|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|
The Joint ILO/WHO Committee on Occupational Health has given the following broad definition of occupational health:
Occupational health should aim at: the promotion and maintenance of the highest degree of physical, mental and social well-being of workers in all occupations; the prevention among workers of departures from health caused by their working conditions; the protection of workers in their employment from risks resulting from factors adverse to health; the placing and maintenance of the worker in an occupational environment adapted to his physiological and psychological equipment and, to summarise: the adaptation of work to man and of each man to his job.1
1 Joint ILO/WHO Committee on Occupational Health: Second report. Technical report series, No. 66 (Geneva, World Health Organization, 1953), p. 4.
There are two main reasons why it is essential to organise occupational health services in agriculture: first, a large proportion (and, in many countries, the majority) of the working population consists of agricultural workers; and second, technical progress in agriculture throughout the world (development of mechanisation, increased use of chemicals, concentration of livestock) has considerably increased occupational risks.
However, the organisation of occupational health services in agriculture is influenced by a number of factors peculiar to the rural environment and to the particular nature of agricultural work:
(1) Unlike industrial workers, agricultural workers are usually dispersed in remote rural areas where public services generally may be insufficient. However, although this dispersal is characteristic of agriculture, its importance should not be exaggerated. Concentrations do exist in agriculture, the most striking examples being the large plantations of cotton, tea, fruit trees, and so on. Moreover, although the dispersal of workers makes it difficult to organise occupational health services, it is not an insurmountable obstacle, as the satisfactory situation in the building industry shows.
(2) A wide variety of jobs are performed by the agricultural worker, especially in small undertakings. Nevertheless, there is a similar variety in other industries and this has not hampered the organisation of occupational health services.
(3) For the most part, the work is done in the open air and consequently the worker is exposed to all weathers.
(4) In all countries, the agricultural environment suffers from a certain technical backwardness as compared with the industrial environment. Tradition in agriculture often hampers the application of modern techniques, of which occupational health services are only one example.
(5) Although new forms of work organisation have made considerable progress in agriculture, the fact that the performance of agricultural work is so dependent on weather conditions is a considerable obstacle to more efficient operation. Thus, while the speed of a production line in industry can be accurately planned, a sudden change in the weather-a rainstorm, for example-will compel the farmer either to work faster or to stop working altogether. Moreover, these changes in the weather can sometimes completely alter working conditions: for instance, plans for the application of pesticides in favourable conditions will be upset if a sudden wind springs up from the wrong quarter-the favourable conditions become both difficult and dangerous.
(6) The agricultural worker's private life and his working life are often interwoven. In certain kinds of undertaking it may be possible to separate the two; however, in most cases the existing situation seems likely to continue for many years to come. Furthermore, as agricultural work is carried on in the countryside, it is subject to the risks inherent in a rural environment, with the workers being dependent on the general standard of public health in such matters as the provision of an adequate water supply and protection against vermin and insects. These factors have a considerable bearing on the health problems of a particular area.
(7) Agricultural work is very often a family affair, and sometimes all the worker's family-children, women, old people-share in it to a greater or lesser extent. The absolute necessity to care for these people modifies the traditional form of occupational health services, which are generally intended for the workers alone.
These and other factors peculiar to agricultural work fully justify the organisation of agricultural health services. Their nature will, however, vary according to the country, the district, the local crops and the method of growing a particular crop. It is impossible to deal here with the needs of each special case, from the large undertaking to the small family farm, but an attempt will be made to establish the general principles which should be observed in order to improve the working and living conditions of the agricultural worker.
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.
1 See also ILO: The role of medical inspection of labour (Geneva, 1968)
Experience has shown that, even in countries where legislation on occupational health exists, it is not always applied according to its expressed aims. Sometimes employers and workers, either because of the pressure of production or because of their failure to understand the importance of occupational health-the significance of which has not always been fully appreciated, perhaps because of its relatively recent creation-have not been too keen on submitting to medical examination, or have made the doctor's task more difficult.
