Questions to Guide the National Agenda is a subset of a larger testing issue faced by the National Toxicology Program. o At a National Institute of Environmental Health Sciences Conference on Agricultur- al Chemical Utilization and Human Health, the need for further chemical testing to address organ function, perinatal toxicity, immunotoxicity, and chronic and delayed effects including cancer and de- layed nervous system manifestations (and testing of combinations of chemicals) was strongly recommended. b A second area where basic research needs to play an important role is in the emerging area of agricultural biotechnology. Genetically engineered microorganisms promise substantial benefits for food production throughout the world. Potential benefits include new crop varieties that will benefit the grower through lower input costs and increased productivity, the food processor through production of higher-quality and consistent products, and ultimately the consumer through production of more appealing and nutritious foods. Use of biotechnology in agriculture has potentially significant implications for agricultural safety and health. Two potentially lowered risks that may accrue through use of agricultural biotech- nology include: 1. Reduced use or replacement of agricultural chemicals now known to be harmful to human health. 2. Reduced field exposures to crop production, especially to farm machinery, which is known to be the single greatest risk in farming. Biotechnology is currently being regulated by EPA through the Federal Insecticide, Fungicide, and Rodenticide Act (FIFRA, 7 U.S.C. 136-136~) and regulation adopted in 1984 (49 Federal Register 40659), the Toxic Substances Control Act (TSCA, 5 U.S.C. 2601-2929), and by the USDA through provisions of the Plant Pest Act (7 U.S.C. lSOaa-jj) and regulations adopted in June of 1987 (CFR Part 330). o While regulation of this emerging tech- nology provides some assurance that ap- propriate testing will be done, from a pub- lic health perspective it is essential that necessary testing for adverse effects on plants and animals be conducted in the laboratory and in small field experiments. Experience to date suggests that the use of biotechnology in agriculture will not be associated with unpredictable exposures that cannot be addressed using appropriate work practices.' Disease and Injury Surveillance The development of disease and injury surveillance or information systems is a very high priority for the advancement of agricultural safety and health research. As surveillance is covered by another speaker, I will confine my comments to those infor- mation systems especially important to epidemiological research. These informa- tion systems fall in two categories-those dealing with health effects (injuries and diseases) and those dealing with exposures (cohorts with specific exposures or systems defining exposures to which human or animal populations may be linked). o Information systems that are especially useful in epidemiology are specific disease and injury registries. Often existing cancer registration data is available from state or 76 Papers and Proceedings hospital data. Use of these information and birth defect registries. Data on the systems is an inexpensive and powerful epidemiologic tool. sale of certain farm chemicals provide another type of exposure registry. Another Through the State Health Registry of Iowa type may be derived from widespread tes- ting of drinking water for nitrates and at the University of Iowa, we are now able pesticides. to register birth defect and cancer inci- dence. An Alzheimer's Disease Registry has also been developed for some counties, While these exposure registries usually provide evidence of exposure to certain and a Rural Injury Surveillance System is now under development. agricultural chemicals, epidemiological research requires much more detail in terms of the types and amounts of specific These health effect registries are especially chemical use, the time-frames of use, the useful as they allow systematic collection type of application, and the use (and non- of large numbers of specific types of birth use) of protective equipment. These types defects, cancers, or injuries that can then of data must almost always be collected be studied quantitatively through the use retrospectively, but could be collected of case control studies. This approach has prospectively in a small cohort or in a been used effectively in the assessment of sample of a larger cohort. risk factors for a variety of specific types of cancer. Collection of representative exposure data is also essential in cross-sectional studies of The same approach is now being applied injuries and health effects. These data are to birth defects, which have an added ad- necessary in order to derive exposure vantage of having a much shorter latency response relationships, which are essential (hence more accessible and valid data). In to the development of guidelines for re- the case of injuries, there is no latency and duction of exposures and the prevention of the circumstances of injury are usually diseases and injuries. clear. This will allow the injury registry to collect more data at the time of the event o There are very few trained industrial and thus reduce the time and cost of case hygienists specializing in agriculture. The control studies. need for these skills in the collection and interpretation of environmental data is Epidemiological Studies critical to advance agricultural health and safety research. o A significant problem in assessment of surveillance and epidemiological data is the lack of adequate exposure data. The development of exposure registries is, therefore, especially attractive, Demonstration and Education Research Closely related to epidemiological research is the area of demonstration and education For instance, large cohorts of pesticide applicators who must be licensed to do their work now provide an especially im- portant opportunity for epidemiological research through record linkage to cancer research that utilizes intervention studies. While epidemiological research may clear- ly show an excess in a certain type of can- cer, birth defect, respiratory disease or specific type of injury, a valid model for Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 77 Questions to Guide the National Agenda intervention may not be available or may be difficult to implement. The traditional intervention model in occu- pational safety and health is that of regula- tion, which has seen some significant suc- cesses, such as the reduction of respiratory disease through the regulation of coal mine dust and cotton dust. Occupational safety and health regulation has, however, been greatly diminished over the past decade, and agriculture has traditionally not been a regulated industry. If we cannot develop a U.S. model for a proven intervention on the single most important cause of agricultural mortality, how can we succeed in addressing less dramatic yet still important causes of agricultural diseases and injuries? As a result, more innovative intervention methods for disease and injury prevention are needed in agricultural safety and health. A good example of the need for such a model is the prevention of tractor roll-over deaths through the application of roll-over protective structures (ROPS) on both new and older tractors. The epidemiological evidence for the very significant risk posed by tractors without ROPS is clear. The data available from Sweden, which mandated such a program, makes it equally clear that ROPS can prevent almost all tractor roll-over deaths. o An important question for this confer- ence is whether an American intervention model can be developed that can produce a significant reduction of tractor roll-over deaths and injuries. A second question, with much broader ramifications, is, "If we 78 cannot develop a U.S. model for a proven intervention on the single most important cause of agricultural mortality, how can we succeed in addressing less dramatic yet still important causes of agricultural diseases and injuries?" Health Services Research An observation made by Dr. James A. Dosman in his summary of the research workshops prior to the conference, "Agri- cultural Occupational and Environmental Health: Policy Strategies for the Future," was the following: It is striking that the organized scientific documentation of specific health risks is occurring at a time when changing rural economic resources and family and rural community infrastructures are leaving few community resources to alter specific risk patterns. Thus, the assessment and pre- sentation of health and family-life deft- ciencies must be viewed in a climate of economic adjustment, rural population decline, and loss of personal, financial, and social control by individuals and families. However, one must realize that whereas all these changes are occurring simultaneously, unacceptable injury, death, and dysfunction are occurring on the farms and in rural areas. This co- nundrum describes a widening gap in diagnostic and preventive health services, and in family support services, between rural dwellers and city dwellers.." While this paper is not intended to address the very broad field of health services research, this quotation points out that there are significant differences between rural populations and their urban counter- parts, which must be taken into account