health or fully discussed in textbooks of
public health or of epidemiology. This gap
reflects the diverging cultures of public
health between schools of public health
and public health practitioners, a diver-
gence recently addressed in a report of the
Institute of Medicine, The Future of Public
Health.

The essence of the motivation for public
health was captured by the 16th century
poet John Donne, who unfortunately came
to the wrong conclusion about surveillance.
Donne wrote:

No man is an island, entire of itself; every
man is a piece of the continent, a part of
the main. If a clod be washed away by
the sea, Europe is the less, as well as if a

Surgeon General's Conference on Agricultural Safety and Health - 1991                67


Questions to Guide the National Agenda

promontory were, as well as if a manor of
they friend's or of thine own were: any
man's death diminishes me, because I
am involved in mankind, and therefore
never send to know for whom the bell
tolls; it tolls for thee.

The public health sentiment is captured in
the following line:

Any man's death diminishes me,
because I am involved in mankind.

This is not a matter of epidemiology or the
technology of public health, but rather a
matter of the philosophy that motivates
public health action.

The antithesis of surveillance is captured
in the following line: "Therefore, never
send to know for whom the bell tolls." In
earlier times, church bells were rung when
people died. Currently we have a need for
similar information to connect us to the
burden of morbidity and mortality and to
call forth public health practitioners so
that deaths and morbid events can be in-
vestigated and recurrences prevented.

Surveillance in modern times is the equiva-
lent of the tolling of the bells with the
added commitment to investigation of the
causation of morbidity and mortality and
dissemination of data and analysis with the
goal of prevention. Surveillance, as de-
fined by Alexander Langmuir, the father of
modern public health surveillance, and the
founder of the Epidemic Intelligence
Service of the Centers for Disease Control,
"means the continued watchfulness over
the distribution and trends of incidence
through the systematic collection, consoli-
dation, and evaluation of morbidity and
mortality reports and other relevant data'13"
for the purposes of prevention of disease
or injury.

It is worth lingering over some of the key
words in this definition. "Continued watch-
fulness" implies that the surveillance pro-
cess continues over time, rather than being
a one-time survey or epidemiologic study.
Repeated surveys from which trends can
be discerned are consistent with surveil-
lance. "Collection, consolidation, and eval-
uation" should differentiate surveillance as
a process from the important, but different
enterprise of registering cases in a disease
register, such as a cancer registry, if this
registry does not include analysis of the
data and dissemination of the results.

"Other relevant data" allows for collection
of information on risk factors for disease,
health or safety hazards, etc., or preventive
interventions, such as immunization, rath-
er than limiting surveillance to collection
solely of data on disease. To differentiate
surveillance from other useful collection of
data, such as marketing surveys for a prod-
uct, "for the purposes of prevention of
injury and disease" should be added to Dr.
Langmuir's definition.

Surveillance should not be so definitively
defined that in-depth investigation of indi-
vidual or sentinel cases is excluded. A
"sentinel health event" represents a failure
of prevention, such as a maternal death or
an industrial injury.

THE ROLE OF SURVEILLANCE IN
PUBLIC HEALTH PRACTICE

The practice of public health can be de-
fined as the logical application of methods
of problem recognition, evaluation, and
intervention for the purpose of prevention
of disease and injury in populations. A
working definition of epidemiology should
reflect both the traditional broad notion
that epidemiology is "the study of the
distribution and determinants of disease

68                                   Papers and Proceedings


frequency in man,"6 which encompasses   In comparison to data purposefully collect-
interest in epidemic and endemic diseases,  ed for a research study, information from
as well the inclusion of the supplemental   death certificates on industry and occupa-
views of theoretical epidemiology.       tion and even cause of death will be col-
Theoretical or modern epidemiology     lected without quality control, by minimally
focuses much more on the use of very    trained observers, and will inevitably con-
sophisticated analytic methodology for    tain errors. However, surveillance data,
understanding the relationship of risk fac-
tor and disease, particularly of endemic   often collected for administrative purposes
                   and secondarily used for disease preven-
disease, rather than on the description of
epidemics.'               tion, is inexpensive and readily available.

