|Guide to Health and Hygiene in Agricultural Work (ILO, 1979, 328 p.)|
|6. Organisation of occupational health services and medical inspection of labour in agriculture|
|6.2. Practical organisation of agricultural health services|
Agricultural health services are governed by the general principles for occupational health services drawn up by the Joint ILO/WHO Committee on Occupational Health, with due allowance being made for the special nature of agricultural work.
As mentioned above, agricultural health services should be organised according to local conditions and needs. The type of service provided will therefore be based on as exact a knowledge as possible of these conditions and needs and of likely future developments.
In the first place, it is essential to ascertain as precisely as possible the number of full- and part-time workers, both permanent and temporary. This figure will include women and children, as well as those doing industrial work followed or preceded on the same day or during the same week by agricultural work. Inevitably, it will be virtually impossible to arrive at an exact figure, but information that is even approximately correct will be useful. It will also be necessary to know the number of persons needing medical supervision, and where they are to be found.
In the second place, the hazards to which workers in a particular area are exposed must also be ascertained. This is a very difficult task. However, fairly reliable results may be obtained with the co-operation of the various organisations which are in a position to know these risks-for instance, the service organisations (fire, civil protection, health and first-aid) and other bodies such as insurance institutions, if any.
While serious accidents, acute poisoning or the effects of particularly adverse working conditions are likely to leave clearly visible effects from which the degree of risk can be assessed, other hazards are difficult to evaluate (chronic conditions due to noise, vibration, cumulative poisoning, and so on).
Some form of administrative organisation for the reporting of risks is indispensable. This should cover all the aspects involved and be equipped to undertake statistical analysis. However, such organisations are often lacking in one respect or another, where they exist at all.
The attention of the medical profession should be drawn to the possible existence of chronic risks, since these often escape notice and, when discovered, are not reported to a competent authority qualified to assess them.
The same is true of epidemiological information, of which there is a world-wide lack. Admittedly, some of the chief epidemic or endemic diseases have been studied; but in all countries, even those with high sanitary standards, epidemiological research has been generally neglected. Investigations should be conducted at the local, regional, national and even international levels. As well as studying pathology in man and beast, the investigators may expect to discover reservoirs of infection in man, in domestic and wild animals and in the ecological environment, together with the vectors capable of transmitting infection. These specialised investigations could either be confined to one disease and cover a fairly large area or be confined to a small area and extend to all possible diseases. Their organisation calls for considerable resources and the co-operation of all the specialists taking part, and their preparation must be psychological, administrative and technical.
The purpose of psychological preparation is to draw the attention of the public authorities and the population at large to the importance of the investigation and the need for it, to persuade the authorities to give the investigators all the help they require, and to persuade the public to submit willingly to all the questionnaires and samplings to which they will be subjected. The population should be prepared by a campaign mounted by the health services (administrators, doctors, veterinary surgeons, social assistants), by propaganda in meetings and in villages, by the regional press and radio, and by various audio-visual demonstrations presented by educational or occupational bodies.
The administrative preparation involves approaches to ministries and subordinate organisations, to prominent persons or representatives of the people, and to educational, trade union and religious authorities.
The technical preparation comprises the mobilisation of the necessary staff and equipment. In addition to a permanent secretariat, the staff will consist of permanent technical personnel (bacteriologists, virologists, parasitologists, doctors or veterinary surgeons, ecologists (mammalogists, entomologists)) and tem- porary technical personnel (botanists, pedologists, climatologists, psychosociologists, economists, accident prevention specialists, industrial hygienists).
Financial resources should be made available for the necessary research equipment (sampling apparatus, marking apparatus, travelling laboratory) and the laboratories which are to examine the samples taken. These should be chosen for their competence and geographical location.