in conducting epidemiological research. In nearly every parameter of health-disease Papers and Proceedings and injury incidence, availability of health agricultural mortality over the past ten care, and related social services years has shown relatively little -people living in rural areas have less improvement and remains higher than that favorable statistics than their urban coun- of mining and construction. terparts.' Especially vulnerable are migrant agricultural workers who are at NIOSH, through its National Traumatic triple jeopardy-poor, rural and uninsured. Occupational Fatalities (NTOF) database, reports 20.7 deaths per 100,000 agricultural o These social service and health-care workers, versus 7.9 deaths per 100,000 for delivery factors clearly influence the inci- the general private - sector workforce.' dence of rural injuries and diseases and Results of epidemiological studies and point up the importance of interaction and newly developed surveillance systems sug- collaboration between those engaged in gest these national estimates may sig- agricultural health and safety research with nificantly underestimate both deaths and rural sociologists and those engaged in farm-related injuries. rural health care delivery research. AGRICULTURAL DISEASE AND INJURY RESEARCH PRIORITIES The Iowa Department of Public Health farm injury surveillance program (SPRAINS) reported 83 deaths for 1990 based on voluntary reports from health- Injury Morbidity and Mortality care providers." As this was the initial year of reporting, it is thought that this Available data on the risk of injury and number is incomplete; yet this number of traumatic death consistently reflect a high- deaths is over 60 percent higher than er injury risk to those living in rural com- previous estimates of farm deaths in Iowa. pared to urban areas, with a mortality rate Epidemiological studies draw our attention for unintentional injuries twice that of to the importance of farm machinery in urban areas.* This excess is attributable to fatalities and severe injuries, to higher several factors, including increased mor- rates of injury among children and the tality from motor and non-motor vehicle aged, and to the substantial numbers of deaths arising from higher speeds on intentional deaths (suicides and homi- poorer roads, less seat belt use, more use cides)." of high-risk utility vehicles, and poorer access to trauma care. At particular risk While it is clear that traumatic injuries and to rural injury are farmers, their family deaths are epidemic on American farms, members, and hired and migrant laborers. we still lack national and state-based information systems (surveillance), a rea- In addition to the several factors that place sonable understanding of risk factors, and rural residents at increased risk are added an adequate characterization of hazards of the occupational risks of farming. The farming associated with injury morbidity National Safety Council estimated deaths and mortality. Therefore, three research among farm residents to be 56.2 per priorities in the area of traumatic injuries 100,000, 30.1 of which were motor-vehicle- are: related, 20.1 work-related (18.1 in farm work), 8.0 home-related, and 4.0 public 1. Development of national and state- non-motor vehicle deaths.4 The trend in based information systems, which will Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 79 Questions to Guide the National Agenda provide essential injury and injury mor- tality incidence data by type of injury (ICD-9 codes), cause of injury (E- codes), place of injury and demographic information on the injured party. 2. From surveillance data or large epide- miological studies, case control studies of specific farm injuries, which will allow much better understanding of risk factors associated with the injury. 3. A much better environmental assess- ment of farm machinery, farm buildings, livestock operations, on and off-road vehicles, agricultural chemical use and storage, and available prevention mea- sures. This assessment is essential to epidemiological surveys and case- control studies Respiratory Health Effects Farmers and other agricultural workers are exposed to a number of respiratory haz- ards, the most common of which is organic dust. Additional exposures, which are known to be important include several agricultural chemicals, toxic gases from livestock confinement facilities, toxic and immunogenic constituents of microorgan- isms, feed additives such as antibiotics, and infestations of insects, which may produce lung disease." l3 A common denominator in these exposures is a significant exposure to organic dust, which has been shown by many epidemio- logical studies to result in acute symptoms of airway inflammation, heightened airway reactivity and asthma, and acute changes in lung function. Pulmonary edema followed by bronchiolitis obliterans and hypersensi- tivity pneumonitis are relatively uncommon but well-known pulmonary conditions aris- ing from certain agricultural exposures. In some agricultural populations with long exposure to organic dust, fixed airway obstruction has been observed. Despite recent interest in this area, there are sig- nificant research gaps including the follow- ing: 1. There is little surveillance data and incomplete epidemiological data on respiratory diseases in several agricul- tural populations. Disease patterns and risk factors are still incompletely understood in the animal confinement and grain handling and processing in- dustries, and from exposures to agricultural chemicals such as anhydrous ammonia. 2. `&here is a very great need for the de- velopment of dose-response data for agricultural exposures in order to allow fuller development of prevention strate- gies. 3. There is a need to more fully explore certain environmental factors, such as exposure to storage mites and the toxic products of certain microorganisms, in both the laboratory and through field studies. Cancer Epidemiological studies reported a decade ago initially raised questions about an association between soft-tissue sarcoma and lymphoma and exposure to acetic acid herbicides and chlorophenols. Since then, over 20 additional cohort and case-control studies have addressed this issue. The results of these studies are not consistent, but excess deaths from non-Hodgkin's lymphoma, multiple myeloma and leuke- mia have shown more consistent positive associations. 80 Papers and Proceedings In addition, excesses of lung, stomach and Assessment of adverse reproductive effects prostate cancer have been observed in has a significant methodological advantage cohort studies of manufactures and appli- over assessment of cancer incidence in that cators.14 Other potential risk factors for cancer incidence include viruses, and the latency from the time of exposure to the time of the reproductive effect is much dietary and other factors as possible shorter than that for cancer, which is gen- contributors to cancer incidence among agricultural workers." A number of erally 20 or more years. The lack of birth methodological issues pose difficulties in defect information systems has greatly hampered evaluation of birth defects in interpreting these findings and indicate association with environmental exposures. priorities for research in this area: Priorities for research in this area fall in two areas: 1. There is a uniform need for better environmental characterization of agri- 1. Additional systematic toxicological test- cultural chemical exposures through the ing of agricultural chemicals and com- development of valid and inexpensive monly used combinations of chemicals environmental exposure protocols. for adverse reproductive effects. 2. Use of exposure registries linked with 2. Further development of birth defect cancer registries promises to provide registries and linkage of these infor- important additional data on cancer risk mation systems with exposure registries, among agricultural workers. and through the development of case- control studies with adequate exposure 3. Improved epidemiological methods to data. assess and validate previous agricultural and other exposures are needed for Neurological Health Effects adequate analysis and evaluation of cancer data. Recent reviews of the neurotoxic effects of pesticide exposure have focused on chronic Reproductive Health Effects neuropsychological sequelae from expo- sures to organophosphate pesticides.19'" Concern about possible adverse While the early (immediate and delayed) reproductive health effects arises from neurotoxic effects are well-described for toxicological testing showing some agricul- organophosphate intoxication, until tural chemicals to be teratogenic, from recently little attention had been given to widespread use of some of these chemicals, evaluation of possible chronic effects. and from some case reports suggesting as- sociations between certain adverse repro- However, as the result of several case ductive effects and agricultural expo- studies and clusters of adverse behavioral sures.16' " The reports on dibromochloro- and neurological findings, the World propane (DBCP) on male reproductive Health Organization (WHO) and the function have provided an important exam- ple of the toxic effects of this pesticide, an United Nations Development Programme (UNDP) are coordinating a ten-country exposure, which now continues in some developing countries." European, prospective epidemiological study on the neurotoxic effects of low-level exposure to organophosphorus pesticides. Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 81 Questions to Guide the National Agenda This study includes both pesticide for- mulators and agricultural workers. Ad- ditional studies of three types are needed: 1. A replicate of the European study through the use of recently developed and standardized tests of neuro- psychological function and extensive characterization of exposures to organo- phosphate pesticides; 2. Well-controlled follow-up studies of workers who have documented cases of acute organophosphate intoxication for possible chronic neuropsychological effects; and 3. Greater attention to neurotoxic effects of agricultural chemicals through toxico- logical testing. Repetitive Trauma Trauma research in agricultural populations has focused almost entirely on acute traumatic injury and death. Yet repetitive trauma is known to be a much more significant problem than acute trau- ma in most industries. There is reason to suspect that significant repetitive trauma may occur as the result of vibration and repetitive tasks in the use of farm machinery and other farming oper- ations. A recent case-control study of hip joint arthrosis among Swedish farmers found a relative risk for this condition between 2.1 and 3.2, varying by length of time in farming.2' There is also reason to believe that long hours of work on agricultural machinery may induce significant muscle fatigue, which may, in turn, contribute to the risk to acute injury. Repetitive trauma has not been systematically studied among farming populations, but should be a research pri- ority: 1. Surveys of farming populations to assess acute injuries or other health effects should also include assessment of repet- itive trauma conditions, especially those involving the back, hip and knee. 2. Collaboration between agricultural engineers and biomechanical engineers should focus on ergonomic factors that may contribute to repetitive injuries and how these factors may be mitigated. Dermatitis Dermatitis is a condition endemic in farm- ing. Data from the Bureau of Labor Statistics (BLS) indicate a five-fold greater incidence of dermatitis among farm workers compared to workers in general industry. Because of the limitations in BLS data for agricultural workers, these findings may represent a significant underestimation of dermatitis in this working population. A recent survey of California grape and tomato workers found a high cumulative incidence of dermatitis, suggesting that dermatitis is a frequent and recurrent problem among these farm workers." 1. There is a need for systematic dermato- logical surveys of Earm workers with attention given to criteria for classifica- tion of dermatological conditions, to the sensitivity and specificity of question- naires, and to the correlation between questionnaire and exam results. 2. There is a great need for environmental evaluation and measurement of derma- tological irritants and sensitizers. 82 Papers and Proceedings 3. Development and evaluation of inter- vention programs to prevent dermatitis among farm workers are further re- search needs. Noise-Induced Hearing Loss agricultural industries and foundations, to the interest and support of several state and federal agencies, to the efforts of the National Rural Health Association, to the work of many university faculty who par- ticipated in the conferences and briefings, and to the commitment of many members Several studies have now reuorted bilateral high-frequency hearing loss io be quite of the U.S. Congress and several state legislatures. prevalent among farmersp Of particular concern is the frequency with which this As a result, and for the first time, a abnormality is observed among farmers healthy dialogue has involved all parties to under the age of 30. This strongly suggests these important issues. Significant resourc- that noise is the cause of this injury. In- es are now available through federal ap- deed, farm machinery and chain saws are propriations and some state appropriations known to generate noise levels above to mount this national research and inter- recommended limits. A further finding has vention initiative. This research effort is been that relatively few farmers use just beginning. The challenge ahead is to hearing protection. Therefore, research maintain this momentum and build upon priorities here include: these gains. 1. Systematic industrial hygiene surveys to CONCLUSIONS characterize farming operations where noise levels exceed recommended lev- 1. The high risk of disease and injury els. arising from agricultural exposures has now been recognized and has now been 2. Development and evaluation of inter- placed on the national public health vention programs to provide adequate agenda. hearing protection to those engaged in these farming operations. 2. Adequate resources and incentives have been provided to address the multiple THE NATIONAL AGRICULTURAL AND research priorities. These resources ENVIRONMENTAL HEALTH INITIATIVE must be maintained and cultivated. Since the publication of Agn'cultire At 3. A healthy dialogue has promoted the Risk: A Report to the Nation, which sum- involvement of most parties. Greater marized the recommendations arising from efforts are needed to involve full the national public policy conference, "Ag- representation of children, women, ricultural Occupational and Environmental migrants, and the rural poor. Health: Policy Strategies for the Future," and the dissemination activities of the 4. The challenge ahead is to prioritize, NCASH, there is a new level of awareness implement, and publish research fin- of the magnitude and severity of disease dings and translate this research into and injury among American agricultural meaningful prevention and health deliv- workers. Significant credit for initiation of ery programs.0 and support for this effort is due to several Research for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 83 Questions to Guide the Natlonal Agenda REFERENCES 1. Coughenour CM and Swanson L. Work Statuses and Occupations of Men and Women in Farm Families and the Structure of Farms, Rural Sociology. 48(1):23-43, 1983. 2. Fassinger PAD and Schwarzseller HK. The Work of Farm Women: A Midwestern Study, Research in Rural Sociology and Development. (1):37-60, 1984. 3. Ungar RL. Farm Women at Risk: Work Roles and Agricultural Bposures. Thesis, Department of Preventive Medicine and Environmental Health, The University of Iowa, 1990. 4. National Safety Council. Accident Facts, 1988 Edition. National Safety Council, Chicago, Ill, 1988. 5. Glass DJ. Agricultural Biotechnology: Occupational Health and Regulatory Issues in Occupational Medicine: State of the Art Reviews. 6(2):301-309, 1991. 6. Dosman JA. Technical Workshop Report: Working Group I: Occupational Health and Safety Strategies for Agriculture, American Journal of Industrial Medicine. 18:353-356, 1990. 7. Summer L. Limited Access: Health Care for the Rural Poor. Center on Budget and Policy Priorities, Washington D.C., 1991. 8. Baker SP, O'Neill B. and Karpf R. The Injuly Fact Book. Lexington, Mass.: Lexington Books, 1984. 9. Myers JR. National Surveillance of Occupational Fatalities in Agriculture, American Journal of Industrial Medicine. 18(2):163-168, 1990. 10. Currier R. Iowa Department of Public Health, Personal Communication, 1991. 11. Stallones L. Surveillance of Fatal and Non-Fatal Farm Injuries in Kentucky, American Journal of Industrial Medicine. 18(2):223-234, 1990. 12. Merchant JA. Agricultural Respiratory Diseases, Seminars in Respiratory Medicine. Thieme, Inc., No.3, 7:211-224, New York, 1986. 13. Merchant JA. Agricultural Exposures of Organic Dusts. Occupational Medicine: State of the Art Reviews. 2(23) April-JuneXl9-425, 1987. 14. Blair A and Zahm SH. Herbicides and Cancer: A Review and Discussion of Methodologic Issues, Recent Results in Cancer Research. 120~132-145, 1991. 15. Pearce N and Reif JS. Epidemiologic Studies of Cancer in Agricultural Workers, American Journal of Industrial Medicine. 18(2):133-148, 1990. 16. Schwartz DA and LoGerfo JP. Limb Reduction Defects in the Agricultural Setting, American Journal of Public Health. 781654-659, 1988. 17. Gordon JE and Shy CM. Agricultural Chemical Use and Congenital Cleft Lip and/or Palate, Archives Environmental Health. 36(5):213-221, 1981. 18. Whorton D. Dibromochloropropane Health Effects, Chapter 48 in Environmental and Occupational Medicine. WN Rom (Ed). Little, Brown and Company, Boston, 1983. 84 Papers and Proceedings Research for Agricultural Safety and Health, May 1, 1991 19. Rosenstock L, Daniell W, Barnhart S., Schwartz D, and Demers PA. Chronic Neuropsychological Sequelae of Occupational Exposure to Organophosphate Insecticides, American Journal of Industrial Medicine. 18(2): 321-326, 1990. 20. Davies JE. Neurotoxic Concerns of Human Pesticide Exposures, American Journal of Industrial Medicine. 18(2):327-332, 1990. 21. Thelin A. Hip Joint Arthrosis: An Occupational Disorder Among Farmers, American Journal of Industrial Medicine. 18(2):339-344, 1990. 22. Schenker MB and McCurdy SA. Occupational Health Among Migrant and Seasonal Farmworkers: The Specific Case of Dermatitis, American Journal of Indusbial Medicine. 18(2):345-352, 1990. 23. May JJ, Marvel M, Regan M, MarveI LH, and Pratt DS. Noise-Induced Hearing Loss in Randomly Selected New York Dairy Farmers, American Journal of Industrial Medicine. 