                   Milham and colleagues found that farmers
                   had a substantial excess in the proportion
Surveillance in modern times is the equiv-    of deaths due to electrocutions. When the
alent of the tolling of the bells with the   deaths were investigated, they found that
added commitment to investigation of the   many were due to contacting electric utility
causation of morbidity and mortality and   lines with portable aluminum irrigation
dissemination of data and analysis with   pipe. While the association of
the goal of prevention.          electrocution and aluminum piping must
                    have been evident to the sphere of people
`i                    involved with each incident, the problem
                    was only brought to the attention of the
A useful model that specifies the role of
surveillance in the practice of public health  public health community by the analysis of
                         minimal information available from death
has been developed by Greenwald,* and   certificates, and the dissemination of
further elaborated by Layde,9 and modified  results for the purpose of prevention.
here to describe the role of surveillance in
the prevention of occupational injury and   Data from the Annual Survey of the Bu-
disease.                 reau of Labor Statistics" provide an exam-
                    ple of tracking an occupational health
o The first step in public health is the    problem as its incidence changes. The
recognition of a problem; a related goal is  Annual Survey collects data from a sample
tracking the trends of a problem as its    of logs of injuries and illnesses kept by
incidence increases.            employers.

Sam Milham provides an example from the  These data demonstrate an upturn in the
analysis of death certificates for industry   numbers of cases of repeated trauma. Sur-
and occupation.l' Usual industry and occu-  veillance has done its job by disseminating
pation is entered onto every death certifi-  information on this apparent epidemic to
cate; however, only in some states is it    those with a need to know for the purpose
coded in order to be machine readable.   of prevention. The related role of
From 1979 to 1987, about 2.9 million    epidemiologic research necessary to deter-
deaths were coded for industry and occu-   mine the reality and etiology of this ap-
pation in approximately 23 states.      parent epidemic should be evident.

Surveillance for Agricultural Safety and Health, May 1, 1991

Surgeon General's Conference on Agricultural Safety and Health - 1991                69


Questions to Guide the National Agenda

o The second step in the process of public
health is the definition of the scope of a
problem. Two examples reflect the value
of ongoing collection of data in this en-
deavor and the usefulness of periodic sur-
veys .

The first example concerns the surveillance
of lead poisoning. In 16 states,
laboratories report to the state health
department if samples submitted for blood
lead determination in adults are in excess
of a state standard. This information
provides a crude estimate for the burden
of occupational lead poisoning for the
United States, currently about 17,000
reports each year."

A second example of the role of surveil-
lance in providing an estimate of the scope
of a problem comes from survey informa-
tion periodically collected by the National
Center for Health Statistics, Centers for
Disease Contro1.13 From 1983 to 1987,
successive periodic surveys provided infor-
mation from approximately 2700 white,
male farmers.

Farmers report 2.7 cases of skin cancer per
hundred farmers. Nonfarmers report less
than one case of skin cancer per hundred
people.

Farmers have three-fold the amount of
skin cancer than do nonfarmers. Thus, the
periodic survey provides a crude estimate
of the scope of the excess of skin cancer in
farmers, in contrast to a research study
that would likely include confirmation of
each case, and which would estimate in
substantially greater detail the exposure of
the farmers, and would likely be designed
to provide information on etiology or per-
haps use of preventive measures.

o The third step in the public health
process is to conduct etiologic research to
determine the cause of a disease. This
step consists of an epidemiologic study, not
surveillance. For example, an
epidemiologic study might be conducted to
determine the differential exposure of
cases of eosinophilia-myalgia syndrome as
compared to controls without the disease.
It does not require the ongoing collection
of information about cases; rather, it re-
quires more detailed information about
cases occurring during the research period.

o Once an etiologic agent or exposure is
identified, the fourth step in the public
health process is the design of an inter-
vention that will prevent transmission of
the infectious agent, exposure to a
chemical hazard, etc. Examples of inter-
vention include immunization, withdrawal
of a food contaminant, provision of a ven-
tilation system, etc. This is not surveil-
lance.

o The fifth step involves a trial of the
proposed intervention system in an experi-
mental situation where a limited number
of important factors are carefully con-
trolled. This type of public health experi-
ment does not involve surveillance.

o Successful interventions in the controlled
laboratory environment sometimes do not
withstand the more rugged environment of
the field test, the sixth step in the practice
of public health. Surveillance can play a
role in selection of field sites for testing.

o The seventh step in the public health
process is targeting scarce preventive re-
sources in order to maximize their effec-
tiveness. A classic example comes from
the eradication of smallpox.`4 While the
burden of smallpox was reduced by mass
immunization, smallpox persisted because

70

Papers and Proceedings


Surveillance for Agricultural Safety and Health, May 1, 1991

there were sufficient unimmunized to sus-
tain transmission. A turning point in ef-
forts to eradicate smallpox came with the
use of intensive surveillance for cases and
the targeting of immunization to the con-
tacts of cases.