The investigation will include a general survey of the region, classifying its geographical, geological, cadastral, demographic, economic, social and medical features. Research may be planned and the human and animal diseases of the region explored on the basis of the findings of the survey. The actual study will consist of clinical examinations of people and animals, paraclinical investigations (allergies, radiological examinations, and so on) and sample-taking from people and domestic and wild animals (a carefully completed record card should accompany each sample).
The appropriate season should be chosen for each investigation according to its nature, and provision should be made for repeating the examination if necessary.
This epidemiological investigation can serve as a model for general health, traumatic and toxological investigations.
Of course, such investigations call for sizeable resources, and not all of them can be undertaken; but they may become possible in the future, little by little, depending on the resources available in the countries concerned. Even investigations of limited scope will furnish a wealth of information.
As part of the preliminary inquiries to be made before agricultural health services are established, it will be necessary to study the labour legislation in force, as regards the possibility of extending it effectively to agricultural workers, and to provide for the amendments and additions needed for the administration of agricultural health services. It will also be necessary to draw up an inventory of all the existing medical, veterinary and health services and their activities, as well as a census of other related professional and auxiliary personnel available to deal with the problems of agricultural medicine. Naturally, none of these activities can be undertaken unless adequate financial resources are available. The scale of the activities will clearly have to be adapted to the funds at the investigators' disposal.
Role of occupational health services
The role of occupational health services is considered in the ILO's Occupational Health Services Recommendation, 1959. The following paragraphs take account of the particular features of agricultural work in this connection.
Pre-employment, periodic and special medical examinations (biological, radiological, etc.). Workers should be medically examined on engagement and at yearly intervals thereafter, except for certain classes of workers, such as pregnant women, young persons, workers exposed to special risks and others in special circumstances, for whom the doctor will decide the appropriate periodicity. Examinations should also be made on the resumption of work after an absence due to illness or accident. In this way, the doctor will be able to gain an idea of a person's state of health and, being aware of his working conditions, to advise him as to the kind of work best suited to him. The examinations should make it possible to diagnose troubles in their initial stages, to see whether satisfactory preventive measures have been taken, and if necessary to assign the worker to another job.
However, changes of job, although easy to arrange in large enterprises, are much more difficult in small family undertakings. In such cases, it is advisable to consider carefully the possibility of transferring the worker to another occupation, with due regard being had to his physical and mental aptitudes and the state of the labour market.
Surveillance of the working environment. It is obvious that a doctor who has to judge the aptitude of persons for certain jobs, and to supervise them medically in the light of the risks to which they are exposed, must be familiar with their working conditions. Job analysis is an essential part of the doctor's work, enabling him to advise the technicians on the methods to be employed to avoid risks (handling of poisons, contagion risks, and so on). He should also check that the personal protective measures recommended have been applied (clothing, respirators, and so on).
Prevention of accidents. In agriculture, the proportion of occupational accidents attributable to the human factor is particularly high. It is essential that the agricultural health service should help actively to instil the safety spirit in the workers by seeing that personal protective equipment is properly used and maintained and by encouraging the adoption of appropriate safety measures. first aid. In view of the difficulties of establishing effective first-aid services in a rural environment, the role of the agricultural health service should include initial and regular subsequent training of first-aid personnel.
Health protection measures. The closer the agricultural health service is to the workers, the easier it will be for it to advise on health measures, whether these measures are concerned with investigations or with the organisation of prevention against scourges such as tuberculosis or malaria. The rural doctor can protect people against certain risks by active immunisation (for example, vaccination against tetanus) or by chemotherapy (for example, distribution of quinine derivatives in malarial zones.)
Surveillance of the hygiene of sanitary installations. The doctor must be an adviser in matters of hygiene and health. He should inspect the workers' housing and the various sanitary installations (water supply, shower baths, drains, latrines, and so on). The inspections will also provide opportunities for educating workers in health and hygiene.