18(2):333-338, 1990. Surgeon General's Conference on Agricultural Safety and Health - 1991 85 Surgeon General's Confemnce on Agricultural Satkty and Health FCWMSAFE 2000 . A National Coalition for Local Action Convened by the National institute rbr Occupational Satrsty and Health April 30 - May 3, 1991, Des Moines, iowa INTERVENTION FOR AGRICULTURAL SAFETY AND HEALTH Myron D. Johnsn.@ Ph.D. Administrator, Extension Service' United States Department of Agriculture Mr. Mark Timm: From Washington, D.C., our next speaker is Dr. Myron Johnsrud, Administrator of the USDA Extension Service. Dr. Johnsrud holds a master's and doctor's degree in administration from the University of Wisconsin and farmed for a number of years in North Dakota. He directed the North Dakota State University Cooperative Extension Service for 12 years. He served as chairman of the Great Plains Agricultural Council, and served on the Board of Directors of the Prairie Public Television Corporation and on the Board of Trustees of the National 4-H Council. Since 1986, Dr. Johnsrud has directed the US. Department of Agriculture's Extension Service. In thls position, he is responsible for a $15 million program and $370 million of federal allocations to the land grant univer- sities for cooperative extension service programs. He is responsible for a major program for redirecting the Extension Service, in partnership with the Cooperative Extension Service, a national network in the 50 states and territories, and more than 3,100 countries. The redirection focuses on current and critical issues of the nation. Dr. Myron Johnsrud will speak to us this morning on the critical issue of lnrervenrion for Agricultural Safety and Health. Dr. Johnsrud: INTRODUCTION are in protecting agricultural workers and "The health of the people is real& the foundation upon which all their happi- ness and all their powers AS a state de- pend ," Benjamin Disraeli, prime minister of Brit- ain, made that statement in a speech over 100 years ago, and it is still right to the point today. Safety, too, which we link closely with health, has long been essential to civilization. Salus populi suprema lex ("The people's safety is the highest law") was a legal and political maxim of ancient Rome. The need for surveillance and research to guide injury control efforts in agricultural safety and health presents many challenges that have been identified by the previous speakers. However, we must ask ourselves how society will judge our success in solv- ing the problems of agricultural injuries. I believe that society will judge our success by how effective our intervention methods 86 helping create the change in their behavior necessary for their success. Intervention countermeasures will rely upon the knowledge gained from research and sur- veillance programs to implement effective solutions to agricultural health and safety problems. What makes agricultural production one of the most hazardous occupations in the United States? As we attempt to prevent and reduce the incidence of fatal and serious accidents and chronic illness on our farms and ranches, do we know what areas to focus on for the most success? How do we keep agricultural safety and health from being overlooked when ad- dressing other issues that confront agricul- ture, such as the environment, animal wel- fare, or energy? How wide is our scope+loes it stop at the farm gate or timber mill? Or, does it include many segments of food, feed, and fiber processing? Papers and Proceedings These are just a few of the questions con- occupational injuries experienced by agri- fronting us today in the important issue of agricultural safety and health. This mom- culture over the past 50 years is due to the accomplishments of these professionals ing I want first to present a brief history working cooperatively through or- and the current status of intervention ef- ganizations such as the National Institute forts. Second, I will pose questions to for Farm Safety and the safety committees guide the concurrent session on developing and standards committees of the American intervention strategies for various targeted Society of Agricultural Engineers (ASAE). audiences, approaches to intervention, and the need for collaboration. Third, I will We cannot ignore the fact, however, that suggest some areas that I see as the pres- the rate of decline in agricultural fatalities sure points, injuries, and fatalities of high- and injuries is much slower than that expe- est priority and the places where we have rienced by mining and construction, the the best chance to intervene successfully. other two most hazardous industries in this nation. Except for this fact, we would not CURRENT STATUS OF INTERVENTION be here today. Because of it and the ef- forts of such organizations as NCASH, the Voluntary safety efforts have had much Congress has recognized the need to com- success. Agriculture has the most exten- mit additional resources to research, sur- sive community of voluntary safety profes- veillance, education, and intervention pro- sionals of any industry in the United grams. States. What was probably the first farm safety effort began in 1933, when the Sixth Most of the new programs are being ad- Annual Rock River Valley Safety Confer- ministered by NIOSH. In administering ence meeting at Fort Atkinson, Wisconsin these programs, NIOSH has recognized the organized a farm safety section. value of supporting existing programs. Au example of this is NIOSH's intervention In 1937 the National Safety Council held a program Agricultural Safety and Health meeting of an agricultural section. Its first Promotion Systems, which is providing farm conference took place in 1947. An funding to enhance educational safety organized professional effort to prevent programs through the Cooperative Exten- farm accidents began in the Cooperative sion System in 15 states. Extension system early in the 1940's with appointment of a full-time Extension farm Two new NIOSH programs crucial to de- safety specialist by the University of Wis- veloping intervention include establishing consin. two new centers in Iowa and California for agricultural research and education and A coalition of farm safety professionals supporting occupational health and safety representing agricultural equipment nurses in agricultural communities. These manufacturers, the Farm Bureau, insurance programs exemplify, too, the key questions companies, and the Cooperative Extension we must ask ourselves in developing System chartered the National Institute for strategies for intervention programs. Farm Safety in 1961 to provide a forum for the exchange of research results, surveil- 1. How do we implement promising and lance data, and effective intervention met- innovative new programs such as nur- hods. Much of the success in reducing the sing services in agricultural communities Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 87 Questions to Guide the National Agenda so that they complement existing inter- vention programs? 2. How do we foster programs that utilize the existing infrastructure of or- ganizations, such as the Cooperative Extension System and the National Safety Council, to enhance our ability to make the most effective use of resourc- es available for intervention programs? What is the current status of safety features on farm equipment? New farm equipment being sold today has the latest state-of-the-art safety technology. When machines are used and maintained proper- ly, injuries and deaths from machinery- related accidents can drop dramatically. ROPS for tractors and tractor seat-belt use could prevent the majority of tractor-relat- ed deaths. Virtually all new tractors sold in the United States have ROPS. Because of the relatively long life of trac- tors, most agricultural tractors in use do not have ROPS in place. Nearly half of the approximately 400 tractor-related deaths that occur each year in this nation involve rollovers. How do we ensure that the older tractors and machines without these modern safety features get retrofitted with modern safety features when feasible or get taken out of use? The issue of how such updating and retrofitting is practical presents a significant challenge. I encourage us not to focus solely on trac- tor fatalities, though they have become a focus of considerable media attention. They account for only a small percentage of nonfatal injuries on farms, compared with traumatic injuries from other causes and chronic occupational illnesses. Engi- neering and safety standards have long been the primary method of injury control. Many manufacturers of agricultural equip- ment rely heavily upon the voluntary stan- dards of ASAE in equipment design when no mandated standards exist. The devel- opment and issuance of technical standards by ASAE has contributed strongly to inter- vention for many years. New standards and updates related to safety are constantly needed. What inter- vention programs do we need to ensure that the vast array of small manufacturers of farm equipment are aware of and comply with both mandatory and voluntary standards? Unlike the situation in many other in- dustries, the autonomy of the agricultural workplace can render many safety stan- dards useless as safety features are discard- ed or overridden. How will this problem be overcome? DEVELOPING INTERVENTION STRATEGIES Characteristics of Target Audiences