CONCLUSION

There are four goals for surveillance.
These include:

Similarly, greater success in cancer preven-
tion might be obtained if screening pro-
grams for breast cancer and cervical cancer
were targeted to high-risk populations.
Another example of the use of surveillance
for targeting also comes from the surveil-
lance of elevated blood lead based upon
laboratory reports. Multiple elevated re-
sults from a single worksite almost insure
that the work environment is in need of
ameli0ration.15

1. The identification of new occupational
health problems.

2. The estimation of the scope or mag-

nitude of the problem.

3. The delineation of the trend in in-
cidence of the illness, disease, or
hazard.

4. The targeting of opportunities for

prevention.

o The eighth step in the practice of public
health is the evaluation of the effectiveness
of the public health intervention. Tracking
the trends of disease is one mechanism for
evaluating the effectiveness of intervention.

Surveillance is a powerful tool in many
parts of the complex continuum of prac-
tices that constitutes the public-health
problem-solving process.

For example, in 1958, Sweden instituted a
law that any new tractor that was produced
had to have rollover protection.16  In the
years thereafter, surveillance data indicate
a decline in rollover fatalities. In 1978
Sweden instituted another law that any
tractor in use had to have rollover protec-
tion, and the problem was eradicated.

Epidemiologists have much to owe to the
modern father of surveillance and field
epidemiology, Alexander Langmuir, who in
his wisdom commented, "Good surveillance
does not necessarily ensure the making of
the right decisions, but it reduces the chan-
ces of wrong ones."3O

REFERENCES

1. Institute of Medicine, The Future of Public Health. National Academy Press, Washington, 1988.

2. Public Health Service, U.S. Department of Health and Human Services, Healthy People 2000. National
Health Promotion and Disease Prevention Objectives, Washington, D.C., 1991.

3. Langmuir A. The Surveillance of Communicable Diseases of National Importance. New EngIand Journal
of Medicine. 268:182-191.

4. Langmuir, A. William Farr: Founder of Modern Concepts of Surveillance. International Journal of
Epidemiology. 5: 13-18, 1976.

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

71


Questions to Guide the National Agenda

5.

6.

7.

8.

9.

Rutstein, D., MulIan, R., Frazier, T., Halperin, W., Melius, J., Sestito, J.: The Sentinel Health Event
(Occupational): A Framework for Occupational Health Surveillance and Education, JAPHA 73:1054-
1062, 1983.

MacMahon Brian, Pugh Thomas. Epidemiology: Principles and Methodr. Little, Brown and Company,
Boston, 1970.

Miettinen OK Theoretical Epidemiology: Principles of Occurrence Reseanzh in Medicine. John Wiley and
Sons, New York, 1985.

Greenwald P, Cullen JW, McKenna JW. Cancer Prevention and Control: From Research through
Applications. JNCI 79:389-400, 1978.

Layde P. Beyond Surveillance: Methodologic Considerations in Analytic Studies of Agricultural Injuries.
American Journal of Industrial Medicine. X3:193-200, 1990.

10. Helgerson, SD., Milham, S. Farm Workers Electrocuted When Irrigation Pipes Contact Powerlines.
Public Health Reports. 1985 May-June; 100 (3):325-S.

11. Personal Communication. T. Frazier. NIOSH. Cincinnati, Ohio, 2/91.

12. Personal Communication. Paul Se&man. NIOSH. Cincinnati, Ohio, 2/91.

13. Brackbill, R., Behrens, V., Cameron, L. Prevalence of Conditions among Farmers 1983-1987. in press.

14. Foege, WH, Millar, JD, Lane, JM. Selective Epidemiologic Control in Smallpox Eradication. Am J
Epidemiol 1971 Ott; 94(4):311-5.

15. Seligman, P., Halperin, W.: Targeting of Workplace Inspections for Lead. American Journal of Industrial
Medicine 20:381-390, 1991.

16. Thelin, A. Epilogue: Agricultural Occupational and Environmental Health Policy Strategies for the
Future. AJIM 18~523-526, 1990.

