When cardiologist Dean Emanuel first practiced at the Marshfield (Wis.) Clinic half a century ago, farmers continually came to the outpatient facility with symptoms of a poorly understood condition called farmer's lung disease.
The year was 1959, and Emanuel and his colleagues at the clinic in the small central Wisconsin town received a grant from the National Institutes of Health to investigate the mysterious malady. After about five years of research, they determined that the pneumonia-like illness was a delayed allergic reaction to certain molds commonly found in hay, grain and silage. After about five attacks the disease can produce permanent damage to the lungs and fibrosis, or scarring, that can be deadly.
"This is a mold that is ubiquitous in the farming industry," says Emanuel, who is also board-certified in internal medicine. "We determined that this was not always a totally disabling disease if the farmer could change his occupation. Later on, we determined that was not necessary, if he took some protective measure to shield his lungs" by using a respiratory face mask. And after that, the Marshfield researchers identified the organisms that caused the condition. "Very definitely, we made an impact," he adds, noting that the clinic is seeing far fewer cases now because of preventive measures and changes in agriculture.
A clinic is born
During the next couple of decades, Emanuel and others at the Marshfield Clinic began to notice other conditions that, while not exclusive to farming, cropped up consistently, ranging from skin cancer caused by incessant exposure to ultraviolet rays, to osteoarthritis from the wear-and-tear on joints from various aspects of farm work. In 1981, they pooled their research efforts on these topics and established the National Farm Medicine Center, which was initially supported solely through the parent Marshfield Clinic Research Foundation.
One of only two such agricultural research centers at the time of its founding, along with what's now called the Great Plains Center for Agricultural Safety and Health at the University of Iowa at Iowa City, the center had a $2.26 million budget in fiscal 2004, two-thirds of which came from grants and contracts, 19% from the clinic research foundation and 15% from restricted donations. No federal funds were used in founding the center.
"We realized that there were other diseases present in the agricultural community that we were just not addressing," says Emanuel, now 82, who retired in 1986 as founding director of the center. "We realized this was a population at risk, and we had to do something about it. (The conditions) are just especially prominent in the agricultural community."
In addition to the occupational hazards farmers face-such as stampeding animals, tractor rollovers and limbs severed after clothing gets caught in high-powered machinery-the farming population is at risk because it's reluctant to seek medical care, Emanuel says. "This is a highly independent population we're dealing with," he says. "They're extremely well-motivated, they're hardworking, and they just don't run to the doctor every time they have something wrong with them."
That's partly because an estimated one-quarter of the nation's 6 million farmers lack health insurance and many others have high deductibles, says Steven Kirkhorn, the center's medical director.
"You find a lot of working poor who are struggling to make ends meet," says Pete Stamas, an emergency medicine specialist whose department ends up seeing many of those who delay care. "They may not have finances for healthcare. People aren't established with a doctor. Who's going to pay their healthcare bills but themselves?"
Marshfield Clinic physicians, who number about 740 in the main facility and 39 regional centers in Wisconsin, become involved in research as clinical needs warrant, Kirkhorn says. "Practitioners develop an interest based on what they see coming into the clinic-seeing people who had an arm amputated on a corn picker, or somebody who has asthma and was having difficulty continuing to farm," he says.
The Marshfield Clinic benefits from the farm center's research in treating patients from its largely rural, 27-county service area in central, northern and western Wisconsin, says Reed Hall, executive director of the clinic, which treated about 365,000 patients from all 50 states and 25 foreign countries in 2003.
Based on patient survey results as well as anecdotal feedback, Hall says patients flock from such distances because of the Marshfield Clinic's Mayo Clinic-like group practice concept, with "so many specialists in one place and the ease of referrals" that results, as well as to tap the clinic's particular strengths in cardiology, cardiovascular surgery, oncology, neurology, neurosurgery and orthopedics.
"Our primary emphasis is rural Wisconsin-that involves taking care of many patients who live in rural areas or directly on farms," says Hall, who could not put a figure on exactly how many patients came from farms. "We do not record that vocational data. It's a substantial number, I know, just because of our service area."
Stamas echoes that assessment, adding that planting and harvest seasons tend to be the busiest times. "You're probably exposed to the larger, heavier pieces of equipment," he says. "Weather can be inclement-you've got to make hay when the sun shines. And you might be out there 16, 18 hours. Fatigue will play into the picture."
The farm center and other facilities, such as the Rural Cancer Research Center within the research foundation, also likely benefit the clinic and its physicians through their focus on preventive medicine, Hall says. "Hopefully it's led to more safety in the farming community, whether it's avoidance of skin cancer or avoidance of hearing loss," he says. "Those are things that are tough to measure, but hope-fully over decades we're avoiding disease."