How wide a net do we cast for our targets? Do we include forestry and logging? Food, feed, and fiber processing? Textile mills? Workers at fast-food chains? Food safety in general, which means all of us who eat? As a first level of how wide we cast our net, let us focus on the 3.32 million per- sons who work on the nation's farms and ranches. Nearly half of these people are self-employed farm operators. The bal- ance are unpaid workers (family), agricul- tural service employees, and workers hired directly by farm operators. What methods would work best for reaching farmers ? A recent study in New York State found that farmers and farm- 88 Papers and Proceedings workers, while acknowledging the need for health and safety, did not have time to may be possible if children do not ride on tractors. attend meetings. Radio, general farm magazines, and con- Studies of the cognitive versations with others are prime informa- physical tion sources. The Cooperative Extension limitations of children at various stages up Service received a very high rating as a through 15 years of age indicate that they source of health and safety information. are being put at risk through farm ac- tivities that they are asked to perform. A sizable share of the farm population is children. Accidents are the primary cause of death among children less than 15 years I have yet to see a farm safety awareness old in the United States as a whole and in or education program that did not stress farming. About 23,000 farm children are the danger of extra riders on tractors. This injured on farms each year. Why are these poses some important questions that need injuries occurring? to be applied to all agricultural safety and health problems. Partly, it is the generally risky nature of the farm environment and the fact that it Why are our safety warnings going un- is both home and office for farmers and heeded? Are we reaching and involving for their spouses and children. Often, the our targeted audiences sufficiently to economic realities of farming create a develop effective education and awareness dependence on children for labor. Fre- programs that change behavior? What will quently, either there is no adequate child be the most effective combination of en- care for them off the farm or it is too gineering controls, awareness, education, costly for farm families. These problems regulation, and enforcement to find exist for both the farm-operator family and solutions to each problem? the migrant-labor family. Studies of the cognitive physical limitations In a recent national survey, farmers of children at various stages up through 15 reported that they allowed their young years of age indicate that they are being children (aged 6-9 years) to ride on a trac- put at risk through farm activities that they tor, and as many as 29 percent of 7-9 year- are asked to perform. Their parents do olds were driving the tractor. Between not understand that risk potential. How ages 7 and 15, farm children were per- do we direct our educational efforts at forming a wide range of farm operations these target populations? Helping farmers with tractors. understand the developmental limitations of their children could significantly reduce When asked about risks of such behavior, child accidents and deaths on farms. farm parents surveyed saw a low accident- risk level for their children when they were Another target population is the estimated riding on a tractor the parent was operat- 3 million migrant and seasonal farmwork- ing or when the children were operating ers from many different ethnic groups. the tractor. As great as a 40 percent Children are about one-third of this popu- reduction in the farm fatalities to children lation. Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 89 Questions to Guide the National Agenda No comprehensive baseline health data exist for them. Some of their health problems and hazards are well documented. Others require much more investigation and research. Their need for a wide variety of education and social services is enormous. What are the unique demographic, cultural, and language prob- lems that must be overcome to provide effective intervention programs for this targeted audience? The average age of U.S. farm operators is 52, with 21 percent of farm operators 65 or older. Farm workers aged 65 and over have two to three times the injury rate of other age groups. Older workers are more vulnerable to injury due to decreases in sensory capabilities (hearing, vision, smell). They also may be suffering from several chronic occupational illnesses that have high incidence rates among farmers. This target audience offers unique challenges for effective intervention programs that reduce their risk of traumatic injury and prevent increasing the severity of existing health problems. What intervention programs are needed by audiences who have experienced an injury? Approximately 600,000 farmers have a disability that impedes their ability to per- form essential farming tasks. This group is also at high risk to further injury. Expanding upon several pilot programs, USDA's Extension Service, in cooperation with the National Easter Seal Society and other nonprofit disability organizations, recently launched an innovative program to help farmers with disabilities continue farming. such services as identification and referral of farmers with disabilities, on-the-farm technical assistance for modification of the workplace, and, agriculture-based educa- tion to prevent further injury and disability. Accident victims can be a powerful influ- ence in creating behavioral change. How can we more effectively involve these in- dividuals and the grassroots organizations they have created, such as Farm Safety for Just Kids? Should we target groups that are not em- ployed in agriculture or live on farms but may become victims of farm injuries? What are the risks to individuals that visit or provide services to farms? Approximately 40 percent of the fatalities that occur in confined-space agricultural accidents are attempted rescuers of farm accident victims. The Cooperative Exten- sion System has trained more than 17,000 professionals in farm accident extrication procedure and nonprofessionals in first-on- the-scene emergency response procedures. These programs are crucial to reducing the risk of injury to the rescuer, reducing the severity of the injury to the victim, and emphasizing the value of injury prevention. Approaches to Intervention Various approaches to intervention have been applied to agriculture. What do we know about the effectiveness of injury control strategies in the agricultural workplace? What new method emanating from the public health approach and hu- man factors engineering will be required to solve these problems. 3 How do we educate to achieve behavioral changes toward bet- ter agricultural safety and health? Many educational programs are in place. Extension agents, disability experts, rural professionals, and volunteers will offer 90 Papers and Proceedings We have our own, ranging from training of national strategy could rest on the belief persons who will be using restricted-use that the most effective preventive efforts pesticides to courses that instruct youth will emerge from a process that emphasiz- (14-15 years old) in operating tractors safe- es identifying and characterizing problem ly. Of the more than 23,000 Nebraska areas and populations at risk. youth that have completed the tractor certification training program conducted by The collaborative efforts of engineers, the Universitv of Nebraska Cooperative Extension Se&ice, only two havg died in ergonomists, safety professionals, industrial hygienists, and experts in biomechanics and tractor-related accidents. the behavioral sciences are needed to address the most compelling problem areas by studying what makes up workplace A national strategy could rest on the systems and the process, tasks, and tools belief that the most effective preventive involved. They must identify potential efforts will emerge from a process that causal mechanisms, opportunities for inter- emphasizes identifying and characterizing vention, and possible prevention strategies. problem areas and populations at risk. How will automatic ("passive") protection be used more in agriculture? Passive pro- How do we educate people to change tection is generally more effective than "active" measures requiring effort by each accident-causing or otherwise risQ worker. behavior? Simple identification of a public problem such as agricultural safety and health is not enough to allow the design Engineering controls are available for and development of successful remedial many known hazards but have not been systematically applied and evaluated. programs. "Passive" measures of prevention could Building meaningful people-involvement involve worker protective-system ventures into the realm of intelligent microenviron- into problem identification, program ments that feature sensors, microproces- development, and program delivery is essential. Failure to involve the real sors, adaptive protective mechanisms, and stakeholders (the farmers and display and imaging technology to protect, inform, and warn workers for hazardous farmworkers) dooms even the most out- conditions at their onset. standing programs to failure. The era of unshared decisionmaking is generally be- How do we ensure that the safety and hind us. health of the agricultural worker is not sacrificed for the sake of other issues? In Need for Collaboration considering common issues, such as selec- tive harvesting versus clearcutting in the What is required. 