Issues That Affect the National Agenda The sense of equality and independence in agriculture points to a positive benefit of democracy, and farmers tend to be fierce defenders of democracy. Sociologists defined rural life, early in the century, as having an habitual character and an even flow. Life rested upon deeply felt and emotional relationships rooted in the steady rhythms of uninterrupted habit. The intimate relations between persons were based upon their individuality and wholeness. The traditional lifestyle was comprised of friendship groups, neighbor- liness, and blood relations. The attitudes of persons involved in 20th century agricultural production result from a lifestyle structured around conflic- ting values; traditional agrarian and con- temporary market values clash. The social values and ideas had their points of reference within these social groups and organizations. Farm-based economic independence and social equality foster the sharing of problems and ac- tivities by collectives engaged in land-based living over time. However, the deepest problems of modern life derive from the claim of the individual to preserve the autonomy and individuality of existence in the face of overwhelming social forces, of historical heritage, of exis- tence, of external culture, and of the tech- nique and technology of life. Farmers ex- perience these problems more than other groups. Agrarian values stress autonomy and individuality, but agriculture neces- sitates a great deal of interaction within the economic and political institutions of the society. Agriculture is a scientific endeavor re- quiring a great deal of educational back- ground reinforced by practical experience. It involves a knowledge base in agronomy, economic projection, and fiscal management training, personnel management training, and a solid knowledge of both the marketplace and government regulatory policy. Farming today, at every level, is involved with local, state and federal governments in, for example, subsidies, tax adjustments, and regulations of both crop output and farm practices. Technological develop- ment necessitates a constantly changing body of regulation in agriculture. The agricultural lifestyles, attitudes, and behaviors today are the outcome of the opposing forces of traditional agrarianism against the economic realities of a highly technical, rapidly changing society. The attitudes of persons involved in 20th cen- tury agricultural production result from a lifestyle structured around conflicting values; traditional agrarian and contem- porary market values clash. The result is a shared pattern of living and thinking, which differs from both the old farm ways and the highly urbanized, post-industrial society. SAFETY AND HEALTH PRACTICE Finally, let us consider how these attitudes are related to farm health and safety prac- tices. There is a paucity of research on the question, but I shall use a few of the avail- able studies to suggest some answers. According to Warwick, everything we know about accidents leads us to the conclusion 726 Papers and Proceedings that faulty habits and attitudes are the prime accident producers.' Murphy, hypothesizing that those farmers who hold different attitudes about health and safety from other farmers would have different accident records, looked at the diversity of attitudes and accidents in Pennsylvania.' Using a semantic differen- tial procedure contrasting attitudes in about 500 farmers, he found no significant difference between the attitudes of persons working where accidents had occurred in the previous five years, and those of ac- cident-free farmers. In fact, no differences in safety attitudes or occurrences were found between farmers, when they were grouped by such demographic and struc- tural variables as farm size, number of workers, type of farm, level of education, or hours worked on the farm. He concludes that other factors are likely to be more related to farm accidents than safety attitudes. His suggestion is that the pressures exerted by society and the low value actually placed upon safety in the decision process is likely to cause more risk behavior and, ultimately, accidents. Napier, et al., conducted an extension- based analysis of farm risks in the state of Ohio.3 Their statistically based research also indicated that there were no sig- nificant demographic or structural variables that would account for the ac- cident rate differentials on farms in Ohio. Further, they considered a farmer's ac- cident background and decided that social learning or experience with hazards does not make a significant difference in ac- cident rates, since people may or may not repeat their mistakes. Farm family attitudes may be related to economic well-being, as the Washington Attitudes and Risk Behavior, May 2, 1991 study suggests. They may revolve around the problems of agricultural productivity and the various costs surrounding preven- tive measures; however, the attitudes and ultimately behaviors could also be con- nected to a range of risk-taking personality characteristics and coping mechanisms. They are also likely to be related to an occupational culture. An excellent example of occupational culture could be considered that of mine workers. Yount found very definite work culture charac- teristics in risk behavior associated with mine workers.4 The manner in which they treated hazards, the interaction with respect to fear, and discourse while in social settings all demonstrated risk-taking and hazard-- coping mechanisms shared by the work culture. These characteristics and attitudes are influenced by the environment of their daily work, and they influence their everyday behaviors. Similar feelings and findings are likely to be found in farmworkers. Other elements such as ethnic or gender culture may also be related to attitudes. For example, a NIOSH/OSHA safety training story comes to mind. An Hispanic male working with hazardous materials was ordered to wear protective clothing: shoes, mask, and gloves. He wore all of these items except the gloves. When ordered continuously to wear the gloves for his own protection, he finally responded that yellow gloves remind him of his mother washing dishes. As a strong male, he could not force himself to wear the gloves. When black gloves replaced the yellow ones, the problem was solved. In the case of this worker, there were personality characteristics associated with Surgeon General's Conference on Agricultural Safety and Health - 1991 727 Issues That Affect the National Agenda the cultural statement of masculinity that were outstanding. These stories are per- vasive in the occupational safety domain. What characteristics and attitudes are at play when engineers monitoring construc- tion sites or hazardous waste sites and educated not to enter sealed tunnels beyond four feet continuously take flash- lights and go into these areas? They have read the statistics, and they are well-educated persons. If asked, they respond that they have been doing it for years, or it is the only way to get the job done, or they shrug and laugh, according to one OSHA-trained supervisor. Do each of you use seat belts? I am sure you have read the studies. And how many of you smoke cigarettes despite warnings? Much as Murphy, Napier, et al., Aherin and others--many others-are suggesting, in order to reduce farm hazards, it will be necessary to undertake a good deal more investigation into the forces behind the for- mation of attitudinal behavior and far communities.U~ The various dimensions of risk-taking behavior and their attitudinal components tend to be at the very heart of this problem. Only through a thorough comprehension of these behavioral dynamics will policy-makers and change agents design successful interventions, which are likely to alter risk-taking in order to reduce farm injuries and health hazards.0 REFERENCES 1. 2. 3. 4. 5. Warwick, W. Safety Education: Man, His Machines and His Environment. New Jersey: Prentice Hall, 1975. Murphy, Dennis. Farm Safety Attitudes and Accident Involvement, Accident Analysis and Prevention. Vol. 13, No. 4:331-337. London: Permagon Press, 1981. Napier, T. L, W.R. Goe, and R.R. Pugh. Incidence and predictive factors associated with farm accidents in Ohio. Ohio Extension Service document, 1987. Yount, Kristen R. Work-emergent behaviors and traits: the segregation of energy workers in boom- towns. Differential Impacts of Rural Resource Development, Pamela D. Elkind (ed.) Boulder: Westview Press, 1986, pp 119-144. Aherin, Robert A. Understanding and Predicting the Safety Behavior of Farmers, Paper presented at the American Society of Agricultural Engineers Conference, Chicago, 1985. 