hello, i'm norman swan.welcome to taking stock: the health hazards of farming, in this international yearof the farmer. i didn't know that -the international year of the farmer. australian farmers and their families face significant healthand occupational hazards. they have poorer health outcomesthan people in the cities, higher mortality,more chronic disease and morbidity and are over-representedin accidents and injury rates.
tonight we'll be taking stockon these issues. we are coming to you across australia through the rural health educationfoundation's satellite network. we have viewers across australiain places such as dalby in queensland, berri in nsw, ballarat in victoria, eneabba in western australiaand shark bay in wa as well. the program is also going out liveas a television broadcast on nitv, so welcome to our nitv viewers. we're interactive as always and you havethe opportunity to comment on issues
and put your questions to the panel. so we want your phone calls, emailsand faxes whenever you want to ask a question. the phone number is 1800 817 268. the other number there is if you'reunfortunate enough to be in the sydney area. and the fax number is 1800 633 410. or you can email us directly at questions@rhef.com.au.
as always, there are a numberof useful resources available for you on the rural health educationfoundation's website - rhef.com.au. now let me introduce our panel to you. clinical associate professor susanbrumby is the founding director of the national centrefor farmer health. that's a partnership betweenwestern district health service and deakin university in victoria. - welcome, susan.- good evening, norman.
susan leads the implementationof five key strategies to improve the health, wellbeingand safety of farm men and women. she has extensive agriculturalexperience herself, managing the family propertyof beef cattle and fine wool for the last 12 years. - how's it going?- super, thanks. 'super'? right. tell us howit's really going on the farm. - always a bit tough on the farm.- is it? - so the rains haven't helped?- oh, well, after ten years of drought,
- ..certainly...- long way to catch up. long way to catch up. professor scott kitchener is a public health physician and gpon the darling downs. he's worked in rural queensland,nsw, western australia, as well as east timor and bougainville. he's now director of thequeensland rural medical education. - welcome, scott.- thanks, norman. scott is in rural practice in cliftonand pittsworth on the darling downs.
jody morton grew up on the family farmin western australia. she is married to a farmerand is the remote area nurse in the eneabba silver chainhealth centre. you'd better tell peoplewhere eneabba is, jody. uh, yeah, thanks, norman.it's between perth and geraldton. - right.- yep. - and classified as 'remote'?- yes. sounds it. jody has completed the sustainable
farm familieshealth professionals course. and last but not leastis associate professor david perkins who's director of the centre for remote health researchin broken hill. welcome, david. david is a health researcher witha background in health management and rural mental health issues. he's also editor of the 20-year-old -20 years old this year - the australian journal of rural health.
congratulations on that.that's a fantastic achievement. an important journal. and a chief investigator in thecentre of research excellence in rural and remoteprimary health care. so welcome to you all. what we're gonna do tonightis start with a case study which brings together some of the issuesthat many of you are well aware of in terms of people who work on the land. john is 34 years old.
he's brought into your surgery by his wife in the car. he collapsed on the kitchen floor with severe abdominal pain and he's sweating profusely. she tells the practitioner that he's had pain for some days and on questioning, said he'd commented that his stools were much darker
than usual but thought he had a case of gastro. he hasn't felt like eating for days. so, scott, you get the callinto the treatment room. thanks, norman.i'm fortunate to work in practices where there are small hospitals and we have a practice nursein each of pittsworth and clifton, so i'd normally come in and... i'm sure the patientwould be on oxygen already,
so we would normally check the airways,breathing and circulation. but the holding capacity of the ruralhospitals attached to the practices are such that we would move this onif it was an acute abdomen. certainly, i'd be calling the ambulanceand cannulating. one benefit of workingin rural practice is that we'd have an idea about the long-term medicalhistory of this patient, so i'd be wondering about whetherthis fellow has an upper gi bleed, particularly with the historyof the dark stools. and knowing that in the communitiesthat i work in,
there's been a lot of financial stressand farmers are having a hard time, it wouldn't be surprising to see... - get a perforated du or something?- that's right. that's the sort of thingthat we would... normally, we would send themup the road 50 kay to toowoomba hospital in the ambulance. jody, he sat on this for a while. he did, which is quite common in thefarming community in my experience. they are very time-restrictedwith the...
they like to get jobs done on time. i mean, their whole financial incomedepends that they get the crop in on time or that they get the cows milked on time- whatever farming that they're in. they also... with the economic climateat the moment, a lot of farmers have hadto put off workforce, so they therefore can't sayto somebody else, 'can you go and do this job for me?' they need to actually go outand do that themselves.
and the majority of farmersthat i'm aware of will actually go and do that jobbefore they look at presenting. i know i've certainly... if a farmer comes into my clinicsaying these sort of symptoms, you take it pretty seriously 'cause you know they're unwellif they're voluntarily coming in. so, susan, how much of thisin your view, is just being a bloke, and a country bloke, versus beingon the land, being a farmer? i think there's a couple of issues.
one is that we certainly know that the further away fromhealth services that you live, the longer people wait at home - whether it's for chest painor abdominal pain like this - and that's whether you're a manor a woman, so i think that's important. i think in terms of men and womenon farms that certainly,the opportunity for men to probably be linked into their health servicesa little bit less than perhaps women that may of course,
have had children or been looking afteror taking kids to doctors, so they're not as linked in as well. but i do think the distance effectis actually really profound and needs to be considered. and i think also on that,when you've got your smaller centres, they don't want to be a botherat one o'clock in the morning. they know that you're there on your own,you're on call 24/7, they don't wanna get youout of bed unnecessarily. so they don't want to interruptyour night's sleep.
