WILLMAR -- The patient's medical history indicated that she worked on a farm, but it still took months for doctors to put two and two together and realize her breathing problems were work-related.
It's a scenario that Dr. Steven Kirkhorn sees far too often.
"All those months she was misdiagnosed," said Kirkhorn, who is medical director of the National Farm Medicine Center in Marshfield, Wis.
Respiratory illness is one of the chief occupational hazards in farming, yet -- as this patient's story demonstrates -- it often goes unrecognized and unaddressed, Kirkhorn said.
It's frequently overlooked by medical practitioners, he said. What's more, state and national regulations to help protect farm workers from potentially harmful exposure are almost nonexistent.
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Kirkhorn is among those hoping to change this situation. Their strategy: raising the visibility of respiratory illness among farm workers, pushing for more education within the industry and providing training for the rural health care professionals who treat farm workers.
Kirkhorn led one such session this past week at Rice Memorial Hospital in Willmar. Aimed at health care providers and televised at three additional hospitals in the region, it was sponsored through a grant from the National Institute for Occupational Safety and Health to the Midwest Center for Occupational Health and Safety at the University of Minnesota School of Public Health.
Respiratory illness among farmers has not, for the most part, been a priority, Kirkhorn said.
"It leads to more chronic long-term problems, so it hasn't received the attention that injuries have," he said. "Because the profit margins are so thin, the emphasis has been on production. Farmers have historically looked at their health as secondary."
The farming industry doesn't even have a national, organized medical surveillance system, in spite of the fact that farming ranks second only to mining as one of the most hazardous occupations in the United States.
"There isn't a mechanism to identify things early. There's no proactive care in agriculture, unfortunately," Kirkhorn said.
There's a long list of airborne substances to which farm workers are exposed on an ongoing basis.
They might be breathing air that contains high amounts of organic dust -- a brew that may include molds, bacteria, animal dander and manure. They can be exposed to fumes from ammonia and chemical disinfectants, or to the exhaust from machinery and farm equipment.
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Over time, respiratory problems such as chronic bronchitis, chronic obstructive pulmonary disease or occupational asthma can develop.
So-called farmer's lung, or farmer's hypersensitivity pneumonitis, is relatively rare but can lead to permanent respiratory impairment.
High concentrations of hydrogen sulfide, which is released from manure, can cause "knockdown," or sudden loss of consciousness, and they sometimes are fatal.
The proliferation of large confinement facilities also means that farm workers increasingly are working indoors, in settings with high animal density and high concentrations of dust and gases, Kirkhorn said.
"That has consequences for the people working there," he said.
Farm workers can be exposed as well to airborne diseases such as avian influenza, swine influenza, and psittacosis, which is transmitted by poultry.
How can rural health care providers get better at recognizing and treating ag-related respiratory illness? One initiative that's under way is AgriSafe, a project based in Iowa that offers specialized training so that health providers can conduct agricultural health screenings and do on-site farm health and safety audits.
Farm workers tend to seek health care close to home, Kirkhorn said. "So if the local practitioners aren't aware of these ag-related conditions, people aren't going to be treated appropriately. ... It's knowing what your local issues are. There should be some rural health care providers that are knowledgeable."
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It's also important to reduce the risk of respiratory exposure, Kirkhorn said.
One way is through better engineering and design of confinement facilities, to improve the ventilation and reduce dust levels. Another is workplace practices such as monitoring for harmful gases and using protective masks or respirators.
Kirkhorn thinks the message is beginning to get through.
"There is more awareness among farmers. Their health is important to them," he said. "Agriculture is such an essential industry. There has to be some recognition of the people working there. We need to allow people to work in an essential industry that feeds us and help them remain safe."