128 Papers and Proceedings Surgeon General's Conference on Agticultural Sakty and Health FARM&FE 2000 o A National Coalition for Local Action Convened by the National Institute for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa INDUSTRIAL CROPS OF THE FUTURE By Daniel E. Bugler, Ph.D. Director, Office of Agricultural Materials U.S. Department of Agriculture Dr. Ronald D. Eckoff: We shift gears a little bit again now. instead of talking so much about the workers, we're going to talk about some other things that are happening that relate. Our next presentation will be by Dr. Daniel Kugier, regarding industrial crops of the future. Dr. Kugler has a Ph.D. in Agricultural Economics from Michigan State University and works for the United States Department of Agriculture. He led economic and policy studies for soil and water conservation programs with special emphasis on the economic impacts of variable cost sharing and soil depletion on the adoption of conservation practices. In 1986, he joined the Cooperative State Research Service in Washington, D.C., to start up and manage the Department's Kenaf Development Program, a program designed to remove barriers preventing the commercialization of this non-wood fiber plant for manufacture of newsprint. in 1989, he was appointed director for the Office of Agricultural Materials, where he oversees research, development and commercialization of a number of crops, which provide new raw materials and chemical feedstocks to industry. Dr. Kugler will speak, this morning, on the topic, industrial Crops of the Future. Dr. Kugler: First, I want to thank the organizers for the opportunity to come here to Iowa and I thought that the best way to illustrate this address this important conference in the area would be to provide you seven area of issues, which affect the national examples of industrial crops of the future. agenda. It is always important to keep in- They have a variety of potentials. Some of them are commercializable now; some next formed of changes that will affect the agricultural industry, which is so important week; some of them may require the remainder of this decade before they can to our country. come to the marketplace. Specifically, I want to offer to you a You will find that a number of them are glimpse of an area of agriculture that many surprisingly common. Others, as I have of you know nothing about or, at most, may not think about on a day-to-day basis. mentioned before, you may have never seen or heard of before. It is an area that we refer to as industrial crops or agricultural materials-these being ASPEN, SOUTHERN PINE crops or materials, which provide non-food, non-feed materials to industry for use in processing and product manufac- The first crop is the very beautiful aspen ture and marketing. These materials tree. Many of you may be familiar with it. This tree is an excellent source of wood generally do not enter the food chain either for human consumption or as fibers and is harvested mainly from the northern United States and from forest animal feeds, although there are some plantations in Canada. notable exceptions in pharmaceuticals and in the area of some by-product meals that are used for animal feeds. The fiber from this tree is very well suited for the manufacture of dry-formed compos- ites. Aspen, in a dry, refined form-very Surgeon General's Conference on Agricultural Safety and Health - 1991 129 Issues That Affect the National Agenda coarsely refined- resembles shredded wheat. When you take it and blend it with syn- thetic fibers such as glass or polyester and add thermal-setting resins, you can create an air-laid, non-woven mat. This par- ticular kind of mat can then be put into a heated compression mold to make a variety of shapes of various angles and depths that can be used in a wide variety of products with which you are very familiar. Common applications include interior car door panels, dashboards, and the head liner that is over the top of you when you sit in your automobile. So, the next time you're rolling down the window in your car, underneath that vinyl or leather panel there may be an aspen tree. CORN, WHEAT, RICE, OR POTATO STARCH The second example is pretty familiar to you folks here in Iowa. Corn is very abun- dant and well known as a food source in our diets. However, there is more to do with corn than to just eat it. Corn is a principal source of starch, which is being extensively explored by government, universities, and industry to make degradable thermoplastics or starch polymers. Here in the United States alone we manufacture, on an annual basis, some 60 billion pounds of plastics from petrochemical sources. There are technologies available right now that can put up to 40 percent starch-and it can be from wheat, potato or other sour- ces-into various kinds of plastic film such as grocery bags and trash can liners. There are other technologies that are in development that will put 85 percent to 95 percent starch into these kinds of plastic materials and use it to make a variety of molded products. There is one effort that we believe is very significant-the Department of Agriculture and Department of Defense have joined hands with several universities and a major private company to produce degradable starch products, which will satisfy the Marine Plastic Pollution and Research Control Act of 1987. That particular act of Congress requires the Navy to cease the disposing of plastics at sea by the end of 1992, unless they are fully degradable in the marine environment. This is a very, very busy project. It is a very challenging and, we believe, achievable opportunity. INDUSTRIAL RAPESEED AND CRAMBE For the next industrial material, you will see a very beautiful slide of a crop in the state of Idaho. It is industrial rape seed. Many of you may know a cousin of this crop, called canola. The canola variety vegetable oil is sold in your supermarket under the Puritan label, from Proctor and Gamble. The industrial variety of rape seed, however, retains a high content of erucic acid, and that erucic acid can be used to manufacture a number of functional fluids, plastics, and nylons. I have several examples of things we are doing with high erucic acid rape seed. We have been working with some com- panies and universities to produce an automatic transmission fluid supplement, which is made from the derivatives of rape seed oil. Tests have shown at this point, when compared to standard factory-fill 130 Papers and Proceedings fluids, that with this particular kind of supplement, wear is reduced 50 percent, oxidative breakdown is reduced 24 percent, and that pentane insolubles are reduced some 60 percent. In another product, we are producing cut- ting fluids from rape seed oil. The cutting fluids show longer use. They show ex- tended tool life. In addition to that, there are no halogenated fluids produced, which require hazardous waste disposal. One other very significant product, which has been made from crambe oil, another crop source of erucic acid, is nylon 1313. Crambe, indeed, is a crop of the future and nylon 1313 is a product of the future because it is very lightweight, has very low water absorption characteristics and shows exceptional dimensional stability. We expect in the near future that nylon 1313 will be used in a variety of aircraft and marine applications. GUAYULE My fourth example is another very interes- ting crop. Guayule is native to the south- western United States and northern Mexico. It is a perennial shrub that reaches maturity at about three to five years of age. We extract natural rubber and resins and a variety of other chemical feedstocks from the plant's steno, branches, and roots. The advanced varieties of this particular plant have about 10 percent high molec- ular weight rubber, which is very similar to and comparable in performance with the Hevea rubber, which we import mainly from Malaysia, Thailand, and Indonesia. We are currently 100 percent import dependent for our nation's rubber supply, Industrial Crops of the Future, May 2, 1991 and it costs us a billion dollars a year in export dollars. Right now we are manufacturing tires made from guayule natural rubber, which will go on the Navy's F18 and A4 aircraft at a Goodyear plant in Virginia. We are also manufacturing light truck tires, which will be used for testing by the Army at a Firestone facility in Illinois. These are very important strides forward in developing a domestic rubber industry. In addition to the natural rubber in this particular plant, there are some very interesting resins. The most notable one can be used to produce a strippable coating for preservation of machine parts and mothballing aircraft. We are currently seeking work with the Air Force to test out this particular coating. KENAF The fifth example is another industrial crop that many of you may know if you have an ornamental hibiscus plant in your yard at home. This is a hibiscus grown for its industrial fibers, called kenaf. It is an annual plant of tropical and semitropical origin, native to east central Africa. In the cotton belt of the United States, this crop will grow 12 to 20 feet tall and produce six to ten tons of dry matter per acre. The fibers of this particular plant are very interesting. There are two fibers in the plant: a bark and an inside core. They make a very natural mixture for manufacture of newsprint. The outer fibers are long and tough and strong. The inner fibers are short and flat and make good filler and surfaces. When you take the entire plant and