they put that over precedenceof their own health. what do we know, david, from the research in termsof whether there's a... ..a culture of attitudes towards health which is overlaid upon the difficultiesof working on the farm anyway? we know that farmers are usedto solving their own problems. we know that they have a cultureof care for the land, of care for their family, of being the one who will stand upand will sort things out
and that moving into a positionwhere you were dependent, where you've lost controlis problematic. we also know that farmershave death rates 33% higher than the rest of thepopulation from all causes, and so the evidence isthis is a group... - so at any age?- at any age, yeah. this is a group of peoplewho are at risk - they're a national health priority,according to... so the life expectancy of a farmer's athird less than the average australian?
no, i'm saying they have death rates a third higherthan the general population and that they're a national priorityand that, as jody says, if a farmer turns upwith a problem like this, you take them seriouslybecause they don't waste your time. but there's also an issue for the wifehere who's brought him in... she's got a dilemma here. she's probably left kids at homewith a neighbour and now we're another 50kmto toowoomba or wherever...
jody: yes, that's right.- and what does she do? does she go in the ambulance withher husband or back to the farm? well, i guess even the instance is that often we find people that havebundled their loved ones - whether it's children or husbands -into cars and travelled at risk... - so they're all there.- and... so the road trip is as riskyas everything else. yeah, absolutely. and rather than sitting at homeand waiting for an ambulance,
because people are fearful and they wantto actually be doing something to help. so, scott, what are some of the myths that are boundaround living on the farm? the myths. well, i think thatit's not a myth that farmers don't tend to become a worried well. one myth i've foundworking in rural practice is the concept that farmers are well-off where in actual fact,as a socio-economic class, they're rather down the scale.
financially, they're not flush most ofthe times and incomes are very sporadic and difficult to predict,so i find that the concept that there's a landed gentryout there in rural australia is quite a myth. jody, what are the mythsfrom your perspective? i'd say probably more that farmingis a healthy lifestyle, that they are all fit and strongand do hard work... it's probably their self-image as well,the rugged farmer, isn't it? yeah, i guess. um...
whereas they're sitting in the tractor. they spend a lot of time now either sitting in the uteor a tractor or a truck. a lot of the actual really physicalfarmwork that used to be done is done differently these days, so they don't have that highcardiovascular workout all day like they used to get. i presume that their food intake reflects their image of themselvesrather than...
very high protein, high... yeah, not the healthiest lifestyle. a lot of it is what they actuallyproduce on the farm themselves as well, so it's not, like, nice, lean meats -it's, um... yeah. and far too big a quantities. i thought australia's beef herd hadbecome much leaner over the years, but maybe they don't eat the best cuts.david? i guess too, the theory that they'reyoung people, they're in their 30s, they're wearing rm williamson hatsand they're young and active,
where the average age of farmersis somewhere in their 50s and many of them are working throughuntil their 70s. so we're dealing with a group of peoplewho are older, who have the problems of ageing, whether it's memory or hearingor problems of previous injuries. and susan? i'd agree with everybodyon what they've said. certainly our experience is very muchabout having a ready source of protein and large amounts of red meatin their freezers,
which of course, when you tell peopleto eat a small amount, 120g, you know, that's breakfast... not even breakfast.doesn't touch the sides going down. certainly, when we've workedwith farmers, that surprise that rural peoplehave a shorter life expectancy than metropolitan people,always comes as a shock, because they will always say they believe they havethe longer life expectancy, that they're much healthier than thecity slickers with pollution and things.
norman: living in the garden of eden. so tell us about thissustainable farm families program. sure. the sustainable farm familiesprogram started actually in 2002with a fund from rirdc - rural industries researchdevelopment corporation - and it was designed to basically addresshealth, wellbeing and safety or farm men and women. and it was initiated because... we come from hamilton, an agriculturalhub, and we were seeing...
norman: hamilton in victoria.- yes. uh, yeah. ..seeing, you know, early casesof people dying from injury, suicide and preventablecardiovascular diseases. so the program was developed. farmers come in over three years, it's very much designedto be farm men and women and they get weighed and measured... so you focus on when they're gatheringanyway, at fairs and so on? no. no, no.
it's a specific, stand-alone programthat runs through an industry group... - ..such as topcrop or...- but you go where they go? yes, we go into their own ruralcommunity. and they go through the programand they learn about cardiovascular disease, diabetes,cancer, men's health, women's health. farm health and safety'scertainly included and gender topicsas well as physical activity. so we have longitudinal data as well asbehaviour over time and knowledge. - and do you get behaviour change?- we absolutely get behaviour change.
and it's been evaluatedby external people. the key thing i think isif people come to the program with three or more risk factors, they are the people that getthe best benefit from the program. and you even teach farmersto read labels in the supermarket. susan: we certainly do. we certainly do.we take them to the supermarket and show them what they'reputting on the plate at home. norman: and we've got a picture hereof farmers.
what are these farmers doingin this next shot here? susan: well, they're very disappointedwhen they realise that there's actually 40 servesof ice-cream in there and they think there's only 10. norman: so they go through workshops?susan: they do and they enjoy that. they like learning about their health,wellbeing and safety. that's good. norman: and what abouttheir uptake of exercise? susan: we talk to them about exactlywhat jody was talking about - about realising that there'sall sorts of different exercise
and it's important to be active. norman: and we've got them here...is this a casualty exercise or what? susan: no, this is actually farmerslearning how to do a meditation. this is the stress session. and i would like to say aboutperceptions is people didn't think that farmerswould be interested in stress, but they certainly are and in learningskills to overcome that. and here we're actually fittinga face mask which is very much... no point in wearing a maskif it doesn't fit you properly.