Since occupational health in agriculture is a comparatively new discipline, many subjects are obviously still very imperfectly understood. The co-ordination of investigations into a particular morbid condition or the working conditions of a particular agricultural occupation can be extremely useful in filling some of the gaps in knowledge. There is no doubt that a medical inspectorate should work in close collaboration with the universities to this end. Moreover, a university is particularly well equipped to undertake certain investigations. Its relationship with the inspectorate will enable it to direct its research work towards the most current and urgent problems.
We may consider an inspectorate as being responsible for a certain geographical region, so that it gains an idea of the different problems of that region. However, since inspectors should have the same qualifications as practising doctors, it would be extremely difficult for them to be specialists in all areas of medical knowledge, if only because of the range and complexity of medical science. Hence, the regional inspectorate should be backed up by a general inspectorate which would not only co-ordinate all the regional inspectorates but also maintain a staff of specialists for matters such as accidents, poisonings and zoonoses. The general inspectorate would thus be able to advise practising doctors or to undertake specialised investigations with a good chance of success.
Under which administrative authority should a medical inspectorate of agricultural labour be placed? Possible authorities are the ministry of agriculture, the ministry of labour or the ministry of health. The answer to the question depends largely on the national administrative policy of the country concerned. What is essential is that a competent medical inspectorate should exist.
One of the distinguishing features of agriculture is that it is carried on in an essentially rural environment where working and living conditions are often closely interwoven. It is therefore necessary to provide the agricultural population with suitable education in hygiene. Hence, agricultural technicians and health officials should have received some training in occupational health and hygiene in agriculture.
As has been seen, in most cases the whole family takes part in agricultural work in varying degrees, or at least lives in the working environment. It is therefore necessary to educate both children and adults, including elderly persons whose useful experience has sometimes been nullified by technical advances in agriculture (by the introduction of new poisons, for example) or by developments in sanitation. To this end, all practicable methods should be employed. Publications may include posters, pamphlets, leaflets and press articles. Since many persons will be illiterate, the spoken word must not be neglected: lectures and broadcasts will be useful.
Furthermore, good use may be made of audio-visual means such as lantern slides, films, television (when it exists) and visits to model villages and model farms.
As regards the question of where health education should be given, the school clearly seems to be the best place for reaching most of the children. However, since education in a rural environment is hampered by a lack of schools, transport difficulties, bad weather, the daily round of work on the farm, and the seasonal employment of children in the fields, the school is not enough and children should also take advantage of courses for older people.
For adults, including the elderly, meetings could be organised in the village, either in administrative or cultural centres or in the premises of agricultural associations. If as much advantage as possible is taken of the various means available, the lessons in health and hygiene will be all the more effective.
The teachers of health education will, in the first place, be health officials, nurses, scientists and engineers, social assistants, pharmaceutical chemists, veterinary surgeons, doctors and perhaps health administrators; but those who have some influence by reason of their function should not be overlooked-members of the teaching profession, whether general or agricultural, technicians, agricultural consultants or administrators and, sometimes perhaps, persons in holy orders.
Specialised services such as medical services, agricultural health services and agricultural medical institutes may be expected to organise health education campaigns. Notwithstanding these campaigns, the day-to-day work of the different authorities will be the most important.
Health education programmes must be both specific and comprehensive. First, they must be specific enough to provide adequate background knowledge for specific remedial solutions to be recommended, and yet general enough so that existing hazards and risks will be recognised and appropriate solutions sought. Topics such as housing, water, waste disposal, nutrition, epidemiological risks, poisoning and accidents should be included.
In conclusion it must be stressed that the multiplicity of problems facing the agricultural sector should be no reason for neglecting education in health and hygiene. It is quite certain that some rural housing problems, for example, will not be solved without adequate economic resources. However, in many cases, simple and inexpensive methods will be sufficient to bring about considerable improvements in both living and working conditions.
Trainees can be divided into two groups: health officials and agricultural officials.
Nursing, social and health personnel. Both in countries where there are enough medical personnel and, with more reason, in those where there are not (and where, accordingly, responsibilities are greater, training briefer and general education poorer), these officials should be aware of the new techniques in agriculture and of their dangers.
