1. Morrow, John MD, MPH

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The article, "Pesticide Exposure Surveillance and Prevention Skills of Staff in Eastern North Carolina" by Robin Tutor et al highlights an important issue for protecting the health of farm workers including migrants. Local health departments do have an important role to play but no more than other healthcare providers involved with the care of these patients especially community health centers, migrant health programs, and the emergency departments of hospitals often frequented by these workers.


Rural health centers and health departments with migrant farmworker programs in North Carolina have been very aware of the risk of pesticide exposures in their patient populations for more than 20 years. However, the lack of any clear or causal association between a patient's disease and a pesticide exposure constrains the capacity of these providers to mount appropriate interventions and requires a broader perspective in seeking remedies to this problem that need to focus on best alternatives for prevention of exposures.


Suspected exposure cases, if acute and severe (such as those reported in this article), are more likely to present to an emergency department clinic or urgent care provider than to a health department clinic. If the exposure is less severe or more chronic, it is likely to present with respiratory or dermatologic complaints that are often ill-defined and require referral for additional testing and proper diagnosis.


The study by Tutor et al suggests that because health departments see some of the same type patients as community health centers, their role is the same with respect to pesticide exposures. Actually, there is an important difference. Local health departments typically do not provide acute, walk-in urgent care services. Staffs of these public health agencies are not as well trained to deal with an acute chemical exposure that would involve decontamination procedures, antidotes, and consultation with the poison control center. The lower dose or more chronic exposures are more commonly encountered in local health department clinics are much more difficult to recognize. Establishing the causal relationships between these exposures and health issues are difficult, if not impossible, to establish.


Healthcare providers, in general, are not well trained in the toxicology of pesticides (as well as other types of chemical exposures). Environmental health specialists working in local health departments often do receive some formal pesticide training because they often deal with vector control issues in food and lodging programs, animal or mosquito control programs, and so forth. Public health departments also get involved with investigations of suspected outbreaks of disease related to these types of exposures. (Pitt health department had a chloropicrin spray-drift investigation about 2 years ago, for example.)


The pesticide exposure issue, as pointed out by this article, is critically important to local health departments and the communities they serve. There is not a health department in North Carolina, or probably nationally, that does not serve clients who are at risk for these types of exposures. Some of these individuals are at substantially higher risk because of their occupation (migrant farmworkers.)


For local health departments, "screening" patients for exposure risk is not likely to be particularly effective. Adding more specific pesticide questions to already-extensive patient interview process will increase patient wait-times (already a big problem in most health departments). It will not add a sufficient increment to the quality of patient's care.


My recommendations are increasing and improving broad public education on the risk of chemical exposures of all kinds (including pesticides). Local health departments can play a role here and also in improving surveillance methods.


Increasing the clinical acumen of clinical staff in recognizing and reporting suspect cases is also needed across the healthcare provider spectrum. In terms of preventing additional cases such as the three infants born with birth defects, we have to identify these high-risk populations and educate them before the exposures occur. This will be extremely difficult to do. It needs to be coupled with NC Department of Agriculture efforts to education and train the farmers using chemicals.