thermo- mechanically pulp it, you make a very high Surgeon General's Conference on Agricultural Safety and Health - 1991 737 Issues That Affect the National Agenda quality pulp that makes a very high quality newsprint, which has been accepted by the newsprint industry as a real commodity. Currently in the state of Texas, there are plans to build a $50 million newsprint mill based on kenaf. We hope to see those plans activated this year and to see news- print in production by the end of 1992 or early 1993. In addition to newsprint, there are a variety of other products made from kenaf fibers, which show premier. These are composites, packaging, poultry litter, high- grade specialty papers, absorbants and soil amendments. PACIFIC YEW TREE The next example of an industrial crop is the Taxus plant, an ornamental yew used as a landscaping shrub all over the country. Bark of the Pacific yew tree and needles and twigs of ornamental Taxus shrubs yield a complex natural chemical called taxol. According to the National Cancer Institute, taxol is the most important anticancer drug in 15 years and is in the last stage of can- cer. The Department of Agriculture has organized an effort to establish immediate, medium and long-term supplies of the tree bark and shrub clippings for extraction of the drug. Agriculture will help provide the renewable raw material for this life-saving drug. SOY BEAN The last example, like corn, is another very familiar agricultural plant. But also like corn, there is more to do with soybeans than eat or feed it. Printer's ink using soybean oil has been under development since the early 1980's and inks with 30 percent soybean oil are in use. Notably, The Gazette in Cedar Rapids, Iowa, under the leadership of Joe Hladky, Publisher and Chair of the American Newspaper Publishers As- sociation Technical Committee for Inks, is the pioneer in daily commercial use. In March 1991, the Department of Agricul- ture announced a 100 percent soybean oil ink that is completely compatible with newspaper presses. This formulation removes all the petroleum from the ink and shows low rub-off, lower cost, and more environmentally soundness in terms of degradation and recycling of old newsprint. If all newspaper ink were made with soybean oil, it would require 40 mil- lion bushels. RENEWABLE MATERIALS We are talking about renewable materials from agriculture, and I stress the word "materials." We are looking to make polymers, functional fluids, composites, structural materials, natural fiber products, and pharmaceuticals-all of which are extremely important to the health of our business and industry in this country. Why do we do this ? There is a variety of reasons. There are some very obvious balance-of-trade implications here, where we can reduce the imports of certain com- modities, in particular petroleum and rub- ber. There are opportunities to turn around and export things that we currently import. There are very obvious areas in which we can improve the competitiveness of our country by utilizing the excess productive capacities of our farmland to produce new 732 Papers and Proceedings crops or to use some of the crops that we are currently producing in excess. All of this, of course, is designed to spur rural economic development, increase our domestic production and add value to our agricultural materials at home, send them to the international market place. In addition to that, we are trying to alter the image, to some extent, of agriculture, and to let this country and the world know that agriculture, indeed, is a very high-tech business. In the area of leadership, one of the things we would like to be able to do in this country is to be a leader in technology development. One thing we have done an excellent job on in this country, for years and years, is research. We are the pre-eminent research country in the world, but the honest truth is, we have not done a very good job of taking those research results and moving them into the marketplace by doing value-added work. Many other countries come here, take our research discoveries and inven- tions home with them, make the products and then deliver them back to us. There is no need for that. We can do much of that here in our own country. Industrial Crops of the Future, May 2, 1991 How are we going at this? The Office of Agricultural Materials is a very small of- fice. We are working very closely with industry, very closely with academia, and very closely with state and federal gov- ernment to do something that Washington calls `precompetitive generic technology development." We are trying to enable commercialization, that is, to bridge the gap that currently exists between the research bench and the marketplace. In addition to that, we are trying to alter the image, to some extent, of agriculture, and to let this country and the world know that agriculture, indeed, is a very high-tech business. We are every bit as sophisticated as and have scientific talent on a par with those that are conducting research on supercomputers, high-performance ceramics, etc. To close, let us look at this slide that shows the official seal of the United States Department of Agriculture. It has an animal-drawn plow in the front and some shocks of corn in the back. Focus your attention at the statement at the very bot- tom, where it says: Agriculture is the foundation of business and commerce. Industrial crops and many other crops can be and are strengthening and enhancing that foundation.0 Surgeon General's Conference on Agricultural Safety and Health - 1991 733 Surgeon General's Conference on Agricultural SatWy and Health FARM&FE 2000 o A National Coalition tir Local Action Convened by the National Institute kw Occupational Sidety and Health April 30 - May 3, 1991, Des Moines, Iowa BIOTECHNOLOGY AND AGRICULTURE By Jane Rider, Ph.D. Biotechnology Specialist National Wildlife Federation Dr. Ronald D. Eckoff: Our final presenter this morning is Dr. Jane Rissler, who will be speaking about biotechnology and agriculture. Dr. Rissler received her Ph.D. degree in plant pathology from Cornell University and conducted postdoctoral research in fungal physiology at the Boyce-Thompson institute for Plant Research. She has taught and conducted research in the university setting for a number of years. Since 1983, Dr. Rissler has been engaged in biotechnology science and regulatory policy work. From 1983 to 1988, she was at the Environmental Protection Agency where she was involved in the formulation and implementation of biotechnology policies. She served as a science advisor for and a project manager of the Pile Technology Project that operated under the Toxic Substances Control Act and was a special assistant in biotechnology to the EPA Assistant Administrator for Pesticides and Toxic Substances. In those position, she helped to develop EPA biotechnology regulatory policy and coordinated EPA's activities in the development of the Federal regulatory framework for biotechnology. She currently is a biotechnology specialist with The National Wildlife Federation. As part of her work in the National Wildlife Federation's National Biotechnology Policy Center, she has recently authored or co-authored several documents: Biotechnology's Bitter Harvest, Herbicide Tolerant Crops and the Threat to Sustainable Agriculture, Natural Resources and Environment, Biotechnology and Pest Control: Quick Fix Versus Sustainable Agriculture published in the Global Pesticide Monitor. She is the co-editor of the Gene Orchange a National Wildlife Federation Newsletter that provides a public voice on genetic engineering. This morning, Dr. Rissier will discuss Biotechnology and Agricul- ture. Dr. Rissier: INTRODUCTION I was asked to come here today to talk with you about potential farm worker health issues raised by the use of biotech- nology products in agriculture. In fulfilling that request, I will briefly explain the tech- nology, where it is likely to be heading in the next decade, and some concerns for worker safety that may arise from the tech- nology. I appreciate the opportunity to provoke discussion of biotechnology and agricultural worker health issues and hope that worker safety experts will consider and evaluate these issues as the technology is developing and before its widespread use. Before I begin, however, I would like to tell you of my biases that are relevant to 734 this talk. I represent a major environmen- tal group, the National Wildlife Federation, the country's largest conser- vation, education, and environmental ad- vocacy organization, with over 5.8 million members and supporters and 50 affiliated state groups. Four years ago the Federation established the National Biotechnology Center, to try to prevent the environmental and human health consequences associated with other technologies, such as the synthetic chemical, fossil fuel, and nuclear tech- nologies. The Center's objectives are to minimize the risks of this new technology and to ensure that the public has a role in the regulation and development of the technology. Papers and Proceedings I am here, not as a proponent of agricul- tural biotechnology, but as a skeptic-a skeptic who fears that the technology poses significant risk and uncertainty. Further- more, from a vantage point of studying the industry for nearly eight years, I seriously question whether biotechnology should or can assume a major role in answering the environmental, human health, and produc- tivity problems facing U.S. agriculture. WHAT IS BIOTECHNOLOGY? Broadly speaking, biotechnology refers to the use of living organisms as products or processes for humanity. People have used organisms for food and drink (e.g., yogurt, bread, wine, cheese) for millennia. From early agriculturalists to 20th century plant and animal breeders, humans have manipulated living organisms to improve food and fiber production. 