Pharmaceutical chemists. In some countries, pharmaceutical chemists can play an important role in health education, prevention and first aid. While some subjects that are useful in country districts, such as cryptogamy and toxicology, are normally taught, it would be desirable to give better instruction on occupational health in agriculture, especially to newcomers to agricultural life.
Veterinary surgeons. The veterinary surgeon has, by his training, a good knowledge of the diseases affecting animals, especially infectious and parasitic diseases. He should in addition be well grounded in agricultural medicine because of his contacts with farm workers and his important functions in the field of epidemiology (since prevention should be for both man and animal) and toxicology (where human and animal problems are the same). Thus he is well qualified to take part in preventive and educational activities.
Doctors. Throughout the world, the problems of agricultural medicine seem to be treated no more than superficially in ordinary medical courses. However, specialised courses should be provided both for those who are actually practising general or specialised medicine in rural areas and for those who are preparing to practise agricultural medicine.
Health administrators. In some countries, it is becoming increasingly common for health administration to be entrusted to non-medical personnel. The lack of general medical qualifications of these people is an added reason why they should be trained in agricultural medicine, especially when they are working in a rural area. Such training facilitates their understanding of the problems they are likely to encounter.
Heads of undertakings. Both on small family farms and in large specialised undertakings, those responsible for management should spend some time learning about agricultural medicine in the course of their training.
In both elementary agricultural schools and highly specialised institutes, courses in agricultural medicine that will be relevant to the educational level of the students must be organised. During his training, the agricultural student acquires the habit of keeping in touch with doctors, so that the medical problems that he will subsequently meet with in practice may be solved more easily.
Agricultural administrators. Agricultural technicians, engineers working on the development of rural zones or on agricultural buildings and agricultural labour inspectors should all, within the ambit of their responsibilities, be familiar with the problems of occupational health in agriculture. Because of the decisions they take and the advice they give, they have an extremely important part to play in education and prevention.
As well as the courses in theory that may be given to health and agricultural officials, practical courses are highly desirable. It would be particularly useful for health officials to take courses in agriculture so as to improve their knowledge and understanding of agricultural technology.
For agricultural officials, it would be useful if they spent some time at medical institutions or services so as to gain a better insight into the problems of rural doctors.
Model farms for the various branches of agriculture could provide courses for health and agricultural officials where, inter alia, they could exchange views on common problems.
The instruction would not always take the same form. Depending on the future career of the students, courses could be organised by agricultural technicians and/or the staff of agricultural health services, agricultural medical inspectorates and agricultural labour inspectorates.
Courses in agricultural medicine, both for health officials and for agricultural officials, should feature in the curricula of educational establishments. However, because of the almost complete lack of such courses in these establishments at present, some post-university or recurrent education or training should be provided.
Education is apt to become sterile if it is not activated with the catalyst of practical experience. Congresses are a valuable means of educational regeneration. They should be organised at the regional, national and international levels. They may be confined to a single subject or cover a number of subjects. Everyone who might be interested (and not merely doctors) should participate. The expression of opposing points of view often leads to fruitful exchanges of information and the clarification of obscure ideas, or to the initiation of research and investigation into hitherto unexplored areas. Comparisons between regional and national experience are equally beneficial.
The teaching staffs of universities are particularly well qualified to conduct training courses. Their experience in research and teaching enables them to master the subjects, express them with the maximum of clarity, keep abreast of changes and (provided that they have the necessary resources at their disposal) undertake research into practical needs.
The medical inspectorate
The medical inspectorate plays an important role in providing agricultural health education in undertakings. It should therefore also co-operate with the universities in the provision of training in occupational health and hygiene. On the practical side, the inspectorate can arrange visits and participate actively in investigations and research projects.
Rural practitioners' experience of specific everyday problems enables them to make a positive contribution to training. They can also participate in education and research through the work of their learned societies and in collaboration with the inspectorate and the universities.
Effective collaboration between the various persons and establishments concerned with training in occupational health and hygiene can most often best be achieved within the framework of institutes. Depending on needs and resources, these institutes may be national or regional in scope.
