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or interesting, the physician may ask for a literature search of medical journals. If neither of these turns up any suggestion that the patient's symptoms may be related to pesticides, most physicians will be quite reluctant to make a diagnosis of pesticide-related illness, particularly because a dispropor tionately high number of such cases wind up in compensation or tort suits in which the physician may have to defend this diagnosis. 5) In many parts of the country, the library resources in occupa tional and environmental medicine are extremely limited and there are only about 800 board-certified specialists in occupational medicine in the U S . A s a result, the physician may not have a local source to consult in this field. A ll of these factors make physicians understandably reluc tant to pursue diagnoses* of pesticide-related illness. Unless the signs and symptoms and history of exposure are relative ly clear-cut, the physician often feels that trying to make the diagnosis will be frustrating, unrewarding and may even ex pose her or him to the risk of professional ridicule or the risk of lawsuits. I realize that this long list of problems may be discouraging to patients and workers in search of help, it may seem to sug gest that physicians should not be expected to learn about pesticide health effects or to make these diagnoses. I do not mean to imply that. A ll general practitioners, including internists, family medicine physicians, pediatricians, obstetri cians and gynecologists, nurse practitioners and physician's assistants, as well as toxicologists, clinical pharmacologists and emergency room nurses and physicians should be ac quainted with the range of symptoms and illnesses which may be associated with pesticide exposure. But it is important to recognize the barriers faced by health providers who are sympathetic and interested in learning about pesticides, and the reasons why health professionals may be hesitant to get involved or may grow discouraged. Steps Toward Diagnosis Physicians who are interested in occupational and environ mental medicine must 1) gather comprehensive occupational histories; 2) provide for appropriate biological testing; and 3) offer worker education. Elements of the occupational history gathered from a worker should include job title, type of in dustry or farm, name of employer, period of employment, jo b duties, protective equipment provided and/or used, addi* tional job-related hazards (machinery, noise, sun, etc.), infor mation on whether other workers have symptoms, prior work history, history of work-related illnesses, accidents and compensation, home pesticide use or exposure, other chemical exposures on the job or at home (e.g., solvents used in hobbies), and most importantly (if the worker knows this), the compounds to which he or she is exposed. If the worker does not know this, it may be possible to approximate an answer. If a farmworker only knows, for example, that she is working in tomatoes, the physician should be able to learn from the county health office or agricultural commissioner what is typically being applied to tomatoes during that time ` period. If the worker knows that symptoms developed after fighting a fire in a particular warehouse, it may be possible to find out what was in the warehouse from the fire department records. N o medical examination of a worker should be conducted without appropriate education of the worker about the potential hazards of their job and the means to reduce the associated risks. Simple instruction about such topics as field sanitation, protection during mixing, loading, and transporta tion of pesticides, proper storage of pesticides, and the early symptoms of poisoning may prevent serious damage. Pam phlets, one-page posters, information sheets, and even short slide programs have been prepared for patient/worker educa tion on pesticide health hazards. > ' Because of the inadequate training which most health pro viders have received in occupational medicine, continuing education programs on pesticide-related health hazards are particularly important. Pesticide reform groups have been successful in some states in sponsoring continuing medical and nursing education programs, or in arranging for county or state health departments to sponsor them. Support for research in occupational and environmental medicine is also important, not just in order to learn more about the health ef fects pf pesticides, but in order to get more of this into the scientific literature so that clinicians in the field have more to refer to when evaluating pesticide illnesses. References ' ____ Barger, K., and E. Reza. Survey of midwestern farmworkers. Department o f Anthropology, Indiana University. Project summary, unpublished, March 7, 1984. Blair, A . 1982. Cancer risks associated with agriculture: epidemiologic evidence. Bible Life Scieiues 21:93-111. . Biown JR, et al. 1978. Human blood cholinesterase activity-- Holland Marsh, Ontario, 197o Bull. Environm. Con turn. Toxicol. 19:617*623. Bureau ot Community Health Service. 1982. Guide to the development of a pestkule health hazard management program. Washington, D .C .: USPH S/BCH D A/Migrant Health Office. ~ Bureau of Community Health Services. 1979. Farmworkers in the U .S . Internal Data. D H EW : Public Health Srevice. Coye, M J. 1984. Biological monitoring of agricultural workers exposed to pesticides. Presented at the N IO S H Conference on Medical Screening and Biological Monitoring for the Effects o f Exposure in the Workplace, July, Cincinnati, O H , Coye, M J and L Rosenstock. 1983 The occupational health history in a family practice setting. A m . Family Physician 28:5:229-234. Kahn E. 1976. Pesticide related illness in California farm workers. ]. Occup. M e d . 18(10:693-696. Levin HS, and RL Rodnitsky. 1976. Behavioral effects of organophosphate pesticides in man. C lin . Toxicol. 9:391-405. Levin HS, RL Rodnitzky, and D L Mick. 1976. Anxiety associated with exposure to organophosphate compounds. A rc h . G en . Psychiatry 33:225-228. Levy, BS. 1985. The teaching of occupational health in United States medi cal schools: Five-year follow-up of an initial survey. A m . ). Public Health 75:79-80, Maddy KT. 1983. Pesticide usage in California and the United States. A g r i culture, Ecosystems and[Eum onment 9:159-1^ _ _____ ___________ ___ \ Midtling JE, et al. 1984. Clinical management of field worker organo phosphate poisoning: Cast report. Accepted for publication, West J . M e d . (July 19). N IO SH : Hazard Evaluation N o . 82-248. N IO S H , M ay 1984. N IO S H : Hazard Evaluation N o . 81-301-1467. N IO S H , 1984. N IO SH : Hazard Evaluation N o. 81-366-1248. N IO S H , 1983. Public Health Service Region IX. California supplement to the B C H S guide to the development o f a pesticide health hazard management program. Rural. Health Unit and N iO S H , San Francisco, and Agricultural Workers Health Centers Inc., Stockton, California, March 1984. Quinones M A . JD Bodgden, DB Louria, and A E Nakah. 1976. Depressed cholinesterase activities among farm workers in New Jersey. Science of the Totid Environment 6:155-159. Spigiel RW , DR Gourley, and TL Holcslaw. 1981. Organophosphate pesticide exposure in farmers and commercial applicators. C lin . Tox Consult. 3:41-45, 45-50. Strigini, P. 1982. O n the political economy of risk: farmworkers, pesticides, and dollars. International J . Health Seivices 12(2):263-292. . Task Group on Occupational Exposure to Pesticides. 1975. Occupational exposure to pesticides (Report to the Federal Working Group on Pest Management). Washington, D C . U S G ovt. Printing O ffice Pub. N o. 0-551-020. Whiting WB. 1975. Occupational illnesses and injuries of California agri cultural workers. J . Occup. M e d . 17(3): 177-180. 6 NCAP NEWS / SPRING 1985