With funding from the federal and state governments, donations and the Marshfield Clinic Research Foundation, the farm center has focused on an ever-changing set of issues, says the center's director Barbara Lee, a registered nurse who holds a doctorate in nursing. She became the center's first full-time employee 18 years ago and rose to director four years ago, now supervising a staff of 20 as well as clinic physicians who undertake pieces of research related to their respective practices.
Lee says that after the initial focus on farmer's lung disease, the center turned to tracking farmers admitted to the clinic's emergency room to study the types of injuries they experienced, how severe they were, how often they occurred and the likely precipitating factors. That work remains relevant to this day, Stamas says. "A week doesn't go by that we don't see some sort of agricultural injury," he says.
At the same time, the center has worked to train emergency rescue teams on the "unique aspects of responding to a farm emergency," Lee says, so the rescuers themselves do not, for example, succumb to micro-organisms or noxious gases such as deadly hydrogen sulfide near manure pits, another common risk on farms. That training "was extremely popular for a number of years," Stamas says, and Lee adds that it's only done "periodically" now because registrations have fallen somewhat.
New focus on cancer
The center's "third big wave" of research, which began in the early 1990s and was spun off as a separate business unit several years ago, focuses on common rural cancers, Lee says. "We took a look at what are the types of cancers that are more common in the farming community, and what is the effect of screening," she says. Among the specifics of this initiative have been skin-cancer screening booths at farming festivals, she says.
The now-separate Rural Cancer Research Center has turned the microscope on prostate, lung, colon, brain and lymph cancers, says Doug Reding, a medical oncologist and the center's director. "It's recognized that farmers are at higher risk for skin cancer," he says. "There's a perception that prostate cancer is higher. We're trying to tease out from our numbers, `Is it just a lot of older men in farming?' "
Since the late 1990s, the farm center's largest effort-currently representing about half of its budget-has been the National Children's Center for Rural and Agricultural Health and Safety. The children's center receives funding mostly from the National Institute for Occupational Safety and Health, or NIOSH, an agency of the national Centers for Disease Control and Prevention, which funds 10 agriculture-related health centers.
"There's a lot of childhood exposure to injury that you don't have in a lot of other situations," Stamas says. "These kids are out driving tractors at young ages; they're out milking cows at young ages. They have potential for injury."
Among the work products of the children's center has been the National Guidelines for Children's Agricultural Tasks, released in 1999, which details what work makes developmental sense for older children; as well as the workbook, Creating Safe Play Areas on Farms, released in 2003, which encourages parents to keep younger children away from work-site hazards, Lee says. "Most people do not have any concept of what, if anything, is acceptable for kids to play on," she says, noting that the center's work often challenges rural cultural norms. "We ourselves fought it for a long time and said it was just better to get them off the farm, and don't structure a play area. But working in the real world of farm parents, we were able to come up with some nice compromises."
NIOSH sees the farm center as an important partner in distributing information about childhood agricultural injury prevention, says David Hard, an agricultural safety and health scientist and program officer at the children's center.
"I view them as being important because they probably have a more direct link to the stakeholder base than any federal agency probably would have," Hard says. "The National Farm Medicine Center has a long history of working in agricultural diseases, and I think they've done good work. I see the children's center as continuing on in that, in a more focused area."
Beyond the children's center, the other half of the farm center's bailiwick is split into three areas of study covering agromedicine, agricultural-safety engineering and environmental microbiology, Lee says. The first two are primarily funded through the clinic's foundation, while the third receives grants from the federal Environmental Protection Agency and the state of Wisconsin, she says.
The agromedicine work, led by Kirkhorn, focuses heavily on educating healthcare providers in how to recognize and treat farm-related maladies, he says. "Agricultural injuries or illnesses come in sporadically," he says. "Nobody sees a lot of it, and anything you see, you don't see a lot of, so people aren't aware of how to treat it, and, just as importantly, how do you prevent it from happening again?"
Mark Purschwitz, a research engineer at the farm center, who handles the agricultural-safety projects, says he's recently been working on a survey of employers and supervisors of youth farm workers, ongoing research on tractor safety and the financial feasibility of retrofitting older tractors with rollover-protection structures, and updating an online directory of resources on how to do so.
Mark Borchardt, a research scientist and director of the farm center's environmental microbiology lab, says he's published studies in the past few years showing that the vast extent of waterborne gastrointestinal viruses in the drinking water of LaCrosse, Wis., was not a problem directly traceable to farms but was a significant rural-health issue nonetheless; the occurrence of such viruses in private drinking wells, which could point to the need for greater groundwater regulation; and the links between septic system density and childhood diarrhea, which he also hopes will lead to changes in environmental policies.
Ed Finkel is a freelance writer based in Evanston, Ill. He can be reached at [email protected]
This article marks the debut of Modern Healthcare's new quarterly feature on rural healthcare issues. Let us know what you think. To share comments or suggest ideas for future Rural Health stories, contact us by e-mail or fax. Write Modern Healthcare online via [email protected]; by fax it's 312-280-3183.