1 I am here, not as a proponent of agricul- tural biotechnology, but as a skeptic-a skeptic who fears that the technology poses significant risk and uncertainty. Advances in molecular biology in the last three decades allow human beings to manipulate organisms in dramatically dif- ferent ways than are possible with traditional breeding methods. Many of these methods have been developed out of basic research in the 1960's and 1970's and have been adapted in the last 15-20 years to produce commercial products. These methods, along with the products and processes developed using them, constitute modern biotechnology. The terms are not used precisely or consis- tently. Sometimes the term biotechnology Biotechnology and Agriculture, May 2, 1991 is used to characterize a small subset of techniques, that is, genetic engineering, gene splicing, or recombinant DNA techni- ques. Other times it is used in varying degrees to include other techniques. A Powerful Technqlogy This is a powerful technology-a technology in its infancy. As an illustration, I use the words from a promotional piece from Monsanto, a company that made a huge investment in biotechnology: A new science destined to take [hulmankind into technology as a scien- tific milestone comparable to the realization of atomic energy or the development of semiconductors and powe#ul computers. ' The power of the genetic en- gineering-gene splicing-techniques comes from the capacity to combine genes from a wide array of organisms: mouse genes in tobacco plants, human genes in bacteria, or chicken genes in potatoes. Traditional breeding techniques are dramatically more limited in the range of possible gene com- binations. Only closely related organisms can be interbred by traditional means. By combining genes from widely disparate or- ganisms, genetic engineers will create a variety of genetically novel organisms im- possible by traditional means. Expected Products Using genetic engineering techniques, cell and tissue cultures, and other modern techniques, the industry promises transfor- mations in the way food and fiber are produced and processed in this country. Among the products already on the market and that we can expect to see in the near Surgeon General's Conference on Agricultural Safety and Health - 1991 135 Issues That Affect the National Agenda future or within a decade or two are the following: 1. 2. 3. 4. Genetically engineered food (grain, fruit, vegetables, oil) and fiber crops-for example, genes from insects, chickens, mice, fish, bacteria, viruses, and unrelated plants have already been splices into crops; these crops have been field tested in the last two years. Food and food supplements from genetically engineered microor- ganisms-cheese, yogurt, alcoholic beverages-for examples, a cheese en- zyme produced by bacteria containing a cow gene is already in wide commercial use and tryptophan, a food supplement derived from genetically engineered bacteria, was on the market; it was removed because nearly 30 people died and hundreds more became ill with eosinophilia myalgia syndrome as a result of consuming the product; whether the genetic engineering contributed to the toxicity is not yet known2 Genetically engineered food animals-cows, pigs, chickens, fish-carp with a trout growth hormone gene are being tested in ponds in Alabama; pigs and cows containing human genes have been produced. Genetically engineered hormones, an- tibiotics, vaccines-among the products thus far developed, bovine growth hor- mone, derived from genetically en- gineered microorganisms, is being used to enhance milk production; a recom- binant vaccine against pseudorabies is already on the market; a recombinant rabies vaccine is being tested in wild animals in Virginia and Pennsylvania. 136 Papers and Proceedings 5. Genetically engineered microorganisms to control plant diseases and enhance crop growth--several recombinant microbes have already been field tested. 6. New uses of crops and animals to produce commercially valuable chemicals-cows producing drugs in milk; tobacco plants producing anti- cancer proteins. While this list is incomplete,' it gives an idea of the power of a technology still in its infancy. BIOTECHNOLOGY COMPANIES The following are companies that are farthest along-as measured by their progress in field testing genetically en- gineered plants and microorganisms-in developing novel organisms for use in agriculture: . Monsanto . Ciba-Geigy = DuPont . Sandoz . Calgene = BioTechnica a Upjohn . Pioneer HiBred . Crop Genetics International . Northrup King * Rohm and Haas * Agrigenetics Advanced Sciences . Agracetus * Canners Seed . Amoco Technology . Boyce Thompson Institute . Wistar Institute H Rogers NK Seed = Dekalb Plant Genetics = Frito-Lay * Campbell Institute for Research and Technology. WHAT FARM WORKER HEALTH ISSUES ARE RAISED BY AGRICULTURAL BIOTECHNOLOGY? Based on industry predictions about the nature and pace of agricultural biotech- nology, it is obvious that farm workers will Biotechnology and Agriculture, May 2, 1991 be exposed to genetically engineered or- ganisms: micro-organisms, viruses, plants, animals. 1 I hope that this presentation will provoke a wide-ranging consideration and evaluation of the potential impacts of biotechnology on farm worker health. Keeping in mind that this is a new tech- nology, one based on a highly artificial manipulation of living things, one that poses significant unknowns and uncertain- ties, it is time to begin discussing the agricultural worker-health ramifications of biotechnology. The organizers of this conference, is placing this talk on its agen- da, recognized this need. I hope that this presentation will provoke a wide-ranging consideration and evaluation of the poten- tial impacts of biotechnology on farm worker health. The experiences that we have to draw on to initiate this discussion come from genetic engineering research laboratories, the pharmaceutical industry where genetically engineered organisms have been used for some time, and industries and agriculture based on traditionally developed microorganisms, plants, and animals. A complete discussion of risP would re- quire consideration of both hazards and exposure. This talk is limited to an at- tempt to identify potential farm worker health hazards that may develop from a large commercial agricultural biotech- nology industry. I have not attempted to describe exposure beyond general statements indicating that more farm workers are likely to be exposed to increased numbers of living or- ganisms-both genetically engineered and conventionally bred ones-and their products. The list of potential hazards I offer may be incomplete; I welcome suggestions. Some are more speculative than others. As the hazards are evaluated by experts, some will be judged as more problematic than others. Some concerns are the same that one would expect with non-engineered organisms. POTENTIAL BIOLOGICAL Opportunistic Pathogens6 HAZARDS Several factors point to the potential for increased problems for genetically en- gineered organisms that are opportunistic human pathogens. Developers may en- gineer microorganisms whose opportunism is unknown. Scientists may unknowingly engineer an opportunistic pathogen for one of two reasons. b First, they are working with organisms about which little, including opportunism, is known. Splicing genes into an organism requires little or no information about the organism's ecological or pathogenicity traits. b Second, engineers may have some infor- mation on the organism's ecological characteristics but, because of isolation between scientific disciplines, the scientists may not know that the same organism has been classified as opportunistic (or even frank pathogens) by human health experts.' The organism may, in fact, have different taxonomic designations in two different disciplines. Surgeon General's Conference on Agricultural Safety and Health - 1991 137 Issues That Affect the National Agenda 1. 