norman: and we also have a photograph of one of the deadliest machineson the farm these days - the quad bike. david, what are the statistics forinjuries on farms these days? and this has really taken overfrom the tractor as the major killer. david: this has taken overfrom the tractor, and the statistics arethat the tractor deaths are coming down very significantly and that they're usually actuallythe tractor running over somebody
rather than the tractor rolling overand there being a death that way. the quad bike deaths... norman: and you don't have open-cabsanymore - there's a cage around the driver. yeah. the roll-over systems. the quad bikes were reallydesigned for something else. they're great for getting aroundthe farm, people love them, but they are given taskswhich they're not designed for and the question arises as to whetherthere can be some mechanism
of ensuring that they don't fallon top of you. and the... norman: so here's one after an accident. david: here's one out of...norman: tell us the story. david: the story here wasthe tocal college decided that they wantedto put that roll-over bar or that compression... a safety baron the back, so they did that. and a student was outtrying to round up some horses and the student went overan uneven piece of ground,
the quad bike tipped overand the student got a broken collarbone. but the college policy was helmetsfor staff and roll-over bars, as it were,for all staff and all students on all quad bikes. and the evidenceand the suggestion of the head was that the student would'vebeen killed otherwise. and if you go to youtube and if you lookup 'tocal college quad bike', you'll see a nice two-minute videowhich tells you about the story. there is an issue here -we don't really know what works.
we know with tractorsbut we don't know with quad bikes. i think this is... it's a good idea,but the risk is that there's no evidence that this is actually protective... yet. there's a manufacturer in toowoombaas well, and he produces a very similar productto that, which is terrific, but i think all we can really say isthat it's gonna change the roll-over dynamics of the vehicle. it isn't necessarily going to work interms of protecting you in a roll-over. in the roll-over protection systemsin a tractor, that david mentioned,
there's a requirement for a seatbelt so that you don't actually fall outand get hit by the roll-over protection system, and that obviously isn't the casein quad bikes. so i think the jury's still out. we urgently and desperately needevidence around this and then a standardisationneeds to be put in place. maybe they need a cage as well. what are the other statistics...we've alluded to them...
you've talked about the 33%age-adjusted death rates. one of the key statisticsis that road deaths... farmers travel a lot of mileson poor roads in fast cars and the road deaths are twice as highas for the australian population. just on ordinary roads. deaths on the farm are high, through farm injuriesand through transport of various sorts. the evidence on obesity, i think,is a bit mixed. some are saying farmers are overweight,
others are saying that it dependson what industry you're in, what sort of farmwork you're doing. suicide is high and for farmersaged over 65, the suicide rate is twice the adult malepopulation of comparable age. cardiovascular disease is at 40% abovethe male population of a similar age. prostate cancer is twice as high... - deaths from prostate cancer?- deaths from prostate cancer. probably with other cancers,late diagnosis. yeah, sure.
lymphatic cancers are almost twiceas high, and cancers of the colon... - that might be occupational exposure.- yep. so the evidence is that there area series of cancers and other conditions where deaths are particularly high. there may be some cancerswhere farming's protective and interestingly, we knowfrom evidence in america and canada that actually, farming is protective, you do betterthan the comparable population. it appears in australiait's actually a risk.
scott: but... and of course,these are deaths. so one of the problems is that... ..the impact upon deathalso takes into account the effect of access to health careand the therapeutic options, and there's good evidence that the further away froma metropolitan centre you are, the more chance you haveof dying from a cancer. norman: later stage of diagnosis. and also access to adequate therapy.
and the other aspect of deaths is that we don't even countthe most common cancer... and particularly it's a problemfor farmers, and that's a non-melanomato skin cancer. it's so common we don't count it. it only probably causes 400 deathsa year, so looking at statisticsaround mortality doesn't really give the gravity ofimportance of this cancer. and child deaths are high?
sadly, child deaths are very highin agricultural populations and they devastate agriculturalcommunities when they occur. norman: and mostly from injury? david: they're vehicle-related,they're dams-related and they're related to horsesand animals - getting animals thatare not appropriate for them at their age or at their skill set. and there's quite a percentage too,of those children that aren't actually the farm children.
the farm children are often educatedby the parents, but the parents don't impartthat information on to the visitors. so little johnny just goesand jumps on the motorbike, so fred goes along with him,having no education, no safety and can get themselves into trouble. sometimes these things can be addressedby simple things like having a safe play area on a farmfor toddlers and for younger children - putting a fence round itor something of that sort. it's amazing how many farms don't havesafe play areas - really amazing.
i think the other aspectin childhood injury on farms is that children are oftenoccupationally involved, they're part of the small industrythat is agriculture and, you know, our family knows quitea number of families working on the farm and all of them will mention injuriesthey've had falling off a tractor or falling offa horse or getting struck by something, and they're working,they're part of the... how much of that is a badge of honour rather than recognising a failurein the system?