3 The attention, effort, forests, we need to be aware that selective and cooperation of individuals and organi- zations at every level of society, from this harvesting may be better for the environ- conference to our offices at home. Should ment but that it places the logger at a there be a national coalition to plan and to greater risk of injury than occurs in clearc- coordinate intervention programs? A utting using modern equipment. Can we engineer machines that allow selective Intervention for Agricultural Safety and Health, May 1, 1991 Surgeon General's Conference on Agricultural Safety and Health - 1991 91 Questions to Guide the National Agenda harvesting and that protect the workers using them? We must apply a systems approach that identifies the multiple benefits and feasibility of intervention methods. For example, closed-container mixing systems for pesticides not only protect the applica- tor from exposure to pesticides, but can also prevent ground water contamination and reduce the possibility of mixing errors. Communication of multiple benefits can be an effective means of creating a change in behavior. FUTURE FOCUS Let us look at success stories in agricul- tural safety and health. What data do we have on them? We know they exist. Prob- ably one of the greatest shortcomings of existing educational farm-safety programs is the lack of scientific evaluations of their effectiveness. We must conduct more comprehensive evaluations. We need more than simple, generalized descriptors- beyond age and sex of the victim, the time of year of accident, and its severity-for us to develop innovative engineering or educational countermeasures. Although more research and more data are needed to direct intervention, we know certain health and safety precautions work; ROPS work. Educational programs by the Extension System and others in health, hygiene, and pesticide use all have their successes in reaching our target audiences. Where do we need to go? We need to focus on injuries that often result in death or severe disability because of their impact on the family and the economic and social costs to society. We need to find workable solutions to tractor fatalities and to reduce and eliminate them, if possible. Tractor-related injuries are about one-third to one-half of all fatal farm injuries. This figure has changed little in 20 years. We also know that the youth and the aged were involved in a significant portion of total tractor injuries. We need to reach these target groups more effectively. Injuries that occur with high frequency and may be easily prevented should receive high priority, even if less severe in nature. For occupational illnesses, we can increase educational efforts in the use of common methods of worker protection from haz- ards and in the use of protective equip- ment and clothing. Some types of clothing and equipment, for example, can reduce exposure to many harmful agents. We need feasible engineering controls to re- duce vibrations, noise exposure, air con- taminants, and other harmful agents. We need to stop the decay of basic health services available in rural areas and to reverse this trend. I have raised many questions for your consideration both now and after you re- turn home. Your presence here today is testimony to the momentum building to address this issue. I think that we can find the answers to solving these problems through the collab- orative efforts of all of you. We can act on measures that we know work now and search for more effective intervention countermeasures. Safety and health are the right of every person involved in agri- culture. I wish us success in solving our agricultural health and safety problems.0 92 Papers and Proceedings Surgeon General's Confemnce on Agriculturel SaMy and Hem FAIWSAFE 2000 o A National Coalition kw Lout/ A&on Convened by the National Inst/tufe for Occupational Safety and Health April 30 - May 3, 1991, Des Moines, Iowa RURAL HEALTH POLICY By Jefiey Human, M.A. Director, Office of Rural Health Policy U.S. Public Health Service Surgeon General's Conference on Agricultural Safety and Health - 1991 93 Has this not been a terrific conference so far? We have outstanding attendance. We have had one excellent speaker after another. The commitment to improve agricultural safety and health has also been striking in these presentations. Groups like the National Coalition for Agricultural Safety and Health and the Farm Foundation have been working extra hours to form consensus on the national agenda we need to develop. This is a time of hope. One of the most interesting things about several of the presentations so far was the emphasis on the movie Field of Dreams, and its use as a metaphor of hope. I asked a city dweller last evening what movies urbanites relate to these days. ~ "Well," he said, "I'd include Deathwish, T i, Mean t Streets, and Escape from New ork." I think there is more hope in the country. This morning's Des Moines Re ' ter ran a nice story on Dr. Novello's sp ," ech, which I thought was a high point of thb meeting. What an anachronism to call her the "Sur- geon General." Her message makes it clear that she is both the "Pediatrician Generat" and the "Family Medicine General." And that is what we need in rural health. ~ Yesterday, everybody had a different ra $ `ng for agri- culture as a dangerous occup ion. It was first, second, third, and fourth'within an hour. Chris Atchison, and this morning, Dr. Bill Halperin seemed to me to have the best idea. Let us set up and run farm health and safety surveillance systems in all states as they do in Iowa. Let us keep track of injuries and deaths and let us export this record-keeping to the other states, so we can keep track on a national basis and so that we can intervene for prevention. We also need to educate the nation's public on the nature and extent of the dangers of farm work to get the assistance we need. It is very fitting that this meeting should be in Des Moines. It was in this city, in 1984, that the Des Moines Register won the Pulit- zer Prize for a series of articles entitled "A Harvest of Harm." Those articles argued, persuasively, that agriculture has become our most dangerous occupation. It was in Des Moines and Iowa City, in 1988, that Jim Merchant and Kelley Donham held a conference on agricultural health and safety; the conference led to the publication of Agricultzue at Risk: A Report to the Nation, a report that has brought the issues we are talking about today to the nation and to the Congress. The 1988 conference also led to the Ixma- tion of the National Coalition for Ag. icul- tural Safety and Health-a coalition that is continuing to keep these issues in the fore- front of national efforts to improve rural health; a coalition that has now integrated its work with the National Rural FIealth Association; a coalition whose work at Medical Intervention Problems and Opportunities raising consciousness made this meeting possible. Iowa's leaders have been very influential in other rural health endeavors. In the mid- 1980's, the administrators of small rural hospitals detailed the problems they were experiencing to the Congress. Don Dunn and Art Spies (who is with us today) of the Iowa Hospital Association, were among the chief spokespersons of the movement. The Iowa Congressional Delegation has been as united as any in the country in rural health advocacy. Senators Harkin and Grassley helped build a Senate Rural Health Caucus of 65 of the 100 members of the Senate, and they have delivered better-funded programs and new programs through the Senate Appropriations Com- mittee, on which they serve. Former Iowa Congressman Tom Tauka was the first co- chairman of the House Rural Health Care Coalition, which now has 165 of the 435 members of the House, including all of Iowa's Congressmen. There is one other Iowa leader we should speak of, but he is our next speaker. I will get to him soon. I am supposed to say something about the Office of Rural Health Policy, which I direct. We act as a voice of the rural constituency in the Department of Health and Human Services and coordinate its rural activities. So I come to meetings like this as much to listen as to speak.. Our primary responsibility is policy, but we also run some programs. For example, this year we will be making around 38 grants to states to help them establish or enlarge state Offices of Rural Health. These offic- es work like our federal offices but at the state level. I think they can be very effective in repre- senting rural constituencies in the state capitals, in working with communities and their health providers to solve local prob- lems, and in working with the farm com- munity on health and safety issues. This year, we will be making anywhere from 60 to 200 grants for local innovative health services programs or programs that support health professionals through edu- cation, telecommunications, or similar means. We expect several agricultural health and safety proposals. We fund seven rural health research cen- ters nationwide. All of them have some involvement in agricultural health and safety and one center-the Marshfield Med- ical Foundation-has agricultural health and safety as its principal emphasis. We heard about one of their projects yes- terday from Secretary Sullivan. It illus- trates the practical applied research I ask for from each center. When we looked at the tractor-rollover problem with Marshfield, we decided that there was no need for further research on the problem. What we decided we needed was a way to help farmers who wanted to retrofit older tractors with roll bars or other rollover protective devices to find those "ROPS," as they are called. So we asked Marshfield to develop and publish a catalog of all American manufac- turers of "ROPS," all products they pro- duce and what make of tractor, model of tractor, and year of tractor they will build. Then Marshfield sent the catalog to all extension agents in the country, so it is available where it is needed. 