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Pesticides and National Strategies
    for Health Care Providers
      Workshop Proceedings

        April 23-24, 1998
             July 1998

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                           Acknowledgments
    The success of the workshop would not have been possible without the efforts of a large number
    of dedicated people. We wish to acknowledge the efforts of the members of the Expert Panel
who gave graciously of their time, experience, and energy in both attending the workshop and
developing a practical product. We are grateful to the three speakers, Augustave Wilson, Mark Robson
and Louise Rauckhorst, for their presentations, and to the many observers who came from all over
the country to attend the workshop and contribute their experiences.

We would like to acknowledge the commitment and enthusiasm of the members  of the Federal
Interagency Planning Committee who helped organize the event and provide leadership in advancing
this historical interagency national initiative. Staff work and planning by EPA personnel—including
Ameesha Mehta, Belen Revilla, Delta Valente, Ana Maria Osorio and Kevin Keaney—were essential
in making the workshop a success. A special thankyou to Susan West, with the National Environmental
Education and Training Foundation, for her expert assistance in facilitating the workshop and helping
to draft these proceedings. We thank Andrea Smith and Mary Davis with the Association of Teachers
of Preventive Medicine for their planning and organizational effort, and Gilah Langner of Stretton
Associates for editorial and graphics assistance. Additional copies of these proceedings may be obtained
by calling EPA at 703-305-7666.
Cover photo credits: Left, Alan Pogue; Right, EPA

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                                  Contents
.. r '  i . . ,     ...
   ^Executive Summary.
  >  Part I: Setting the Stage

       1.  Introduction ............................ . ............. ..... . ..... . ......................... ,    _              2

   , ., , 2.  A Collaborative Effort ............... [[[    7

    1   3. « Facts About Pesticides ; ........ ... ....... : ...... ........................ „....                     12

       4.  Practitioner Perspectives: Lessons Learned and Success Stories ............... . ..... .....   16



    Part II: Findings and Recommendations of the Expert Panel

       5.  Findings [[[           26

  r     6.  Preamble to Expert Panel Recommendations ............ ..........................................   29

       7.  Recommendations of the Expert Panel ............................................... .................   30

             Strategy I: Defining Recommended Competencies ........................................   30

             Strategy II: Impacting Education and Training ............................................. ..   34

             Strategy III: Raising Awareness ................................... . ..................... ; ..............   37

             Strategy IV: Maintaining and Developing Resources ......................................   42

       8.  Recommended Next Steps [[[   43



   Appendices


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Vybf'ksbpp OW peyeloping National Strategies
                                                            frililill^^  iHgiUfr
1
               Executive Summary

                 In April 1998, EPA and several other federal agencies convened a workshop of experts
                 in the field of health professional education to identify strategies for educating
               health care providers on how to recognize, diagnose, manage, and prevent adverse
               health effects from pesticide exposures.

               The workshop reflected the collaborative nature of EPA's initiative and the need to involve
               a wide group of stakeholders in this issue. The workshop brought together an expert
               panel representing associations of health professionals from the medical, nursing, and
               physician assistant communities; farmworker and community interest groups; academic
               faculty; and pesticide experts. In addition, an invited group of observers from state and
               federal agencies, health clinics, community-based programs, farmer and farmworker
               groups, and other interested organizations participated in question and answer sessions
               with the expert panel.

               At the federal level, EPA is coordinating and pooling resources with the Department of
               Health and Human Services (Health Resources and Services Administration, National
               Institute for Occupational Safety and Health), the Department of Labor (Occupational
               Safety and Health  Administration,  Employment Standards Administration), and the
               Department of Agriculture (Agricultural Marketing Service and Cooperative State, Research,
               Education and Extension Service).