(chuckles) i don't think that... i don't think that people do itas a badge of honour - they do it because of the necessityof having children work on a farm. susan: mm. i think there's also... as a parent that raised childrenon a farm, there is also something pleasantabout working with your children and actually teaching them aboutlivestock and animals and how things grow. i do think on reflection though, asa parent who now has grown children,
when i look back at some of the tasksthat our children did, maybe i actually did think that theywere more grown-up than they were. and i think that's often somethingthat happens. i would like to just go backto david's statistics. i think it's important that... they'remale statistics, aren't they, in 2002? and that perhaps recognising that farm women aren't often includedin statistics. - very much so.- it is important. yes. and we don't really knowwhat's happening in hobby farms,
we don't know what's happening... we actually have a comment from wagga.welcome to the program. on phone: thank you. good evening. my name's patrick ball. i'm at the school of pharmacyat charles sturt university. (voice echoes) sorry, i'm just getting an echo here... ..sound in this roomto do anything about it. is it coming through ok?
yeah, if you just turn down the volumeon your set there, that's why you're getting the feedbackand that'll work well for you. (laughter)nice to hear myself back. the problem is that the set doesn'tactually have an obvious volume control. ok. that's fine. i think it's a bitbetter now. so go on, patrick. patrick: ok, basically, my query wasaround the role of alcohol consumption in all these health issueswe're talking about. uh, in particular,i've just been involved in a project with the linden community,monash university, sydney university,
where we've actually looked at some ofthe levels of alcohol consumption in farming and fishery workers, suggesting that there isquite a lot of alcohol use and some of it at quite high levels, particularly at the sort of levels wherepeople are not going to sleep it off, the alcohol has saturable metabolism, and people are still likely to beimpaired the following morning. what does the panel feel aboutthe role of alcohol in some of the statisticswe've been discussing?
- susan?- thanks, norman. certainly, patrick, with our workwith farming men and women, we've found a higher level of short-termhigh-risk alcohol consumption, and i think some of the challenges forsmall communities and sporting clubs is very much that the communitiesoften revolve around the consumption of alcohol. but it's much higherwhen it's age-standardised than in metropolitan populationsfor short-term high-risk drinking. norman: jody?
i think some of that short-termalso pushes out to quite long-term. you see themand they'll start by saying, 'yeah, it's just one or twoto relax after work,' but it does go on. and especially when you start gettingfinancial pressures, um... so they can start the next dayquite impaired? jody: yeah. definitely. and if you've gotta drive, you might bedriving under the influence. do we have statistics on this?
no, i think we have statistics,as patrick has said, from small studies where, you know, numbers of people of60, 70, 80, 100 have been questioned. i think we need broader datathat looks at population... norman: patrick's got some of that datacoming through. scott? well, i think aihw do indicatethat rural people - and i would draw the attention to the difference betweenrural and agricultural communities - but from the rural... so you could have a large regional town
which only on the peripheryhas an agricultural... yes, so we need to be very carefulin using rural data to project upon farmingand agricultural communities, but the data that i've read indicatesthat there's more problematic drinking amongst rural communities thannecessarily higher levels of drinking, and i think, patrick,you need to be looking at... so it's a bit analogousto aboriginal communities where not necessarily everybody drinks,but those who do drink, drink to excess? drinking in circumstanceswhen it has health impacts,
and so drinking and driving,drinking and operating machinery, is more problematic than drinkingand not operating machinery. so my question then is, and it's linkedback to sustainable farm families, is should there... i mean, clinicians are very busy,whether you're a nurse, an allied health professionalor a gp in the country, but if the problemsare not coming to you, is there a role for somehowgetting out to the families with the clinical professionals?
so i think when we're doinga farm families program... our data on alcohol is on 2,500farm men and women, so it is purely... norman: i'm talking aboutmore than alcohol here. susan: ok. i'm talking aboutgeneral health issues. is there an outreach role here? most agricultural fairs these dayswould have a pit stop or some sort of event wherethere would be a screening opportunity, gymkhanas, all sorts of country eventsat which farmers are represented.
and there would be a range ofactivities, from taking bloods to measuring waiststo doing a k6 or a k10 to see people's levelsof psychological distress. and what often happens is thata combination of the health service, the gps, the flying doctors, perhaps, the aboriginal medical service, willget together and do that screening... norman: that's a kind of outreach. i mean, scott, how do you organiseyour practice, or do you at all, to cope with the fact thatthey don't necessarily come to you?
the problems are brewing out thereand... look, it's very difficult. i think that you've got tomake yourself available, but the service demands are suchthat it's very hard to actually get out. norman: out of the office, yep. i think you've got to be availablewhen they want to come in. i think you've got to use a lotof opportunistic consultation. so, farmers, in my experience,have a lot of signalling behaviour, so they'll come in for somethingthat they consider to be acceptable
to go and speak to the doc about. norman: their ticket of entry.- that's right. so then, you've got to belooking beyond that and you've got to take that opportunityto do skin checks, check their blood pressure,talk about their exposure to grains and see if they're getting other issues. if you don't do that, then you'regoing to miss a golden opportunity, and the reality is that gpsin agricultural communities see a large proportion of the communityevery year,
and if they don't see the actual farmer, they'll see someone elsefrom the household. so there are a lot ofhealth promotion opportunities. - opportunism is the name of...- absolutely. and you use your registrarsand medical students as a bit of outreach, don't you? certainly, medical studentsget heavily involved in - and these are the longlook studentsfrom griffith and uq - and they get involved in medical supportto rodeos and other events -
they love the polo - and it's great for them becausethey love to get some experience, but it's very good to raise the profileof the medical profession not just to the farmers,but also to their children to consider health professionsas a valid career path. so i think there's... we also talk to our registrarsabout how, in a small community, they are a leader from the point of viewof being a role model for alcohol, for smoking, for, you know,health in general,
and they need to assume that role, and that role is not really existingin metropolitan circumstances where the anonymity allows youto wander around and not take that position of leadershipin the community. go clubbing with impunity. jody? i think it's a matter of learningwhat your community is actually wanting from you, as well. um, i know silver chain developed,or conducted, a very thorough health needs surveyjust recently in eneabba,
but it's also done itat some other local sites. but the way that they actually worktheir health needs survey is to start with a basis questionnaire. they actually hold a community meetingwhere the public come in and look at the questionnairethat we've got, and we say to the community,'are the right questions on there?' 'are we asking the right information?' and i know we had a very good responseat eneabba where they significantly changedthe health needs survey
that was being put out so that we were able to get the answersthat they wanted us to get to, so now that that's just been collated, we would now take that backto the community to say, 'ok, this is what the resultswere. where do we go from now?' 'where do you guys want us to head?' what services, whether it's working outagreements with medicare local or introducing other servicesinto the town. but the community drives it,
and from other experienceat other silver chain sites, when the community's driving it,you have more success, they actually come and participate more. i think it's interesting you mentionedthe medicare locals, because my understanding of their task is to identify who falls throughthe gaps in health services, and to actually find waysof filling those gaps and by encouraging peopleto work together. thank you very much, patrick,for that call from wagga.