72

Papers and Proceedings


Surgeon General's Conference on Agricultural SaWy and Health
FARMSAFE 2000 o A National Coalition for Local Action
Convened by the National Institute tbr Occupational Safety and Heatth
April 30 - May 3, 1991, Des Moines, Iowa

RESEARCH FOR AGRICULTURAL SAFETY AND HEALTH

James A. Merchant, M.D., Dr.P.H.
Professor, Preventive and Internal Medicine

Director, Institute of Agricultural Medicine and Occupational Health
         The University of Iowa

Mr. Mark Timm: Our next speaker is Dr. James A. Merchant, Director of Agricultural Medicine and
Occupational Health at the University of Iowa. Dr. Merchant received his B.S. from Iowa State
University, his M.D. from the University of Iowa, and his Doctor of Public Health in epidemiology from
the University of North Carolina. In 1988, he became an Epidemic Intelligence Officer at the Centers
for Disease Control with an assignment to the North Carolina Board of Health. After this assignment,
he served as Assistant Professor in Medicine at the University of North Carolina. In 1975, Dr. Mer-
chant became Director of the Division of Respiratory Disease Studies at NIOSH. In 1981, he became
and currently is Professor of Preventive and Internal Medicine at the University of Iowa.  Dr. Merchant
has published broadly in pulmonary medicine and epidemiology. His early work was in associating
cotton dust exposure with byssinosis. He has published broadly on different lung diseases, which
include problems with vegetable dusts and other organic dusts in agriculture, farmers' lung, and
asthma.' Dr. Merchant is active in professional organizations and in chairing and serving on expert
committees at both the national and the international levels. Allow me to introduce to you Dr. James
Merchant to speak on Research for Agricultural Safefy and Health. Dr. Merchant:

ABSTRACT

In identifying research priorities for agricultural health and safety, one must first define the
populations at risk. In agriculture, those at risk greatly exceed the number of farmers who
report sole or primary employment from agriculture. Agricultural production is now
changing dynamically, resulting in a substantial increase in farmers with non-farm jobs,
greater involvement of women and seasonal workers, and involvement of children and
recreational farmers in agricultural operations. All are exposed to some degree to multiple
farm hazards-farm machinery, livestock, chemicals, organic dusts, and a wide variety of
biological hazards. Priorities for research in agricultural safety and health include disease
and injury surveillance; epidemiological investigations of morbidity, mortality and risk factors;
studies of toxicological effects and mechanisms of disease; and the opportunity for
meaningful intervention for disease and injury prevention. Those engaged in this research
must also recognize the influence of poverty, limited access to health care, and limited in-
surance coverage among many living and working in rural areas. As the result of the
national initiative in agricultural and environmental health, federal, state and foundation
funding is now available to address these research priorities. The challenge is to maintain
and cultivate these research opportunities through targeted research designed to advance our
understanding and prevention of diseases and injuries among those with agricultural
exposures.

THE POPULATION AT RISK

ry employment in farming; 3.1 million
reported some farm income; there were

The population at risk to farming expo-    2.7 million hired to do farm labor; and
sures is not known with precision, In 1980,  there were an additional 6 million farm-
some 2 million Americans reported prima-  family members, some of whom did farm

Surgeon General's Conference on Agricultural Safety and Health - 1991                 73


Questions to Guide the National Agenda

work. But the number of full-time farmers
is being reduced as agriculture moves
dynamically to larger numbers of corporate
farming operations, with greater numbers
of part-time farmers and farmers with off-
farm jobs, and more farm wives employed
in both farm and off-farm jobs, while sig-
nificant farm work is contributed by chil-
dren under the age of 18.

A state-wide survey of Kentucky farms
found 26 percent of farm men had off-farm
jobs, 15 percent of farm women had off-
farm jobs, and 23 percent with both farm
men and women holding off-farm jobs.'
Women's role in agricultural production
has been largely ignored in the occupation-
al literature, yet the proportion of women
participating in the agricultural workforce
has risen steadily from 11 percent in 1940
to 46 percent in 1980.'

In the University of Iowa Farm Family
Survey of 1988 that included Iowa, Wash-
ington and New York states, 25-40 percent
of women (depending on the state) were
employed full-time in farming, and 45-55
percent were employed part-time in farm-
ing. Only 11-30 percent reported doing no
farm work.' In addition, 3549 percent of
the farm women surveyed were employed
in off-farm work. Thus, many farm men
face two work exposures (farm and off-
farm job) while many farm women face
three (farm, off-farm job, and home).