94 Papers and Proceedings Producing that catalog is not the best step we could take as a society. As we have seen in the slide on the Swedish experi- ence, the best step we could take would be to require "ROPS." But as an Office, it was the best we could do. We fund a national information center on rural health. It is a part of the U.S. De- partment of Agriculture and is within their National Agriculture Library. So if you want some rural health information, call l- 800-633-7701. The nice thing is that you can also get agricultural information or rural economic development at this same number. Add $24.95 and postage, and we will include all the hits of Boxcar WiZZie. That is l-800- 633-7701. Offer is not valid in Mexico or Canada. My own office is also a sort of information clearinghouse. In my presentations, I try to share ideas on the things that are hap- pening in the states and communities and in Washington that affect rural health. Thus, I talk around the country about the problems of rural health and about the potential solutions. For example, I tell state officials that they should train more nurses because we have a national rural nurse shortage. If they ask where to get the money, I suggest they cut back on training so many lawyers at taxpayer ex- pense. If we are short of nurses, we are short of essential health services for our people. If we grow short of lawyers, however, what are we short of? Essential lawsuits? Certainly with a few less lawyers we might have fewer malpractice suits. Seriously, let us confront conventional approaches and Rural Health Pblicy, May 1, 1991 make new choices with limited funds, choices that help solve rural health prob- lems. I tell people in other states about the package of programs offered to local sub- scribers by the University of Iowa's Insti- tute of Agricultural Medicine and Agricul- tural Health. I do not have time to tell you the specifics today, but I will mention three features of the program, which is based on a Swedish model. 1. It is hospital based and contributes to the viability of rural hospitals. That is important because 10 percent of all of America's rural hospitals closed their doors during the 1980's. 2. The program includes continuing medi- cal education for physicians. A 1979 survey showed that 70 percent of all medical schools offered no instruction in agricultural medicine. The other 30 percent offered an average of four hours of instruction during four years of medical school. The young physician new to an agricultural community may be baffled by pulmonary and cardiac conditions caused by agricultural dusts or chemicals. Ellen Widess' stories yesterday play out over and over again, and many times with worse endings when we do not prepare our physicians properly. 3. The program trains farm families to be responsible for their own health and safety. For example, they are shown how to make animal confinement hous- es safe for themselves and the animals. For more information, see Jim Mer- chant or Kelley Donham or David Pratt, who know more about these and other similar programs than I do. Surgeon General's Conference on Agricultural Safety and Health - 1991 95 Medical Intervention Problems and Opportunities I want to tell you about one last program. It is called "Stress Country Style," and it is in Illinois. A network of health workers throughout the state are available to help farm families. Farmers call an 800 num- ber, and help comes to them. There is no stigma because the encounter is private at the farm. Counseling is offered. Referral to mental health or debt consolidation or one of 100 other programs is offered. Oklahoma and Iowa have similar pro- grams. Seriously, let us confront conventional approaches and make new choices with limited funds, choices that help solve rural health problems. I We need more innovative stress reduction programs like these. In Ontario between 1979 and 1982, 95 of the 273 farm deaths were suicides, and the farm suicide rate has been documented to be high in this country as well. Mental health must be an important part of our national strategy. Incidentally, we need to place a special emphasis on teenagers when we look at mental health in the farm community. A survey by the University of Minnesota's Extension Service and the Medical School indicated that 5 of every 100 rural adoles- cents surveyed has attempted suicide with- in the past month. Nationally, the figure was 2 of 1,000. This was in the early 1980's during the height of the farm crisis, but other studies have shown pervasive high levels of depression among rural adolescents. I should also mention that our office pro- vides staffing for the National Advisory Committee on Rural Health. I have left some brochures about our office at the registration desk. If there are none left, call l-800-633-7701, and they will have us send you one.0 96 Papers and Proceedings Surgeon General's Conference on Agricuttud Safety and Health FARMSAFE 2000 o A National Coalition for Local Action Convened by the National Institute tit' Occupational W&y and Health April 30 - May 3, 1991, Des Moines, Iowa MEDICAL INTERVENTION PROBLEMS AND OPPORTUNITIES IN RURAL AREAS By Governor Robert D. Ray Chairman, National Advisory Committee on Rural Health Policy Mr. Jeffrey Human: My last assigned task is to introduce our next speaker. My honest impression is that Bob Ray is a real enigma. This is a guy who was elected to five terms as Governor of Iowa, and then found a life after politics on his own. He did not lose an electior+he quit. There was no scandal. He just left the political life. He wanted to try something new. This is almost unprecedent- ed in American politics. Then Bob went out and got jobs on his own and made a mark. He ran a successful insurance company, and now he is president of Blue Cross and Blue Shield of Iowa, with a million subscribers. He is not some absentee figurehead president either. A top official of Blue Cross nationwide tells me he has personally turned the program around in this state. Secretary Sullivan tcld us yesterday that Bob Ray is one of his advisors. Well, he should be, because Bob is chairman of the National Advisory Committee on Rural Health. That committee has provided Secretary Sullivan and the Congress with a series of challenging recommendations on rural health that have led to changes. For example, the Outreach program I told you about is partially a result of a recommendation of the committee. There is a great revival of interest in national health reform. There are many competing proposals. One of the best and most influential, based on universal insurance coverage, is from the National Leadership Commission on Health Care. The Commission's members read like a Who's Who in American health policy. The chairman is, of course, Bob Ray. Bob Ray also was a U.S. Delegate to the United Nations and former chairman of the Indochinese Refugee Panel, providing leadership in efforts to resettle Vietnamese and Cambodian refugees. Bob is a graduate of Drake University's Law School, and he has a lot of honorary degrees and distinc- tions. Those of us who work with him and for him with the National Advisory Committee on Rural Health have discovered more important things about Bob. We have found him to be intelligent, funny, caring, realistic, charming, articulate, and an excellent leader. He is one of the best listeners I have ever met. He knows more about health care than most of us. It is a pleasure to introduce one of America's great leaders, Robert D. Ray: Jeff, thank you. Thank you very much. I just learned a great deal about Jeff Hu- man. I have always admired him and his talent and his ability and I have watched him in Washington, knowing that he is not just a bureaucrat. He is a person with tremendous compassion and understanding of people, their needs, and their problems. Jeff, what I did not know about you is how flexible you can be. You have talked to us about education; you have talked to us about tractors; you have talked to us about Federal programs; you have talked to us about Boxcar WiZZie; and you have talked to us about me. I am here to tell you that I am sure thankful I do not practice law anymore. I am not sure I should have been invited to speak to you today at all because I am not sure of my own commitments. There is probably no one who is working harder or who believes more that we should hold down health care costs than I. Earlier this year, I was in an automobile accident and was taken to the emergency room. I was laying there flat on the slab and looking up, and two white spotlights were shining down on me. It was very, very warm and very comfortable. Surgeon General's