remember, the number to call in onis 1800 817 268. we're delighted to put you on airif you phone in and if you want a degreeof greater anonymity, the fax number is 1800 633 410. please send in your questionsor comments. our next case study is judith, who's 60. she lives and works on her farm about 50 kay from town. she came in to see the locum a while ago
complaining of a cough and occasional breathlessness. she was diagnosed with a possible urti and she's now back at her husband's urging to see the doctor. scott, when you look at her, you see a suspicious-looking spot in the crease of her nose
which needs investigation. what are you going to do about judith? well, i think,coming in with this history, you still need to consider that peoplein agricultural communities get common conditionsand have common risk factors, so i'd be asking about smoking, i'd be considering whether or notshe has asthma, it's very important to look ather full history, although it's likely that we havea medical history for this woman
over a number of years, and that's a great advantage. if i am working up in the directionof asthma, i'd be looking at doingsome spirometry - at the very least, a baseline - but given that she's from a farm, i think coming to seean agricultural health practitioner, you really need to be consideringthe possibility of farmer's lung, in this case,or even a chemical exposure
that's occurring on a recurrent basis, and investigating that. with respect to the spot on her nose, i would identify it, and then, given the complexity of where we'regoing with the respiratory symptoms, i'd be asking her to come back, and putting a reminder in, as well,to make sure she does come back, and taking that as another conditioni'm dealing with later on. norman: will she come back?
look, i find that if you putthe right weight on it and indicate that it is manageable,um, then... a lot of farmers and peoplefrom agricultural communities, if you put it in the right context - and the right context, in my experience, is to analogise it to looking afterthe machinery on the property, which they're very clear aboutunderstanding maintenance schedules and to maintainthe life of the equipment - then they do come back.
but then it doesn't also hurt to havethe receptionist call up and say, 'you've got an appointment at this time.i'll see you then.' so give us a 30-second tutorialon farmer's lung. it's a hypersensitivity pneumonitis, which is a type 3 allergic reaction. and in english, essentially,there's an immune response to some of the... norman: so this is grains and dust? some of the antigens,in particularly hay and other...
and you can geta fixed abnormality here, a fixed respiratory abnormality. typically, it doesn't fit the asthma. the farmer's lungs that i see, they've had asthma diagnosedand it doesn't seem to respond. you take a history of compliance.are they compliant? you listen to their chest, you get themed student to listen to their chest, and they're not wheezy,even though they're short of breath, they have scattered crackling,
suggesting that it's actuallya distal condition. and so i find thatif you modify their treatment, particularly away from the beta agonist, then, um, you geta much better response. now, a question has come infor you, susan, and it's from linda,a nurse in queensland. 'can anyone train inthe farm families program?' we actually have a postgraduate subjectin agricultural health and medicine, which is actually whatjody and scott have both done.
so jody, you're a walking,living example of this? susan: and scott.jody: yes. (laughs) so give us the sales pitch.is it worth linda doing the program? definitely. i travelled across from wato do the intensive week in hamilton. it was fantastic. i learnt things eventhough i've grown up on a farm. that's where you learned aboutfarmer's lung, for example. it is, because i, like i said,grew up on a farm, i went to university to becomea registered nurse, i've had 20 years remote experience
and i actually hadn't heard of the term'farmer's lung' until i went and actually didthis course. um, yeah. there was lots in zoonosesand all sorts of different... definitely very well worth going.i'm really pleased. scott: and a great lecture on zoonoses. oh, a sensational lecture on zoonoses. and just a comment - a general practitionerin southern nsw comments, 'i'd be lucky to see most malesin farming families once a year,
and usually in an emergency. not much chancefor opportunistic screening.' well, that's better than none, and the reality is thatunder those circumstances, there is an opportunity to talk to themabout other matters, and the statistics clearly showthat we do see these people and very often it is associatedwith trauma, but that's an opportunityand it can't be missed. and, susan, do we know whether or notthere are particular hazards
or things that happen to peoplewith particular tasks on the farm? so whether you're a cropper,you do mostly cropping, or whether or not you're most...you're... you've got... ..you're in livestock, for example? certainly. we certainly know thatif you've got livestock, you're most likely to be injuredby livestock. they're the things that causethe most amount of injuries. the things that causethe most amount of death
is obviously the four-wheelersand tractors. but certainly sheep, in particular,are pretty nasty, and so are cattle. uh, in fact,dairy tend to just get bruises rather than serious kind of kneesand those kind of things, so we do know that. we also knowfrom our respiratory studies that sheep and cropping people were themost likely to have respiratory issues. let's go to our next case studywho's tommy, 13 years old. fell off his quad bike,
has a head injury. his father's brought him in to jody, the remote area nurse in eneabba. he's bleeding. his father's anxious for you to expedite his son's treatment. - jody?jody: ok. start off by doing an initial assessment -
airway, breathing, circulation. doing a secondary assessment. also, while doing that,finding out exactly what did happen so you can look and investigatewhat sort of injuries you would be looking at. then, depending on the results of that, whether, if it was a simple suturing,i could do that. norman: i think we can show youwhat happened here. jody: ok. (laughs)
scott: this was actually a boy that cameinto pittsworth a couple of weeks ago that i got a photograph of, and he'd, in fact,come off his quad bike. norman: he knocked himself out? scott: he wasn't knocked out,fortunately, and he also wasn't driving, so it's not just the personin charge of the vehicle that's at risk. but.. and he wasn't wearing a helmet. jody: obviously.