               Among the themes and findings that emerged from the workshop are:
               •  The lack of adequate training for health care providers on potential adverse health
                   effects from pesticide exposures;
               •  The need for partnerships among the stakeholders involved in this issue;

               •  The diversity of peoples and cultures affected by pesticides;
               •  The importance of addressing both child and adult pesticide health issues;
               •  The importance of addressing  both agricultural and non-agricultural (including
                   urban) sectors;
               •  The need for multidisciplinary approaches to diagnose, investigate, and prevent
                   adverse health effects from pesticide exposures;

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                                                                            • Executive,' Si|mmary|
 •  The importance of addressing this issue in the context of the larger health care and
    public health systems; and

 •  The need to maintain existing programs and disseminate information about model
    programs and resources that address pesticide health issues with health care providers.

 The expert panel decided that the target of this initiative should be primary care providers,
 defined as physicians, nurses, nurse practitioners, physician assistants, nurse midwives,
 and community health workers specializing in one of the  following areas: family
 medicine, internal medicine, pediatrics, obstetrics/gynecology, emergency medicine,
 preventive medicine, or public health. As the "gatekeepers" of our health care system,
 all primary care providers should possess basic knowledge and skills related to pesticide
 and other occupational or environmental exposures. The  panel  outlined desired
 outcomes in the knowledge and behavior of primary care providers, in general, and for
 three stages of education: basic education, specialty training, and  practice settings/
 continuing education.

The panel agreed on recommendations for further development in four main areas:

•  Strategy I: Defining Recommended Competencies for primary care providers. The
    panel made initial recommendations for specific competencies and the appropriate
    emphasis of training during basic education, specialty training, and in practice
    settings.

•  Strategy II: Impacting Education and Training to motivate and train students and
    practitioners on the subject of health effects resulting from  pesticide exposures. The
    panel made initial recommendations for basic education, specialty training, and
    continuing education/practice settings.

•  Strategy III: Raising Awareness of the broader primary provider constituency through
    a variety of mechanisms. The panel identified examples such as professional meetings,
    marketing and outreach efforts, materials and resources development, journal articles,
    distance learning, and support networks including the Internet.

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-"Workshop on Developing National Strategics
               •  Strategy IV: Maintaining and Developing Resources. The panel recommended
                   exploring the centralization of resources for primary care providers and strengthening
                   links to existing resources.

               The next steps  in the development of a more detailed implementation plan for the
               strategies are outlined at the end of the workshop proceedings.

               This initiative is conceived of as a  long-term effort. Achieving its goals will depend on
               the collaboration and involvement of a great many organizations and people. The
               initiative will be integrated in the broader context of other national initiatives in
               occupational and environmental health, to avoid duplication of effort. EPA encourages
                 -'  '                 '                                    ,                    '
               all interested organizations to play a role in the development of the initiative and to
               stay up-to-date  by visiting its Web  site at http://www.epa.gov/pesticides/. Feedback on
               these workshop proceedings and the  initial recommended national strategies are
               welcomed by EPA and its federal partners. Questions and comments can be directed to
               Ameesha Mehta, EPA, at 703-305-7666.

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 I.    Introduction

     Pesticide poisoning is a commonly under-diagnosed illness in America today.
     A new initiative of the U.S. Environmental Protection Agency, entitled Pesticides
and National Strategies for Health Care Providers, is aimed at ensuring that health care
providers become better aware, educated, and trained in pesticide health issues.

                        In April 1998, EPA convened a workshop to develop national
                        strategies to improve the education and awareness of health
                        care providers in dealing with pesticide-related health issues.
                        The workshop brought together an expert panel of key
                        organizations involved in this issue, representing associations
                        of health professionals from the medical, nursing, and
                        physician assistant communities; farmworker and community
                        interest groups; academic faculty; and pesticide experts. In
                        addition, an invited group of observers from government
                        agencies, health clinics, community-based programs, farmer
                        and farmworker groups, and other interested organizations
participated in question and answer sessions with the expert panel.
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            The goals of the workshop were to:

            •  Design national strategies on how to effectively educate and train health care
                providers about potential adverse health effects from pesticide exposures in the
                agricultural and non-agricultural sectors;

            •  Create a cohesive and multidisciplinary team of experts that represents stakeholder
                groups;

            •  Identify possible collaborative efforts between stakeholder organizations and federal
                agencies to address recommended strategies; and

            •  Produce workshop proceedings to be disseminated to stakeholder groups and others.