Conference on Agricultural Safety and Health - 1991 97 Medical Intervention Problems and Opportunities I felt pretty good about that, but then I looked kind of from one side to the other, and I saw these green things running around. There were doctors standing here and there. Once in awhile one would lean over and look at me, and I would look at him. The funny thing about it is that never one time did I look up and say, "How much is it going to cost, Doctor?" And so there are conflicts within all of us. We want the best health care system possi- ble. We do not always want to pay for it. We believe that there are ways in which we can cut and save-but not on the service that we get. So, it is very difficult when we talk about what is needed and what is doable. If at first blush you think it is just overwhelming and impossible, you would quit. Then when you realize that things do hap- pen-maybe slowly, but they do happen. There is always change going around. Maybe the change will inure to a system that we want to change. That is the reason it has been exciting to me to work with Jeff Human and the people in Washington and DHHS. Some of the business people and the major leaders of this country are trying to do something about health care. We have long learned that you can not do some- thing about cost alone because if you con- trol cost, you reduce access. You cannot do something about quality of care alone, even though that, by itself, might reduce health care costs 30 or 40 percent, because it costs money to do cer- t ain things. You cannot just provide more access for everybody without affecting costs and qual- ity. So we have to deal with all of those aspects of health care and the health care delivery system together. I think that it is awfully easy for us in the rural areas to be neglected because we do not have the votes they have in the big states: California, how many congressmen do they now have? New York? It has been very impressive, what has hap- pened in Congress over the last several years. Jeff already mentioned how many members belong to the House Coalition on Rural Health. So, a lot of good things have happened, and our advisory commit- tee, I think, has had some influence, some impact, and I am pleased to be associated with them. I am pleased that the Surgeon General decided that we should have this confer- ence and that our senators endorsed it, and Tom Harkin helped to get it here in the State of Iowa. There is no better place we could have a conference on rural health than right here in the State of Iowa. I think we ought to have one of these every 50 years. An awful lot has happened to change the landscape of American health care during this past 50 years. Advances in technology and the proliferation of medical specialties allow us to live longer and healthier lives. That is good. But unfortunately, farm families, farm workers, and rural farming communities do not share equally in all of this achievement with our neighbors in urban areas. This conference is very timely, and I am pleased that it is here in the State of Iowa. And I want to thank the Surgeon General for being here. 98 Papers and Proceedings Medical Intervention Problems and Opportunities in Rural Areas, May 1, 1991 There are so many people that I would like to acknowledge on the federal level, on the state level, and on the regional level-our Senators, Congressmen, Dr. Donham and Dr. Merchant, and the list goes on and on. I am going to save you-spare you-the time that it will take do that. to Let it suffice to say, I truly appreciate what you are doing because this is important- not just to those people who live on farms, but even those who live in small towns; it is important to every one of us. I will get back to that. The diverse groups of people like yourself who focus specifically on rural health at this conference give us a unique chance to build and strengthen active, vital, rural health networks. It offers the opportunity to develop links between the researchers and the health professionals, between health professionals and extension agents, between extension agents and surveillance experts, and between surveillance experts and researchers. The list goes on and on; you get the picture. We just finished a rather tasty meal. You have probably had better; you have un- doubtedly had worse, but by most stan- dards, let me tell you, there are people in this world who have never, ever had a meal that good. Let me give you some food for thought. Just stop and pause and reflect for a mo- ment with me about who produced that food. I am not talking about the culinary part, the chefs part, but about the people who provided the labor and the risk and the sacrifice that we enjoyed at noon: we are spoiled. We in this country try to decrease the calories that we eat, while the rest of the world measures growth and progress by the increase in calories their people eat. Our farmers only get a very small fraction of what we spend for food. They get 4 cents for the wheat that goes into a loaf of bread, which costs roughly a dollar and a quarter. They get 5 cents for the corn that goes into a 7-ounce box of corn flakes, which sells for a dollar and a quarter. We in this country spend a smaller percent of personal income on food than any other civilized country. You people pay, on the average, 11.9 percent of your personal income for food. It was 18 percent in 1959. It has been reduced. Yet, in other countries, like the European countries, they are paying around 17 per- cent; Japan, 19 percent; the Soviet Union, 28 percent; India, 54 percent; China, 48 percent. We have a bargain. Look at what is happening in the Soviet Union. During our lifetime we have grown up knowing about two superpowers-one the United States of America and the other the Soviet Union. Today the Soviet people stand in lines for hours. You see them on television. You can watch them-waiting for a little piece of bread that they cannot even afford. Add to that the fact that the suicide rate for farmers is now 30 to 40 percent above the national non-farm rate. L We are fortunate, yet we take it all for granted. Our farmers produced the food that the chef prepared for us today, but they did it accepting some risk: the possi- Surgeon General's Conference on Agricultural Safety and Health - 1991 99 Medical Intervention Problems and Opportunities bility of an untimely death or serious injury or acute or chronic illness-all of that-while they were growing the food and raising it. RURAL STATISTICS Earlier at this conference, if I understand correctly, you heard some alarming statis- tics. Let me briefly reiterate what I think some of them were. Although farmers and farmworkers com- prise only 3 percent of the work force, they suffered 14 percent of work-related deaths, according to National Safety Council fig- ures. Agriculture, as you heard just a moment ago, precedes mining now as the most hazardous occupation. Unlike mining, where the death rates have been decreasing, agriculture mortality rates have remained consistently high during this past decade. The fatality rate in farm work is five times the average for all U.S. industry-five times. Researchers have discovered that midwest- ern farmers have a higher-than-normal chance of dying of leukemia. The cause is uncertain. Some experts fear an unusual incidence of leukemia is linked to the use of modern pesticides in raising corn. A serious new hazard known as "hog lung" is also one of the by-products of the mod- ern system of raising hogs in confinement. In a half-dozen or more of our cities, water supplies contain greater than acceptable amounts of pesticides and other synthetic organic chemicals. Millions of rural poor people are risking health problems because of substantially substandard diets. That problem is attrib- uted to the pride of rural poor who are unwilling to accept food stamps and other assistance. These numbers do not even take into account all the children who die each year in farm-related activities. In addition to deaths, there are 130,000 to 170,000 disabling farm injuries every year. These injuries entail an enormous hospital rehabilitation cost, and nearly half of all survivors of serious farm trauma are per- manently impaired. Add to that the fact that the suicide rate for farmers is now 30 to 40 percent above the national non-farm rate. Jeff just gave you some other information about that fact. He mentioned that I had served as a representative to the United Nations. When I was there, I found myself frequently talking to those of other coun- tries, and especially Africans, who no lon- ger could produce enough food for their own people. They had joined a crowd of socialized countries, and soon learned that they just could not produce food like they used to. They liked talking to me because they knew that I came from the State of Iowa, one of the best farm states in the country, in the world. We spent hours talking about how our farmers could produce food better than anybody in the world. I believe that we could help them. We used to talk about how we might do that. One day I was telling them about how wonderful our farmers were and how well they could produce food. Then, the very next day, I picked up the New York Times and there on the front page was a dateline story from Spencer, Iowa; and this is a quote, "More suicides on Iowa farms." I just hoped that my friends I talked to the 700 Papers and Proceedings