2. Farmers and farm workers, as a population engaged in one of the nation's two most hazardous jobs (the other is mining), may often be unheal- thy and highly stressed as a result of their occupation"-and more susceptible than the population at large to oppor- tunistic infection. In addition to their occupational stress, the farm worker population is likely to show an increase in the number of immunosuppressed or compromised persons as a result of the epidemic of acquired immune deficiency syndrome (AIDS) and related diseases. Persons with suppressed or compromised im- mune systems are generally more sus- ceptible to infection by opportunistic pathogens. One example of an opportunistic pathogen that already is the subject of biotechnology research and development is the vaccinia virus-the virus originally used to immunize the human population against smallpox. The vaccinia virus has long been known to cause, though rarely, disease and death, including encephalitis,' in im- munocompromised/suppressed persons. Recently, three persons infected with AIDS reportedly died after being inocu- lated with a vaccinia viru~.`~ Work is underway to genetically engineer vaccinia virus to make vaccines against a number of animal diseases, including rabies and rinderpest. To create these vaccines, one or a few genes is taken from the rabies or rinderpest virus and spliced into the vaccinia virus. The genetically en- gineered vaccinia virus then is used to inoculate animals to prevent rabies or rinderpest from developing. FRANK PATHOGENS" Generally, we expect that companies will not use and regulators will not permit the use of genetically engineered human pathogens in agriculture. However, a problem arises because of the potential for splicing genes into poorly characterized or- ganisms, some of which may be human pathogens. As noted above, scientists may engineer organisms about which they know little in terms of ecological or pathogenicity traits. Another question that may arise is whether genetic engineering could transform a non- pathogen into an opportunistic or frank pathogen. Because pathogenicity is generally a complex trait controlled by many genes, it is not likely that splicing in one or a few genes could create a pathogen. On the other hand, there are instances where engineering an organism that is closely related to a pathogen, i.e., already possesses most of the characteris- tics of a pathogen, might change that or- ganism into a pathogen.12 ENDOTOXINS3 Greater use of gram-negative bacteria (e.g., pseudomonads and rhizobia) in biotechnology applications may increase the incidence of respiratory problems among farm workers. Some scientists have hypothesized that the endotoxin portion of the gram-negative cell wall may be respon- sible for the respiratory disorders as- sociated with a number of agricultural industries: grain and silage handling, pork and poultry production in confined facilities, composting, and poultry proces- sing.`" 738 Papers and Proceedings ALLERGENS" Allergens, which incite a hypersensitive reaction, include substances produced by plants, animals, and microbes. If biotech- nology achieves even a portion of the suc- cess promised by its proponents, there will be an increase in the agricultural use of living and novel organisms-and their products. Consequently, we may see an increased incidence of hypersensitivity-due to greater exposures to living organisms, in general, and due specifically perhaps to changes caused by genetic engineering. Genetic engineering may introduce new allergens, for example, by producing ex- pected secondary metabolites in microor- ganisms. Foreign genes in crops may produce new allergens in the plants and their pollen. ANTIBIOTIC RESISTANCE Many novel organisms are genetically en- gineered to resist one or more antibiotics. This is a trait added, not to improve the organism, but to confirm that gene splicing has been successful. Splicing in antibiotic resistance is part of standard genetic en- gineering methodology. The worker health issue that arises is the extent to which the unintentional ingestion of antibiotic- resistant microbes could result in the sub- sequent transfer of antibiotic resistance to gut microflora and eventually to pathogens.16 Transfer of antibiotic resistance to path- ogens could make them resistant to therapeutic control by the drugs to which they are resistant. Thus far, most drug resistances used in genetic engineering in this country are antibiotics not widely used clinically. Biotechnology and Agriculture, May 2, 1991 UNEXPECTED/UNKNOWN HAZARDS This is a category of hazards whose definition will only be known in retrospect. Generally, what I am proposing is that there may be unexpected and as yet unknown hazards associated with this high- ly artificial technology-perhaps a new illness or an old one unexpectedly as- sociated with genetically engineered or- ganisms. Already genetic engineering has produced unexpected effects. Three examples are: 1. 2. 3. Naked DNA from human cancer cells can unexpectedly trigger tumors when the DNA is applied to abraded skin. It was previously thought that DNA had to be transported into target cells by a carrier." Human or bovine growth hormone genes spliced into pigs gave the ex- pected result-leaner pigs. However, the genetically engineered pigs also displayed unexpected deleterious ef- fects: arthritis, gastric ulcers, weak muscles, and lethargy.l* Experiments with petunias, genetically engineered to alter pigment production in flowers, showed "results . . . completely different form those the scientists expected."" Not only was the actual frequency of nonpigmented flowers ten times greater than expected, but the flower pigmentation responses to environmental conditions were total- ly unexpected. POTENTIAL CHEMICAL HAZARDS One of first agricultural biotechnology products to reach the market will be crops engineered to resist herbicides, that is, Surgeon General's Conference on Agricultural Safety and Health - 1991 139 Issues That Affect the Natlonal Agenda crops created so farmers can apply more of certain herbicides to obtain weed control and not harm plants. Some of the her- bicides for which plants are being en- gineered for resistance are 2, 4-D, bromoxynil, glufosinate, glyphosate, and sulfonylurea. Increased use of certain herbicides, particularly those like 2, 4-D and bromoxynil, which are known or suspected to be human health hazards, poses risks to workers who apply them or are otherwise exposed." On the other hand, a potential improve- ment in farm worker safety may come from genetic engineering for pest resis- tance, such as splicing insect toxin genes into plants. Pest-resistant crops may provide at least a short-term decrease in the use of dangerous insecticides and fun- gicides. WHAT SHOULD BE DONE TO ENSURE WORKER SAFETY IN AGRICULTURAL BIOTECHNOLOGY? Four actions will go a long way toward enduring the safety of farm workers ex- posed to agricultural biotechnology products. 1. Evaluate risks. Public and occupational health experts should begin to evaluate the risks that a growing agricultural biotechnology industry poses to farmers and farm workers. 2. Use only no- or low-risk organisms, ones that are well-characterized and thoroughly evaluated, for potential human health hazards. Only these should be approved for agricultural use. 3. Reduce exposure to biotechnology products. Standard approaches, such as worker protection equipment, procedure, and training, should be adopted to reduce worker exposure to biotechnology products. 4. Initiate and maintain medical surveil- lance. The case for surveillance is best made in a report from a Centers for Disease Control/National Institute for Occupational Safety and Health (CDC/NIOSH) Ad Hoc working group on medical surveillance for industrial applications of biotechnology?' Uncertainty provides the strongest ar- gument for maintaining medical surveil- lance over workers engaged in industrial applications of biotechnology. As is the case for any newly developed technology, there is a lack of information concerning the nature or severity of any acute or chronic health hazards, which might be associated with the industrial applications of this technology. The CDC/NIOSH working group is of the opinion that medi- cal surveillance of biotechnology workers constitutes prudent medical practice. Such surveillance should be aimed at the early detection of sentinel disease events. The detection of any occupational illness caused by recombinant organisms or their products will have important biological and public health consequences and should be actively sought.0 140 Papers and Proceedings Biotechnology and Agriculture, May 2, 1991 REFERENCES AND NOTES 1. 2. 3. 4. 5. 6. 