david: and the quad bikewasn't designed for two people. well, they are designed for two people,but not the way he was riding. - (laughs)norman: enough said. but it was a great opportunity for himto go and get his helmet thereafter, and a good opportunity for a medicalstudent to learn how to use the glue. david: when i hear thatsomeone's who's going out mustering can't possibly wear a helmet because they're gonna be out in40 degree temperatures for 12 hours a day,
i mean, how do you respond to that? well, you probably see more40 degree temperatures than i do. jody: i see lots of that. there's actually new helmetsthat have been designed now. they're a lot lighter-weight. they actually come up higherabove the ear, so... another argument that farmers used tothrow up was that they couldn't hear - if they were mustering as a group, theycouldn't hear either each other speak and they couldn't...
if the sheep were beginning to pant orthings like that, they couldn't hear it. whereas the new-style helmets,they are a lot lighter and they are able to hear each other,so that's no longer... scott: i think the other aspect isthe sun protection, and my youngest son, william, wears a hat with coverageunder his bicycle helmet, and there's no reasonwhy you can't do that. it doesn't look spectacular,but it's certainly protective. particularly if you've got melanomain the family,
it's the sort of thing that farmers needto be instilling in their children at the start. we take the shorty helmetthat jody was talking to all our farm families projects, and they often have never seenthe shorty helmet. i guess the other thing that is ofconcern, though, for 40-degree heat, is there is some evidence to suggestthat you can get cerebral heating, and i think that is a real concernin hot populations. how much do the manufacturers takeresponsibility for some information?
i mean, the manufacturers of tractorshave taken increasing responsibility for safety on the tractors - that's because they've been forced to. but the extent to which there arepartnerships available with industry for safety, 'cause it's not inthe manufacturer's interest to get a bad name for quad bikes,for example. do we know? one of the difficulties is, of course, if quad bikes are thought ofas dangerous,
that goes againstthe manufacturer's interest in terms of selling and marketing. norman: which, indeed, they are.- well... i think you'll find the guidelinesby the manufacturers is very clear. that you are expected to wear a helmet and that you're certainly not to puttwo people on it, and you are not to add extra bitsand pieces to the quad bike, because once you do that,you alter the centre of gravity. so it is, um...
i guess there's both sides to this... norman: which is scott's point, that youmight not necessarily be making it safer with some of the kit that you put on it. absolutely, but you also shouldn't havetwo people on it. they're not... let's go to allan now. allan's 28 years old, banana picker from north queensland who presents with flu-like symptoms. he's only here
because his wife made him come. he doesn't think he's unwell and he likes to look after himself and he thinks he's wasting the doctor's time. he says he also has chills, he doesn't look that well. he's got headaches, bit of tummy pain. when you look at him, scott,
he looks a bit jaundiced. so, uh, it's good that his name's allan, because i suspect thatit may also be friedrich. there's a lot of transient workersdo fruit-picking during the season, and they're incredibly valued partsof the industry, and necessary for the industry. the likelihood, the possibility,is that this fellow may actually have gone throughsouth-east asia and this was his next stop,
and this may in fact be hepatitis a,but i think, given the exposure... norman: in other words,nothing to do with the farming at all? incidental, and you always needto take a full occupational history, which includes travel. but in this case, i think we really needto be thinking about leptospirosis as a possibility,because of the exposure to picking and his probable lack of adequatebriefing on protecting himself in the occupational circumstance. so for people like me whohaven't dealt with leptospirosis
since we got a multi-choicequestionnaire in our membership exam, just give us the lowdown on lepto. leptospirosis is a spirochaete that exists in a numberof domesticated mammals. it's transmitted in a number of ways and gets into humanspotentially by inhalation, but not uncommonly by damage to skin. and if there's contaminated urineon a banana-tree stem, for instance, and this fellow's been grabbing itand probably damaging his hands,
then you certainly can contract itthat way. but there has beena number of outbreaks recently, bruce chater and katie goot in theodore identified four casesduring the floods last... norman: just after the floods.- just after the floods. and that was essentially in peoplethat were cleaning up, they were in water, standing in water, and probably had damaged handsor damaged skin on their legs and probably contracted the illnessin that way, and were diagnosed...
norman: id physicians in the citydidn't believe them. well, look,i think it's to bruce and katie's credit that they stuck to their gunsand identified it, confirmed it, treated it and managed these cases. and, i must say, since those cases and since the queensland floodsof 2010-2011, there's been a significant increasein leptospirosis in queensland. and it's prevented how?protective clothing? uh, it's prevented by not gettingin contact with the spirochaete.