            This initiative is a long-term integrated effort. Achieving its goals will depend on the
            collaboration and involvement of a great many organizations and people. EPA and its
            counterparts on the Federal Interagency Planning Committee that organized the
            workshop encourage all interested organizations to play a role in the development of

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the initiative. Feedback on these workshop proceedings and the initial recommended
national strategies are welcomed by EPA and  its federal partners. Questions and
comments can be directed to Ameesha Mehta, EPA, at 703-305-7666.


Background on the Initiative

The initiative on pesticides and health care providers received its impetus from a
number of sources. A primary contributor is EPA's Worker Protection Standard which
is designed to reduce pesticide exposure to agricultural workers, mitigate exposures
that occur; and inform agricultural employees of the hazards of pesticides. The
regulation, implemented in 1995, mandates that millions of farmers, pesticide
applicators, and farmworkers be educated about the health effects of pesticide exposure
and the need to get medical treatment for such effects. This in turn is expected to
create additional demand for services from health
care providers.
After the first year of full implementation of the
Worker Protection Standard, EPA held nine public
meetings to evaluate the progress of implementation
and hear the experiences of the people most affected
by the regulation. One clear message from the public
meetings was the need to improve the recognition,
diagnosis, and management of adverse health effects
from pesticide exposures on the part of all primary
care providers of the health care community.
   Unfortunately, we have all too few
^.statistics on the rates of pesticide illness,
   but from the few states that do have
sr^reporting on pesticide illnesses, we know
'_ ~ihat there are very high rates among
[,  some occupations...
•. ~_ ^ i believe that the use of methyl
*  parathion [in homes] is probably
-*r
!gT indicative of a broader problem of lack of
   understanding about pesticide usage in
--' our society, and lack of recognition of
£  those exposures when they do occur.
            — Dr. Lynn Goldman, EPA
Although the primary populations affected by
pesticides are the 3 to 4.5 million, farmworkers in
America  and  the million or  more pesticide
applicators, pesticides have become ubiquitous in our society. Urban and suburban
exposures to  pesticides through lawn care products and insecticides in the home and
workplace are affecting the population at large. Health care providers in urban settings
are even less likely to "think pesticides" in taking patient histories or diagnosing illnesses.

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Workshop on Developing National Strategies
               Americans look to their health care providers for guidance on health concerns.
               Increasingly, such concerns include the effects of environmental and occupational
               hazards — such as pesticides — on their health. While some progress has been made in
               introducing environmental health issues into the curriculum of medical and nursing
               schools, most health professionals still do not have adequate knowledge and tools to
               address patient and community concerns about pesticides and other environmental
               hazards. Nor is the recognition and management of pesticide health effects an integrated
               part of the clinical training program of health care providers.

               The need for improvements in health care provider training has been expressed by health
               provider groups as well as government and community organizations. In 1994, the
               American Medical Association adopted a resolution urging Congress, government
               agencies, and private organizations to support improved strategies for the  assessment
               and prevention of pesticide risks. These strategies included systems for reporting pesticide
               usage and illness, as well as educational programs about pesticide risks and benefits. In
               addition, two Institute of Medicine (IOM) committees have dealt with the general issue
               of environmental health education, focusing on nurses and physicians, respectively.
               Both committees recommended an integration  of environmental  health issues
               throughout the various stages of training and clinical practice for health care providers.
               The expert panel convened under the current initiative discussed the lOM's reports at
               length and chose to adopt a revised IOM statement as a preamble to the expert panel's
               recommendations (see section 6).