7. a. 9. "Out Front in Biotech," Monsanto Magazine, Fall 1986. "L-Tryptophan Puzzle Takes New Twist," Science, August 31, 1990, page 988. See The Gene Exchange, Volumes 1 and 2, National Wildlife Federation, Washington, DC, 1990- 1991, for additional information on many of these organisms and products. In the 1970's the major risk associated with the new genetic engineering technologies was the potential for disease among laboratory researchers and the public. Conferences were held and experiments were conducted to evaluate the human health risks (see for example, Risk Assessment of recombinant DNA Experimentation with Escherichia coli K12, Proceedings from a Workshop at Falmouth, MA, published in The Journal of Infectious Diseases, Volume 137, Number 5, May 1978). Since that time, in the absence of epidemics attributable to recombinant DNA, the fears have largely dissipated. However, as far as we know, there have been no extensive, systematic studies monitoring the health of recombinant DNA researchers-recent disturbing report may cause a reconsideration of the safety of some aspects of genetic engineering research. See, for examples, "Some DNA Lab Work Raises Cancer Risks," BioWorZd Today, October 12, 1990, page 1; "Cancer Deaths Probed at Pasteur Institute," Science, June 27, 1986, page 1597. To understand the complexities and limitations in fully describing the human health risks of some biotechnology products, see "The Toxicology of Genetically Engineered Microorganisms" by L.S. Katz and J.K. Marquis, pages 51-63 in Risk Assessment in Genetic Engineering, M. Levin and H. Strauss, eds., McGraw-Hill, New York, 1990. Pathogens that do not cause disease in healthy individuals but may do so in certain unhealthy or stressed persons. "Plant-associated bacteria as human pathogens: disciplinal insularity, ambilateral harmfulness, and epistemological primacy" by M.P. Starr, Annals of Internal Medicine 90: 708-710, 1979. See, for example, Agriculture at Risk: A Report to the Nation by the National Coalition for Agricul- tural Safety and Health, Institute of Agricultural Medicine and Occupational Health, Iowa City, IA, 1989. "Vaccine Technology: Developmental Strategies," Bio/Technology, Volume 5, page 1038-1040, October 1987; "Smallpox, Vaccinia, and Cowpox" by A.R. Rao, pages 1672-1686 in Medical Microbiology and Infectious Diseases, edited by A.I. Braunde. W.B. Saunders, Philadelphia, 1981. 10. "Deaths of 3 Patients Not Included in Report About AIDS Experiment," New York Times, April 14, 1991. 11. Outright pathogens; pathogens that cause disease in healthy persons. 12. See "Phenotypic Properties of Source Microorganisms and Their Genetically Modified Derivatives," pages 99-112 in National Research Council, Field Testing Genetically Modijied Organisms: Frameworkfor Decisions, National Academy Press, Washington, DC, 1989, for a discussion of the potential effects of genetic engineering on pathogenicity. l3. Components of the cell walls of gram-negative bacteria. Surgeon General's Conference on Agricultural Safety and Health - 1991 141 Issues That Affect the National Agenda 14. See discussion and references in "Inhaled Endotoxin and Decreased Spirometric Values" by R.M. Casteban, SAA. Olenchock, K.B. Kinsley, and J.L. Hankinson, The New Engknd Journal of Medicine 317: 6054510, 1987. 15. Substances which induce hypersensitivity/allergy. Hypersensitivity in humans is a specific and deleterious reaction to a substance that does not, in similar amounts, affect other persons. 16. See, for example, "Emergence of Antibiotic-Resistant Bacteria in the Intestinal Flora of Farm Inhabitants," by S.B. Levy, Journal of Infectious Diseases 137: 688690, 1978. 17. "Some DNA Lab Work Raises Cancer Risks," BioWorld Today, October l2, 1990, page 1. 18. "Gene-Watchers' Feast Served Up in Toronto: Putting Foreign Genes into Domestic Animals, Science October 7, 1988, pages 32-33. 19. "Jumping Genes Confound German Scientists" by D. MacKenzie, Nau Scientist, December 15, 1990, page 18. See also "The German Experience Gained with Field Testing of Genetically Modified Plants" by P. Lange, pages 161-164 in Biological Monitoring of Genetically Engineered Plants and Microbes, Proceedings of an International Symposium, Kiawah Island, 1990. 20. Biotechnology's Bitter Harvest: Herbicide-Tolerant Crops and the Threat to Sustainable AgricuIture by R. Goldburg, J. Rissler, H. Shand, and C. Hassebrook, 1990, Biotechnology Working Group, Washington, DC. 21. "Medical Surveillance of Biotechnology Workers: Report of the CDC/NIOSH Ad Hoc Working Group on Medical Surveihance for Industrial Applications of Biotechnology' by P.J. Landrigan, M.L. Cohen, W. Dowdel, L.J. Elliott, and W.E. HaIperin, Recombinant DNA Technical Bulletin 5133-138, 1982. 142 Papers and Proceedings Surgeon General's Cont&ence on Agricuttural Salty and Health FARMSAFE 2000 o A National Coalition lor Local Action Convened by the National Institute ti~or Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa SURVEILLANCE: A PHYSICIAN'S VIEWPOINT &y John J. May, M.D. Director, Bassett Farm Safety and Health Project New York Center for Agricultural Medicine and Health The title of my talk today is A Physician's Viewpoint, which is a nice title. For a while I thought maybe I would just talk about the Chicago Cubs. Then a couple of weeks ago, I thought perhaps I would ex- pound about the Internal Revenue Service for a while. Actually, what I will try to do today is present a physician's point of view-a practicing physician's point of view-regarding our role in the surveillance of agricultural health and safety problems. I will try to build upon Dr. Halperin's very excellent discussion of surveillance this morning, focusing in particular on the potential contribution of the rural physi- cian. Next, I will review some of the likely obstacles or roadblocks that, at least in my mind, might prevent effective physician surveillance. Finally, I will try to suggest some ways of using existing resources to enhance physician surveillance. I will try to define a couple of terms. The first term is surveillance, which refers to the collection, collation, analysis, and dis- semination of data for purposes of pro- gram planning, implementation, and evalu- ation. For my purposes, when I talk about physi- cians, I am referring not only to medical doctors and doctors of osteopathy but also to registered nurses, to nurse practitioners, to physician's assistants, to anyone who is involved in the delivery of primary care in a rural setting. By "health department," I am referring to any body that processes the information that is reported to it and who collects and analyzes surveillance data. By "farmer," I am referring to a broad group: anybody who does physical work in agriculture. How is it that the physician gets involved in this scheme of surveillance, which was so nicely outlined earlier this morning? Well, of the methods that were described earlier, you will recall that some are based upon examination of large, existing, data bases, looking for evidence of trends in morbidity and mortality. Some are based upon recognition of excess hazard, possibly using some of the data that has been col- lected over the years by NIOSH or by OSHA. SENTINEL HEALTH EVENTS Dr. Halperin also mentioned the recognition of individual cases or sentinel health events. This is where, in my view, the practicing physician can contribute to surveillance. The sentinel events are oc- currences that have been determined to be of public health significance. Dr. Halperin described many of the other characteristics of the ideal sentinel event. The recognition of a sentinel event is im- portant, both for the individual case and for others experiencing similar risk. An appropriate response to a sentinel event Surgeon General's Conference on Agricultural Safety and Health - 1991 743 Surveillance - Agriculture-Related Diseases, Injuries and Hazards may involve an intervention aimed at the index case, which, hopefully, can reverse the problem or at least prevent further morbidity. . ..the intervention should affect other workers by either addressing the hazar- dous exposure, by screening similarly exposed workers, or by insuring that at least adequate protection is provided to similarly exposed workers. Additionally, the intervention should affect other workers by either addressing the hazardous exposure, by screening similarly exposed workers, or by insuring that at least adequate protection is provided to similarly exposed workers. These events can be detected in several ways. Screening programs Screening of specific worker populations can occur in various settings. A lot of this is done by employers both under duress from OSHA and on their own. It can be done through an occupational health clinic. If such screening uncovers evidence of occupational disease in a worker, this event should trigger a careful analysis and possibly an intervention. Reporting programs Alternatively, sentinel cases may be picked up in reporting programs, which may re- quire reports from physicians or, in some cases, laboratories. Examples of this might include patients who turn up with clinical evidence of occupational asthma, or situa- tions in which blood samples are deter- mined to have elevated lead levels. In most states, such situations are reported to the department of health. Often this is a 144 legal requirement for the practitioner. The value of this kind of case identifica- tion was demonstrated very nicely in a number of Dr. Halperin's examples earlier today. PROBLEMS IN PHYSICIAN REPORTING OF OCCUPATIONAL SENTINEL EVENTS For the next few moments, I would like to review some of the potential problems associated with the surveillance of sentinel events, both in theory and in terms of applying it to the agricultural setting. It is widely acknowledged that this type of surveillance leads to the detection of only a significant