The institutes discussed here may specialise in agricultural medicine or form part of a health institute or an occupational medical institute.
Their personnel should include not only teachers, medical inspectors and practitioners but also all who can contribute to the declared educational and research goals. Some of the staff would be directly concerned with agricultural medicine (veterinary surgeons, toxicologists, bacteriologists and virologists, physiologists, agricultural engineers), while others, indirectly concerned, would make useful contributions of a statistical, psychological or sociological character.
The function of these institutes would be to harmonise education and research. Their three fields of action would be education, research and evaluation.
The importance of evaluation cannot be over-emphasised. It is poor practice to undertake research without knowing whether earlier work has been undertaken on the same subject and, if so, what its results were.
Such an institute, serving simultaneously as a centre of agricultural medicine, a documentation centre and a statistical office for the rational processing of information, should be supplemented by a centre for conditions of employment, which would be concerned with job analysis, rationalisation, ergonomics, and so forth. There should also be a centre for occupational pathology, which would study toxicology, epidemiology and various advanced medical and technical subjects as the need arose, and a centre for psycho-sociology.
The need for collaboration between the different disciplines must be especially stressed.
The organisation of first aid in agriculture is particularly difficult-first, because the accident generally occurs at a place far removed from a treatment centre; and second, because of the inadequate means of communication and transport. It is therefore advisable to make advance provision for the administration of first aid, in order that disastrous mistakes, or indeed a total inability to save the life of a person in danger, may be avoided. The plans should provide for medical care as well as for first aid.
The agricultural doctor should do his best to encourage people to become proficient in first aid. First-aid attendants should be chosen from among both men and women, and even from among young people of either sex, who often take a great interest in first aid.
First-aid training may be organised at the agricultural doctor's medical centre. According to the trainees' opportunities for attendance, it could be either spread over several weeks or concentrated in a short period. However, in countries where training is provided by public or private organisations, the doctor should get in touch with these and preferably co-operate with them.
The training course should include the study of different accidents and the methods of administering first aid to the victims, with particular emphasis being laid on the mistakes to be avoided. However, the specific content should follow approved standards of first-aid practice; special attention should be given to problems which are particularly significant in the country or agricultural area concerned.
Practical exercises showing whether the lessons have been well learned are indispensable, and the award of a certificate after success in an examination is often an encouragement to the trainee.
First-aid personnel should also be provided either with pamphlets or with multigraphed instructions with which they can subsequently refresh their memories. These instructions should be simple and clear.
The training of first-aid personnel should not lead to the neglect of arrangements for medical care, and in no case should the administration of first-aid treatment cause delay in summoning a doctor. The purpose of first aid is to do what is necessary pending the arrival of a doctor. It must not be looked upon as makeshift treatment which, if unsuccessful, can be remedied by the doctor. The administration of first-aid treatment and the summoning of the doctor should be, and in most cases can be, simultaneous.
When there are good roads, transport by ambulance is practicable; however, for various reasons (bad roads, no roads, impassable roads) provision must sometimes be made for transport by helicopter. Every sizeable treatment centre should have a landing place for helicopters.
The ambulance or helicopter should be so equipped that treatment can be begun during the journey-for instance, with resuscitation apparatus, perfusion equipment, oxygen and first-aid equipment.
Some treatment centres specialise in certain injuries (such as burns, poisoning or snake bites). If rapid transport is available, the victim can be taken straight there. If this is not possible, he must first be treated at a primary care centre staffed by competent doctors.
The frequency of poisoning, not only of agricultural but also of industrial, domestic and medicinal origin, is enough to justify the creation of poisoning prevention centres. The diversity of agricultural chemicals is too great for anyone but a specialist to diagnose and treat cases of poisoning correctly. Modern methods of resuscitation require specialist personnel. It is therefore desirable to provide for the establishment of such centres, especially in rural areas.
These regional poisoning prevention centres could act as both treatment centres and information centres. If treatment cannot be given, information becomes necessary.
To keep the information provided by the regional centres up to date, it would seem desirable to set up national centres that would centralise and disseminate new knowledge.