- you could argue...norman: yeah, well, that's good. so, as a transient worker,you need a microscope. take a slidebefore you walk on the field. and a postgraduate education. well, yeah, potentially, you could usesome prophylaxis, chemoprophylaxis, but i think, ideally,the best way to prevent it is the way the cane workershave prevented it, and you rarely see leptospirosisin cane workers now because they harvest the canein a tractor,
and they're away fromthe at-risk exposure. norman: so no exercise, they get fatter, they get heart disease,but they don't get lepto. they don't get leptospirosis. (laughs) - and penicillin is the treatment?- i would normally use doxycycline. norman: doxycycline.susan: you love doxycycline. which i think is what bruce usedin theodore. i think the other one is in dairy farms and, of course, you can inoculate cowsnow for leptospirosis,
but obviously, urine splashis very common for dairy farmers, so we see it a lotin our farm families... scott: and that's a great exampleof engineering-out risks as well in that, if you have a urine deflectorin a dairy battery, then you significantlyreduce the risk of leptospirosis. jody: not only dairy as well.i've seen cases of it from beef cattle. norman: let's move on to elsa who's recently been referred from the sustainable farm families program
where she had screened for diabetes. she came up with an ausdrisk score of 15, fasting blood sugar of 5.9. she's only seen you intermittently over the last 20 years 'cause she lives three hours out of town. since you last saw her, she's put on quite a lot of weight. bmi 35,
she's got a 14-year-old daughter with her who's also overweight and she's come to see you following the diabetes screening,scott. well, this certainlyis a concerning level, and can i say that it reflectsthe diversity of practice in rural medicine, that you get to see a numberof these different cases. and a metabolic condition like thisis very common.
it would also be commonly identifiedin routine health checks. this woman clearly needs to befurther investigated, uh, and the possibility is -or the probability is - that she is at a much higher riskof developing diabetes and potentiallycardiovascular disease risk. her waist circumference is 100, her blood pressure is 160/95. so she's heading towardsthe unholy four. i'd be interested in knowingwhat her lipid profile is.
- high triglycerides, high ldl.- and low hdls, no doubt. so she's at very high riskof going on to develop diabetes and that's going tosignificantly reduce her life and the quality of her lifeat the end of it. the nhmrc guidelineswould say lifestyle change. and i would be the firstto identify that and talk to her about that. given her relative isolation, the chance of her accessing structured,ready-made
lifestyle modification programsis limited. we're fortunate that a numberof the general practice divisions that i'm associated within southern queensland are very good at providing these and projecting them outinto rural areas. but nevertheless,it's very difficult working on a farm to access an exercise physiologistand a dietitian... ..and get these sorts of servicesto actually make changes to her life so i would tend to have a...
i would certainly be lookingto see her again in the very near future to see how she's progressing,provide as much counselling as i can. very often, i find that practice nursesin rural practices are multiskilled and probably could providesome of this advice. jody, what do you doabout something like this? 'cause it is hardto get lifestyle change. she's probably working on a farm,the farm is not doing well and there's all sorts of other thingsgoing on in her life which are more importantthan her health.
i would actually sit with herone on one, probably investigate what she thoughther biggest issue was, seeing how we could work together, whether it's gettingtelehealth services in, whether they be dietitians, physioor anything like that or actually me workingone on one with her to try and change her thought process and show her thatthere is actually a way... so this would be like skyping from home?
- with a dietitian?- yes. yep. do you think she might be depressed? there's certainly the possibility. susan: we would have done a screeningat sustainable farm family so we'd have that data. norman: well, she wasn't depressedbefore you did... (all laugh) if i was doing the full assessment,i'd be doing an assessment. yeah, we use the dess score.
certainly, depression is associated withweight gain. we have a better spread of alliedhealth workers across rural australia than we do gps for instance and you know,a number of them are trained in behaviour changeof one sort or another. and this notion of lifestyle change, do you have any successto claim for sff? certainly, if they havethree or more risk factors which clearly elsa does.
but it looked like it was all menyou were dealing with, not women. i don't know, we have 54% men,46% women so we are very much about farming menand women, farming families. so certainly we'd be expecting elsato come back, obviously, the following year. she'd be developing an action plan and we have also done some workwith a dvd called farming fit which shows farmershow to exercise on farm, - which may sound a bit funny.norman: give us some tips.
well, actually, being able to usedoorways, workshop benches, steps on the front verandah. one of our studies found that in fact they didn't knowwhile they couldn't access a gym, they were interested in learninghow they could do it on farm. tell us about your toolkit, david. well, the australian college ofagricultural health and safety at moree have put all this stuff together,they've looked at the risks, they've looked at the actions thatcan be taken to address the risks
and they've put it together in a toolkitwhich has checklists, which has dvd and which has posterswhich you can put up in a practice. and our initial thoughtwas this might be of use for people who are practitioners,you know, gps in general practices. where it seems to havea considerable effect is for people in training,trying to get a culture amongst rural health practitioners and an understanding of what it istheir clients and their patients need,
what they experience and howthey can address some of those issues so they are competent and capable of addressing the needs of ruralresidents and farmers in particular. but, scott, just to round off on elsa, your trigger presumably forpharmacological interventions would be low... i tend to have a low threshold andgetting her back and reviewing how she's going, i'd be looking to seewhether she's actually going at all.
and moving on to pharmacologicalinterventions, because you're more likely... they're more likely to needto progress to that, they're not going to have accessto the sort of services and therefore you need to dowhat you can to head off diabetes. norman: yeah. jim's a sheep farmer, he's 57. referred to scottfrom a rural financial counsellor and over the last four months,
he's lost weight, he's not sleeping, he's got aches and pains, listless and he's finding all this is becoming quite debilitating. he lost a lot of stock in the bushfires and floods and he's drinking a bit more since his wife has been away being treated for breast cancer.