               Over the years, states, universities, and federal agencies have conducted a  number of
               successful programs aimed at increasing awareness and training. However,  few efforts
               have been sustainable overtime and national in scope. In pursuing this issue further, EPA
               realized the importance of bringing together federal agencies working in this area and as
               many stakeholder groups as possible. Moreover, to capture all pesticide-related health
               issues, the scope of the effort must be geared toward both agricultural and non-agricultural
               sectors. A Federal Interagency Planning Committee was created in Fall 1997. Its first goal
               was to conduct a workshop that would develop national strategies for health care providers.

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                                                                                Introduction
Convening the Workshop

The workshop held on April 23-24, 1998 in Arlington, Virginia was sponsored and
planned by EPA in collaboration with the Department of Health and Human Services,
Department of Agriculture, and Department of Labor. The Association of Teachers of
Preventive Medicine  and the National Environmental Education and Training
Foundation worked with these federal agencies to organize the initiative (see list of
Federal Interagency Planning Committee members in Appendix A).

In an effort to advance the initiative, the planning committee convened an expert panel
with representatives of 16 health organizations involved in this issue. The workshop
was conceived of as a deliberative session of the expert panel, open to the public, with
comments and questions taken from the audience of observers, who often were experts
themselves in the issues raised. The expert panel included representatives from the
following organizations:

       •   American Academy of Family Physicians;
       •   American Academy of Pediatrics;
       •   American Academy of Physician Assistants;
       •   American Association of Colleges of Nursing;
       •   American Association of Poison Control Centers;
       •   American College of Emergency Physicians;
       •   American College of Occupational and Environmental Medicine;
       •   American Nurses Association;
       •   Council of State and Territorial Epidemiologists;
       •   Migrant Clinicians Network;
       •   National Center for Farmworker Health;
       •   National Organization of Nurse Practitioner Faculties;
       •   National Pesticide Telecommunications Network;
       •   National Rural Health Association;
       •   Pennsylvania State University/National Agromedicine Consortium; and
       •   Suncoast Community Health Centers, Inc.

       The list of expert panel members can be found in Appendix A.

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These workshop proceedings are intended as a working document to raise awareness,
spark discussion and debate, and involve a still wider group of organizations. The
remainder of Part I of the proceedings presents background information, including a
brief outline of the federal agencies and other groups collaborating on the initiative
(Section 2); facts about pesticides and pesticide-related health concerns (Section 3);
and the perspectives of practitioners in the field (Section 4).

Part II of the proceedings contains the findings and recommendations of the expert
panel.  The panel identified its target audience as primary care providers, defined its
overall goals for the initiative (Section 5); adopted a preamble (Section 6); and developed
four strategies for primary care providers (Section 7). Section 8 outlines the next steps
for the initiative. Two appendices to the proceedings identify selected resources in the
field and list contacts for the Federal Interagency Planning Committee, the expert panel,
and observers at the workshop.
EPA and the members of the planning committee welcome the involvement in this
initiative of all groups interested in pesticides and health care issues. Please contact
members listed in the appendix for more information, or visit our future Web site on
the Internet at http://www.epa.gov/pesticides/. The Web site will provide up-to-date
information on the status of the initiative, as well as more detailed information about
the stakeholders involved, workshop proceedings, and documents produced during the
course of the initiative.

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2.    A Collaborative  Effort

      Getting an initiative of this magnitude underway requires the collaborative efforts
      of a large number of agencies, organizations, and decision-making bodies. The
success of this initiative will depend on the extent to which it can reach and involve the
hundreds of groups and organizations whose missions are directly relevant to this effort.

EPA is coordinating and pooling resources with the Health Resources and Services
Administration and the National Institute for Occupational Safety and Health of the
Department of Health and Human Services; the Occupational Safety and Health
Administration and the Employment Standards Administration of the Department of
Labor; and the Agricultural Marketing Service and the Extension Service of the U.S.
Department of Agriculture. State and local governments will also play a vital role, working
both with federal agencies and directly with organizations dealing with pesticide exposures.