Consultations on health problems. In the event of occupational or other disorders, agricultural workers should be encouraged to go to the agricultural health service for information on any questions of health or hygiene. Such personal contacts will increase when the doctor has been able to gain the confidence of those in his care, and they will be extremely useful for the prevention of risks and for the promotion of health education, especially as regards nutrition.
Medical treatment. The rural doctor might participate in the treatment of mild conditions. However, if medical aid is difficult to obtain, the doctor may be allowed to give any necessary treatment to agricultural workers and their families.
Health education. The doctor has a major role to play in educational health programmes, as regards both general health problems (general hygiene, nutrition, and so on) and problems relating to occupational hazards and the protection of workers. He should maintain close contact with all the different bodies concerned with questions of the farmers' health, safety and welfare in rural areas, as well as provide direct advice on occupational health in agriculture.
Co-operation with other medical services. The doctor must not work in isolation from other medical services. He must rather establish contact with other kinds of preventive medical services (health agencies, school and sports medical services, and so on). He must meet other practising doctors and visit hospitals and supervisory medical services (participation in inquiries into occupational accidents and diseases, furnishing opinions on resumption of work jointly with medical inspectors, of insurance institutions).
Agricultural health services must be operated in close co-operation with the local veterinary services, practitioners and/or administrators in order to deal with zoonoses, and with agricultural technicians and labour inspectors.
Records. It is essential that records be kept up to date if the agricultural health service is to function efficiently. This is all the more important if the doctor is to monitor a worker's state of health and to follow its evolution, particularly as regards chronic affections and cumulative poisons.
The statistical processing of records by a central organisation would make it possible to undertake comparative studies at the regional, national and international levels. This is particularly so if the health services are to take part in research (inquiries, specialised examinations) and in education.
The number of qualified medical personnel available determines the way in which agricultural health services may be operated:
(1) In countries where there are enough doctors (say, one doctor for every 800 inhabitants, with the term "doctor" covering both general and specialist practitioners and supervisory and preventive personnel), provision may be made for occupational health doctors specialising exclusively in agricultural medicine.
(2) In countries where there are not enough doctors but where there is no serious shortage, an agricultural health service may be incorporated in a system of preventive medicine serving the population among which the doctor concerned works (e.g. public health service, industrial medical service).
(3) In countries where there is a chronic shortage of doctors, which unfortunately is the commonest case (it is estimated that about two-thirds of the world's population have no means of obtaining adequate medical treatment), the agricultural doctor may consider participating in the treatment of workers and their families.
Fixed or itinerant medical installations may be provided, according to the density and the distribution of the population of agricultural workers. Fixed installations are to be preferred, because better health services can be provided than with itinerant installations, with, at the same time, minimal restrictions on the occupational health doctor.
Characteristics of a health service
Two basic conditions are essential for the organisation of a successful health service. First, the doctor must be competent. His competence in handling the problems of occupational health in agriculture can be enhanced through specialised educational programmes that take account of the continuing evolution of agricultural technology. Second, the doctor must have sufficient time in which to practise agricultural medicine. Ideally, the maximum workload for a full-time doctor would be 3,000 workers.
The doctor must, of course, be provided with the installations and equipment needed for his work, as well as the necessary nursing staff, secretarial staff and possibly social staff in support.
Type of organisation
Agricultural health services can be organised either on a geographical or on an occupational basis. Obviously, the greater the degree of specialisation, the greater the efficacy of the service, since the doctor will not have to be a specialist in so many areas.
However, apart from a few exceptions (large undertakings, single-crop areas), it is practically impossible for an occupational health doctor to specialise in agricultural medicine. Sometimes, even in rural areas, artisans and tradesmen for whom there is no suitable occupational health service available can be cared for by the agricultural health service. Nevertheless, when feasible, specialisation in agricultural medicine is to be preferred.
In many countries, agricultural workers constitute only a small proportion of the wage-earning population. Farmers may reasonably be asked to help to finance agricultural health services from which they benefit. It is, however, unlikely that agricultural health services would be set up by private initiative.