scott, you're having a busy day. not straightforward cases. it's always busy in rural practice butit's a great diversity of practice and in this case, weight loss,sleep disturbance, somatic symptoms,listlessness and fatigue, potentially substance abuse, this fellow's startingto meet the requirements for the diagnosis of depression. and so, i guess oneof the first questions i'd be asking
after actually attemptingto create some rapport, i find the best way to create rapportwith these people is to actually understand thecircumstances they're coming from and to be able to speak sensibly aboutthe agricultural community and his industry. but you really got to getto the question of suicide... which is an important issue, particularly for a new practitionerin the area. you've got to know the lingo.
we take our registrarsand our students to farms, we get them to meet farmers,to walk around with farmers, to start to speak the lingo. it's a great way to create rapportif you can understand the crop, if you can even mention the cropthey're growing and ask them how they're going, how much land have they gotunder sorghum and... it indicates that you have an empathyfor what they're doing and particularly ifyou're going to ask somebody...
and don't ask themwhere the best coffee is locally. (all chuckle) but particularly if you're going to moveon to the question of suicidal ideation which you absolutely have toin this case, you need to have created some rapportand it can't be something that takes multiple consultations to develop. you need to determineif this fellow is at risk. but there are other possibilitiesfor this and obviously,we need to investigate for,
are there organic causesfor this condition? but in my experience,this fellow's got a reasonable reason to be depressed and probably the most practical thingwe can do is to find a way thathe can get to see his wife. i had a great case about two weeks agoin clifton where we had a gentleman whose wifewas dying in a palliative care unit and he didn't have a licence and we were able to get his licenceback, get him in his car
and there was no need to treat himwith antidepressants, all it needed was to give hima practical means for him to spend the lastcouple of weeks with his wife. and i think those arethe sort of solutions that i'd be looking for in this case. and i'd also be looking at the optionof a financial counsellor, whether some good... i realise he has an issue with his wife but if he's lost stock,if he's having a bad season,
financial pressure may be on so by getting that financial advice... so, practical problem-solving is reallywhat we're talking about here. jody: definitely. which is like, you know, the storythat you get with floods and fire is that people don't needthe grief counselling, they need a carpenter and a plumberand an electrician. and they need it now. some of the research has shown thatthe role of the financial counsellor
and the networksthat provide health care are critical and that rural practitioners need tohave much broader medical networks, they need to have social networks,they need to be aware of these things and they need to be able to refer peopleto non-medical sources if that's where the help'sgoing to come. let's look at some useful websites,david. well, we've got three useful websites here: one is farmsafe australia.
and the second which i know better is the australian centre for agricultural health and safety which is the producer of the toolkit and which has put together a lot of the information that people need if they're to understand the risks and the responses that make sense in rural farm health.
and the third one is the national centre for farmer health which is susan's centre which we've been talking about this evening, and is running programs so that farmers can address the risk factors and the lifestyle factors that will give them better health.
just before we close, scott, just comingback to something we said before we came on airabout assessment tools and how you modify them forthe practical aspects of rural living. look, i think the beyondblue website is another one that i would commonlyrecommend for patients and on that, you can get the k10 but i find that if you just use the k10as written, it comes over clunkyand with cultural insensitivity, you really need to be modifying it,
not withstanding that you're potentiallymodifying its validity but you've got to put it into wordsthat sound natural from you, that fit with the circumstanceof the individuals in an agricultural community and k10 wasn't written for that. look, i'd also mention in this case the situation of the perception that agricultural communitieshave greater resilience collectively and i think in this caseit's a relevant feature
and you need to be able to mobilisethat resilience in a community to support this familyand you see that... even though they might bephysically isolated, they're not necessarilysocially isolated. rarely are they socially isolated i findin rural communities and that's one of the great strengthsof these communities. and you need to tap into that. it's somethingthat's not readily identifiable but if you can find a way to assist themfrom the community,
then it's better than most ssris. what are your take-home messages? david? my take-home messageis that we've got to invest in the mainstream services because it's those servicesthat are available day by day, it's the services that scott's part of,that jody is part of and that farmers need to be able to, and their familiesneed to be able to access, services that are aware of their needs,that are responsive
and that are high quality so invest in the mainstreamday-to-day services because they're there. i think probably havinga multi-disciplinary approach but also having the communityinvolved in that, having the community fully awareof the services that are available and working together to make surethat the right services are actually in that community so that you can have the best outcomes,health outcomes.
norman: scott? there needs to be an awarenessinstilled in training of the circumstances that people are in. particularly, i think,it's important to develop applied knowledgein agricultural health and medicine in the discipline of rural health. that needs to be in the trainingfrom early on and to identify that this is a distinctdiscipline within rural health. norman: susan?
norman, i think that farm men and womenand agricultural workers are a specific target groupand need to be treated as such and health professionals need to beculturally competent when working with those people. and remember,women work on the farm too. absolutely. don't forget that. i hope you've enjoyed the programas much as i have - fascinating, i've learned a lot. if you're interested in obtaining moreinformation about the issues raised,
there are a numberof resources available don't forget to completeand send in your evaluation forms and register for cpd pointsby completing the attendance sheet. our thanks to the departmentof health and ageing for making the program possible but our thanks also to you for taking the timeto attend and contribute. i'm norman swan, i'll see you next time. captions bycaptioning & subtitling international
funded by the australian governmentdepartment of families, housing, community servicesand indigenous affairs�
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