Community-based organizations, agricultural and migrant worker groups, universities,
and associations of health professionals are important front-line providers of information
and health care to people affected by pesticides. Community and migrant health centers
tending to migrant, rural, and farmworker populations understand the health care needs
and cultures of individuals who are most likely to seek care for pesticide exposures.
Academic faculty (e.g., from agromedicine, environmental and occupational health,
pediatrics, and family practice) and medical, nursing, and physician assistant associations
provide vital information on the skills that health care providers must possess to diagnose
and treat pesticide exposures. The organizations participating in this initial meeting are
listed in Appendix A. As the initiative develops, other organizations will be involved in
drafting and finalizing the strategies and implementation plan.
 Federal Agency Collaboration

 A fundamental approach and unique feature of this initiative is that it brings together a
 number of federal agencies with pesticide-related mandates in a cooperative and interactive
 working arrangement that avoids duplication of effort. Following is a short description of
 the mandates of each of the federal agencies involved in the initiative, along with a brief
 quote from the remarks of the official representing the agency at the workshop.

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Workshop on Developing National Strategies
                U.S. Environmental Protection Agency (EPA)
                EPA regulates the use of pesticides through its pesticide registration program. In addition, EPA
                works in partnership with state and tribal agencies to implement two field programs — the
                certification andtrainingprogram forpesticide applicators and the agricultural worker protection
                standard — to protect workers and handlers from pesticide exposures. EPA sets national
                standards for certification of over 1 million private and commercial pesticide applicators.

               The Worker Protection Standard represents a major strengthening of national efforts to
               safeguard agricultural workers. The goal of the regulation is to: inform employees about
               the use and hazards of pesticides; eliminate or reduce exposure to pesticides; and mitigate
               the effects of exposures that occur. The regulation contains requirements for worker
               pesticide safety training, worker notification of pesticide application, use of personal
               protective equipment,  restricted  entry intervals after pesticide application,
               decontamination supplies, and emergency medical assistance.

                         "Due to high pesticide use in both the urban and agricultural sectors
                         there is even a greater need for health care providers to be able to identify
                         possible pesticide-related conditions and make the appropriate treatment.
                         The incorporation of environmental health concepts, and particularly
                        pesticide issues, into professional education is critical for minimizing the
                        occurrence and the severity of pesticide-related illness and injury."
                               — Dr. Lynn  Goldman, Assistant Administrator, Office of
                                      Pesticides, Pollution Prevention, and Toxics, EPA
               Health Resources and Services Administration (HRSA),
               Department of Health and Human Services
               HRSA works to improve the nation's health by assuring equitable access to comprehensive
               health  care. HRSA's efforts are directed at special needs, underserved, and vulnerable
               populations. Among its offices and bureaus are the Office of Rural Health Policy, the
               leading federal advocate for better rural health care services; the Bureau of Primary Health
               Care, whose mission is to increase access for the underserved to comprehensive primary
               and preventive health care; and the Bureau of Health Professions, which provides national
               leadership in assuring a workforce of health professionals that meets the health care
               needs of the public.

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          "I would like to make sure that we stay interdisciplinary, which is a  .,
          critical aspect; that we stay consumer oriented; and that we deliver to
          the American people a quality product that we hope we'll be able to
          move ahead on your advice."
                    — Neil H. Sampson, Acting Associate Administrator
                                         for Health Professions, HRSA
National Institute for Occupational Safety and Health (NIOSH),
Department of Health and Human Services
NIOSH is the federal agency responsible for conducting research on occupational disease
and injury. NIOSH may investigate potentially hazardous working conditions upon
request, makes recommendations on preventing workplace disease and injury, and
provides training to occupational safety and health professionals.