minority of cases. This is most clearly seen in the infectious disease experience. Here is a study from Vermont that looks at the typical or passive mode of reporting and compares it to an active approach in which physicians were contacted on a weekly basis. You can see that with the customary model, the passive model, only about half as many cases of hepatitis, mea- sles, rubella, and Salmonella were reported when compared to the more active ap- proach. If we look at occupational health, the news is not really any better. One example is physician-generated reports of occupational disease in Maryland from 1981 through 1983. There were 17 clinics in the Baltimore area that were doing a substantial amount of occupational health as part of their practice. There were 16 board-certified occupational physicians in Maryland, and there were at least 143 worksite clinics in operation in the state. Papers and Proceedings Surveillance: A Physician's Viewpoint, May 1, 1991 In 1982, 279 cases in total were reported. Twenty-three percent of these were report- ed by one physician, and 62 percent were reported by another physician. So, 85 percent of all the case reports in Maryland in 1982 came from two physicians. Obviously, there are some potential prob- lems with the reporting of sentinel events in that the afferent limb of the reflex here is certainly not flawless. There is another set of problems relating to the other side, the efferent part of the reflex. The public health body, which is the recipient of these notifications, must have the personnel, the interest, and the funding to provide an appropriate analysis and response to these notifications. But look at what we know about the effective- ness of this interaction. This is from a 1985 survey of the health departments of 50 states as well as the health department of New York City and Washington, D.C. You can see that about 60 percent of the departments mandated physician reporting of selected occupation- al illnesses. Lead poisoning was the most commonly required reportable condition, yet only five of these health departments had developed criteria for evaluating reports of lead poisoning. Eighteen departments indicated routine or periodic efforts to obtain ad- ditional details on reported cases. Only 10 departments used the case report, so only about one-third of those who mandated reporting used the case reporting in any of their interventional activities, only seven departments had ever published a sum- mary of information from case reports, and no department reported having evaluated its surveillance program to determine the rate of reporting. So, it is clear that the surveillance of occu- pational sentinel events is a complex activi- ty. It is not currently being done optimally by any of the participants. PROBLEMS IN PHYSICIAN REPORTING OF AGRICULTURAL SENTINEL EVENTS: Physical and Farmer Interaction Now, let us look at some of the potential challenges involved in applying this model to agricultural health and safety. The physician and farmer interaction is not always a many-splendored thing. First of all, some farmers feel that they do not have the funding or the time required to see their physicians on a regular basis. A second issue is the farmer's perception of the physician's expertise regarding agri- cultural health problems. If I tried to assure an audience of farmers that their physician could consistently recognize occupational hazards and could always advise them reliably on the proper treat- ment and prevention, my statements might be received by the farmers with an ele- ment of skepticism. Physician Recognition of Sentinel Events This leads us into the second aspect of the issue of reporting, and that has to do with physicians. My observations over the last 10 years are that physicians, in general, tend to have relatively limited sophistica- tion with regard to agricultural medicine. There are a variety of occupational prob- lems, which have been outlined by Dr. Novello and a number of other speakers, that can affect farmers. Surgeon General's Conference on Agricultural Safety and Health - 1991 145 Surveillance - Agriculture-Related Diseases, Injuries and Hazards Some of these are clearly job-related, and others are probably job-related. Many physicians would have difficulty diagnosing some of these conditions and would sel- dom relate others to the farmer's oc- cupation. Physician Reporting of Sentinel Events If we assume that the farmer does come to see the physician and that the physician correctly diagnoses the problem, does it get reported ? This relates to the physici- an's awareness of the responsibility to re- port as well as their interest in doing the reporting. I cannot show you any data on the level of this interest. As a practicing physician, I can assure you that when things get relatively busy, the interest in reporting is limited. Public Health Response to Sentinel Events Now, a final challenge in the physician reporting of agricultural sentinel events, in my mind, has to do with the need for a mutually productive interaction between the reporting physician and the health department. Reliable reporting will con- tinue only if it is clearly beneficial to either the physician or to his patient. Yet these departments have limited resour- ces. Even if there is sufficient interest at the health department level, it is unlikely that most health departments have the expertise in agricultural medicine to mount an effective response to this kind of infor- mation. For the past 10 minutes I have outlined a series of problems and roadblocks involved in this issue that make it seem that the likelihood of effective physician surveil- 746 lance is somewhere between slim and none. I believe, however, this is an effec- tive activity that can be made to work, and there are resources available that can be applied to the task. RESOURCES The National Coalition for Agricultural Safety and Health (NCASH) was formed, following the meeting in Des Moines and Iowa City. This group has successfully worked to secure funding to begin some of the efforts that we are seeing today. NIOSH certainly had contributed to this field prior to the beginning of the NCASH endeavor. Since then, it has received fund- ing needed to begin a more organized attack on these problems. Now, through NIOSH, there is a wealth of experience with occupational problems, although not specifically with agricultural problems. The recently designated NIOSH centers should be able to provide consultation and educational support that is specifically aimed at agricultural issues. As you know, these are located in Iowa and California. Another NIOSH-initiated program is the Rural Nurse Sentinel Program, which I suspect Dr. Freund will expand upon to- morrow. Briefly, this is a program that proposes to locate specially trained occu- pational nurses in rural regions where they will interact with rural physicians and oth- ers to form a network for surveillance pur- poses. In addition to NIOSH-funded programs, there are a handful of other groups around the country that have a particular interest and expertise in agricultural medicine. In New York we have been working in this field for about 10 years. We were preced- ed in this by the group from Marshfield, Papers and Proceedings Wisconsin. In other places in the country, there certainly are a number of interested individuals who have considerable experi- ence working with farmers and farrnwork- ers. Certainly, a number of the land-grant uni- versities have developed expertise in engi- neering and safety issues, and, in some cases, this has expanded into the area of health and health education. An example of this would be Bill Field at Purdue, whose interest in rehabilitation of injured farmers has resulted in his acquiring a knowledge of rehabilitation medicine that makes most of us physicians envious. Some occupational medicine groups have become increasingly interested in this field and clearly have become resources. Our previous speaker and her program in Seattle are certainly an example of this. In general, however, I think that agricultural problems are not an area of expertise or even of particular interest for many oc- cupational physicians. POSSIBLE SOLUTIONS Let me see if I can spend a few minutes proposing ways in which some of these resources might be used to help us get around the various obstacles that I de- scribed a few minutes ago. Physician and Farmer Interactions The physician and farmer interaction is a difficult problem, and it certainly needs to be addressed. Currently physicians are not viewed as being particularly knowledgeable with regard to agricultural problems, nor are they affordable or convenient to the farmers. Surveillance: A Physician's Viewpoint, May 1, 1991 Some of these issues can be improved, certainly with aggressive efforts at con- tinuing medical education. As you heard at lunchtime? here in Iowa interested physicians w&in a community may some- times enter a program in which they re- ceive intensive training in agricultural health problems at the center. Such in- dividuals then become local