In addition to the occupational risks posed
by the off-farm jobs, there is a significant
additional risk of travel to and from the
off-farm job on rural road-ways, often
under poor driving conditions. As 64 per-
cent of the nation's 48,700 motor vehicle
deaths in 1988 occurred in rural areas,
travel to and from work poses an addition-
al occupational risk, which has often been

ignored in occupational health and safety
research.4

There is even less information on the num-
bers of children at risk to agricultural
operations. In the University of Iowa
Farm Family Survey, the proportion of
farms reporting children regularly doing
farm work ranged from 18 percent (New
York) to 23 percent (Iowa).3 It is recog-
nized, however, that the number of
children at risk to agricultural operations is
much larger, as they are often exposed to
farm machinery, buildings, and livestock
while not engaged in routine farm work.

Migrant farmers are the most fluid popula-
tion at risk in agriculture. The numbers at
risk are not adequately defined, but it is
known that migrant farmers assume some
of the highest risks from exposure to
agricultural chemicals, long hours, and
some exposure to agricultural machinery,
in addition to poor living conditions,
limited-if any-insurance or health care,
and often an additional risk of extensive
travel over the harvest season.

Migrant farmers are especially challenging
to study, as they are highly mobile, have
variable exposures, and are a difficult
population on which to obtain valid data
because of language and legal barriers.
Migrant farmers are, nevertheless, a very
high priority for research because of their
extensive exposures and other risks to
health.

An additional population at risk in agricul-
ture is the weekend or recreational farmer
who typically farms a few acres using older
farm machinery, often has some livestock,
and often uses the same farm chemicals as
full-time farmers. The number of weekend
farmers is not known, but is increasing as

74                                    Papers and Proceedings


urban areas encroach on adjacent farm     factors and the multiple risks they face
land.                    in agricultural work are.

Thus, the total population at risk to agri-   These questions will be high priorities for
cultural exposures is large, but the number  the NIOSH Farm Family Health and Haz-
is unclear-while the number of full-time
farm workers appears to be decreasing, the  ard Survey and should also be priorities for
                   others engaged in health and injury surveil-
total population at risk to agricultural    lance and epidemiological studies of agri-
operations may not be, given the diversity   cultural workers.
of multiple work roles of farm men, wom-
en, children, and migrant workers. Cur-    RESEARCH METHODS
rently, there is no uniformity in classifica-
tion of farm men, women, and children in  Research approaches to agricultural safety
regard to farm work and off-farm work.   and health may be divided into five broad
Clearly, development of such a classifica-   research methodologies:
tion would be useful for assessment of
agriculture - related diseases and injuries   1. Basic Research (Toxicology and Mecha-
among those living in rural America.      nisms).

Therefore, four research priorities are:    2. Disease and Injury Surveillance (Infor-
                    mation Systems).

1. To determine the distribution of farm
men, women, and children and the total  3. Epidemiological Studies.
population at risk in agriculture.

                        4. Demonstration and Education Research
2. To develop the best standard classifica-   (Intervention Studies).
tion of farm men, women, and children,
by on-farm and off-farm employment,    5. Health Services Research.
that will provide the most relevant clas-
sification for health surveillance and     Basic Research
epidemiological assessment.

Basic research is essential for adequate

3. To assess what additional occupational  development of prevention strategies for
morbidity and mortality is attributable   agricultural safety and health. While this
to off-farm work and to travel to and   is less true for injuries, there is still a great
from off-farm work, and what the inter-  need for basic research on the toxicology
active effects of these multiple risks on  and mechanisms by which various agricul-
disease and injury incidence are.     tural exposures cause adverse health ef-
                         fects.

4. To determine, especially among migrant
farm workers, what non-farming mor-   b One clear need for greater basic
bidity and mortality is attributable to   research is in the area of toxicological
living conditions, limited availability of  testing of agricultural chemicals, especially
health care delivery, and extended trav-
el and what the interactions of these   older pesticides that have not yet been
                   tested for acute and chronic toxicity. This

Research for Agricultural Safety and Health, May 1, 1991

Surgeon General's Conference on Agricultural Safety and Health - 1991                75