          "Pesticide-induced issues are found in priority categories within all
          three of the main areas in NIOSH. These include disease and injury,
          work environment and the workplace, and in research tools and
          approaches."
                          — Dr. Stephen A. Olenchock, Senior Scientist
                                      for Agricultural Research, NIOSH
Cooperative State, Research, Education and Extension Service (CSREES),
U.S. Department of Agriculture
CSREES, more commonly known as the Extension Service, works with its university
partners, the state land-grant system, to provide farmers and ranchers information to
reduce and prevent agricultural-related work incidents. The Pesticide Applicator Training
program trains applicators in the safe use of pesticides and coordinates pesticide-related
safety training programs. The Extension Toxicology Network,  EXTOXNET, provides
science-based information about pesticides to health care providers treating pesticide-
related health concerns.

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Workshop an Developing National Strategies
                         "Training and education can have positive impacts on reducing
                         pesticide-related illnesses. We all have an important role in that trend."
                                                                  — Barry M. Brennan,
                                                   Associate National Program Leader,
                                                 Pesticide Applicator Training,  CSREES
               Agricultural Marketing Sendee (AMS),
               U.S. Department of Agriculture
               AMS administers the pesticide recordkeeping program under which certified pesticide
               applicators are required to maintain records on restricted-use pesticides. These records
               must be made available to licensed health care professionals treating patients who may
               have been exposed to restricted-use pesticides. AMS supports an outreach project to
               educate health care professionals about the availability of this information.

               Wage and Standards Division, Employment Standards Administration (ESA),
               U.S. Department of Labor
               The Wage and Standards Division administers the wage, hour, and child labor provisions
               of the Fair Labor Standards Act, as well as several other programs covering prevailing
               wages for government contracts and farm labor, family and medical leave, immigration,
               and polygraph testing.

                         "Since early in 1997, the Wage and Hour Division has been the
                        primary federal enforcement agency for enforcing the field sanitation
                        standards developed by OSHA ten years ago...Perhaps the single most
                        important protection from pesticide hazards aside from preventing
                        exposure at all is the availability of handwashing facilities to remove
                        pesticide residues that could otherwise be absorbed through skin or
                        transferred and consumed."
                                   — Corlis L. Sellers, National Program Administrator,
                                                         Wage and Hour Division, ESA

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Occupational Safety and Health Administration (OSHA),
U.S. Department of Labor
OSHA's mission is to protect lives, prevent injury, and protect the health of America's
workers. More than 100 million workers and 6.5 million employers are covered under
the Occupational Safety and Health Act. OSHA and its state partners have approximately
2100 inspectors, plus investigators, standards writers, educators, physicians, nurses, and
other staff in over 200 offices across the country. OSHA sets protective workplace
standards, enforces the standards, and reaches out to employers and employees through
technical assistance and consultation programs.

          "If your front line clinicians are seeing migrant farmers, typically there
      •   will be a labor camp in place, and so typically OSHA will have some' ;
         jurisdiction. What I want to ask you to think about is figuring out a
         way to help us effectively convey to your front line clinicians that if they
         have bad stuff that is obvious, if they have heat stroke, if they have a
         patient who has lost a limb, had an amputation, had a major accident,
         or who has even... the chronic effects of lifting with back injuries,
         shoulder injuries, that sort of thing, as well as clinical pesticide
         poisoning, that it is worth a phone call to the local OSHA. You can  '•  •   - •
          look them up in the blue pages of the phone book."
                                       — Dr. Rosemary Sokas, Director,
                                 Office of Occupational Medicine,  OSHA

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             3.    Facts About  Pesticides
             Pesticides