resources. Educational efforts by physicians can go a long way towards building bridges between farmers and physicians. Jim Hartye has developed an innovative approach at his clinic in North Carolina. Periodic health screening events are scheduled for the farm community. When these people come in for free spirometry or free blood pressure checks or free cholesterol checks, these are coupled with discussions of safety practices, protective equipment, etc. Mary Lee Hill, from our group, will pres- ent a poster later this week demonstrating the effectiveness of a similar program. A proposal for this type of approach was recently discussed by the American Academy of Family Practice. The experience that we have had in New York is that educational programs are a very effective way to reach out to the farm community. For this reason, we never decline an invitation to speak to a farm group, whether it be large or small. We have an educational booth that spends a lot of time on the road going to various farm shows and programs. We design the programs that accompany this booth to be interactive in some way. Frequently, there is some sort of a come-on with free hearing testing or free respiratory testing. The main point is to Surgeon General's Conference on Agricultural Safety and Health - 1991 147 Surveillance - Agriculture-Related Diseases, Injuries and Hazards obtain a teachable moment with this group and spend some time educating. These kinds of contacts with farmers and their families have enabled us to learn a lot. It also, at the same time, has strength- ened our relations with the agricultural community in New York and has enabled us to gain some recognition with the com- munity as having some experience and expertise in agricultural health problems. Now the local practitioner is unlikely to have the time, interest, or expertise to approach farmer education in this way. However, if one were supported in this effort with teaching materials, with exam- ples of acceptable protective equipment, as well as a basic understanding of this mate- rial, these efforts might prove not only possible but actually productive, not only in terms of educating but in terms of alter- ing the relationship that currently exists between physicians and farmers. In the waiting room of a rural clinic in Sweden that is run by a physician, with a particular interest in agricultural medicine, prominently displayed are various types of protective equipment as well as instruc- tions. He provided fairly sophisticated discussions of ergonomics for his patients. I think these kinds of effort go a long way to building bridges with the farm com- munity. Physician Recognition of Sentinel Events The problems in physician recognition relate to the level of sophistication that the physician has regarding occupational and specifically agricultural health problems. The potentially large number of events, many not clinically certain or absolutely related to work, clearly poses a problem for these physicians. Here again, aggres- 148 sive, continuing medical education is part of the answer. In addition, I think the number of report- able events must be limited to a few. These should be defined for epidemiologic rather than clinical purposes. For exam- ple, if we agree that farmer's lung is an appropriate target for surveillance, we would not require that a case demonstrate repeated recurrences, antibody positivity, and a predominance of lymphocytes in the bronchoalveolar lavage fluid. Rather, we would want to hear about any febrile reactions with myalgias or cough that occur following dusty work. The determination of whether this is farmer's lung, or organic dust toxicity, or simply pneumonia would be made later on by a different part of that reflex loop. A form that we use in the Occupational Health Network in New York allows for a sub- stantial amount of uncertainty regarding the clinical diagnosis. Nevertheless, these people get on the re- cords and it is possible at a later date to sort out how certain we were and how good the evidence was that this was a bona fide case. So I think that although physi- cians have a need to be quite certain, epidemiologists are more comfortable with less certainty. Physicians have to be edu- cated to this difference, if they are going to report these cases. Physician Reporting of Sentinel Events Physician interest in reporting agricultural or any illness is going to be affected by the level of antipathy felt towards the local health department. In my home state of New York, this is considerable, and the easiest way to infuriate a New York physi- cian is to send him a letter that says, "Dear Provider, The New York State Department Papers and Proceedings of Health now requires that you do the following." There is no way to enforce these kinds of laws, and so I do not think it is a productive way to approach the physicians. Interest in reporting is further moderated by the amount of time and effort needed to do so as well as by the natural reluc-, tance to get wrapped up in what is some- times a quagmire of workmen's compensa- tion. If the health department hopes to receive reports, the system must be readily accessible, user friendly, and perceived as beneficial either to the physician or to her patient. A system like the Poison Control Center Network, which provides consulta- tion and support to the physician, will at- tract a lot more interest than simply another annoying letter from the health department. Active surveillance has repeatedly been shown to be more effective and well- received by physicians. Once again, I will use an example from the infectious disease literature. This is a study from Rochester, New York. They divided the physicians into three groups. Some received a weekly phone call, some received a weekly post card, and most just performed passive surveillance as is typical. Not surprisingly, there was substantially more response in the telephone group than in the post card group. There was better response in the post card group than in the passive group. So the message is that active surveillance is better, and I think NIOSH, recognizing this, has initiated the nurse surveillance program, which I men- tioned earlier. Surveillance: A Physician's Viewpoint, May 1, 1991 Public Health Response to Sentinel Events Now, the final series of roadblocks, as I see them, are at the level of the health department. We have already seen that health departments often have poor, if any, response to the cases of commonly report- ed occupational illness. The response to agricultural illness is likely to be worse, since it's unlikely that the department will have any experience, much less expertise, in the area. It is not likely that agricultural problems will be able to compete in a busy, urban- based, overworked, and underfunded health department. What is the solution to this particular set of problems? I would propose that the health department ought not to be directly in- volved in the feedback part of this loop. Ideally, this would best be done by a group, which is interested in and knowledgeable about agricultural problems-a group that could offer the "poison control center"-type of approach with support and consultation for the refer- ring physician. Ideally, industrial hygiene and agricultural engineering consultation would be offered to the physician's patient. Who can provide these kinds of services for the health department? In some cases, it might be a medical school. In general, however, I think most medical centers' lukewarm approach to occupational health, abysmal records in rural health, and lack of appreciation of agricultural medicine make it likely that we should look else- where for help. The resource, which I would favor, is the existing NIOSH program for Centers for Agricultural Research, Education, Disease Surgeon General's Conference on Agricultural Safety and Health - 1991 149 Surveillance - Agriculture-Related Diseases, Injuries and Hazards and Injury Prevention. Expansion of this program on a regional basis throughout the country would enable education of physicians so frequently mentioned in the last few minutes. These centers would interact to support the nurse sentinels, provide user friendly feedback and support to practicing physicians, and help bridge the gap between the farm community and the medical establishment. In summary, I believe that the practicing rural physician can definitely make a valu- able contribution to the detection of occu- pational sentinel events in farmers. There are particular problems, or potential problems, that are related to the ability of health departments to coordinate respons- es to these reports, related to the compe- tence of physicians in agricultural medi- cine, and related to the farmers' percep- tion of the physician relative to the farm workplace. I believe that there are potential solutions to these problems and that many of these might best be approached by the use of regional centers for agricultural health and safety, which could provide education, consultation, and support services to prac- ticing physicians and farmers.0 750 Papers and Proceedings