             •  Currently in the U.S., there are over 17,000 registered pesticide products and over
                800 related active ingredients. Seventy-six percent of the pesticides used annually
                (approximately 950 million pounds) are used in the agricultural industry. Twenty-
                three percent of the pesticides used annually (approximately 294 million pounds)
                are used in the urban sector (U.S. EPA, 1997).
•  EPA regulates the use of pesticides in the United States
under the authority of the Federal Insecticide, Fungicide, and
Rodenticide Act (FIFRA)  and the Federal Food, Drug and
Cosmetic Act. Pesticides differ from other substances regulated
by EPA because they are intentionally applied to crops and
targets, rather than representing by-products of industry or
other human activity. Pesticides are likely to be found in nearly
every home and business in the United States, in the form of
insecticides, weed killers, flea controls, disinfectants,  and
swimming pool chemicals. They are also used in schools, parks,
and other public places.
                                    •  EPA is responsible under FIFRA for registering, re-registering
                                    and de-registering pesticides to ensure that, when used according
                                    to label directions, they will not pose unreasonable risks to
               human health or the environment. This involves: 30 major pesticide producers; 100
               smaller producers; 3,300 formulators; 29,000 distributors; 40,000 commercial pest
               control firms; approximately 1 million farms; several million industry and government
               users; and approximately 90 million households (U.S. EPA, 1998).


            Pesticide  Poisoning

            •  Agricultural workers and pesticide handlers appear to be at greatest risk for acute
               pesticide poisoning. Based on states with required reporting of pesticide poisonings,
	^^-	:...:	:	::	iiig

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    EPA estimates approximately 250-500 physician-diagnosed cases occur per 100,000
    agricultural workers (including pesticide handlers). It is believed that the number
    of actual cases would be twice as high if undiagnosed and unreported cases were
    included (Blondell, 1997).
    A substantial number of people in the U.S. are
    also at risk of pesticide poisoning from non-
    agricultural  uses. Data collected from the
    American Association of Poison Control Centers
    found that in 1996, almost 80,000 children were
    exposed to common household pesticides in the
    United States. It is estimated that one quarter of
    those children developed symptoms of pesticide
    poisoning. Over 34,000 adults were exposed to
    various types of pesticides and an estimated 72%
    of them developed symptoms of pesticide
    poisoning (Litovitz et al, 1997).
    We are looking more and more at
  ^suburban pesticide use. One of the things
        concerns us is the number of people
    *
   "that are using pesticides in the house at
     >ur and five times the rate, the mindset
    being that if one teaspoon is going to kill
       bug, darn, five teaspoons are really
5> * going to Ml the bug. So we repeatedly
^'"tsee people in our clinic that have just
    been  exposed because they applied it six
    and seven limes instead of once like  the
 iis:, label  says.
                   — Dr. Mark Robson,
       Environmental and Occupational
               Health Sciences Institute
•   In addition to accidental poisonings, since 1994,
    EPA has responded to several pesticide misuse
    incidents occurring in Midwestern and Southern    ^                    ~ ~
    states. Those incidents involved people who had illegally sprayed homes and other
    buildings with methyl parathion, a highly toxic agricultural pesticide registered for
    outdoor use only. Investigators found high levels of methyl parathion residues in
    homes. Based on urinalysis of residents, about 3,400 people were relocated from
    their residences. The widespread misuse of methyl parathion is a real public health
    threat, especially to infants and children. Public agencies have spent well over $72
    million to date responding to this emergency (U.S. EPA, 1998).


Training of Health Care  Providers

•   For many years, health care providers were not trained in environmental issues related
    to human health. In 1985, only 50% of U.S. medical schools included occupational
    and environmental health in their curricula, with an average of only four hours of

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   instruction over four years (Levy, 1985). By 1992, 66% of schools required about six
   hours of study in occupational and environmental health (Burstein and Levy, 1994).

•  A survey of 89 departments of internal medicine at U.S. medical schools found that
   only 22% offered occupational medicine experiences, almost all of which were
   elective (Cullen and Rosenstock, 1988).

•  In 1988, an Institute of Medicine (IOM) committee on the role of the primary care
   physician in occupational and environmental medicine recommended that all
   primary  care physicians be able  to identify possible occupationally or
   environmentally induced conditions and make appropriate referrals for follow-up
   (IOM, 1988). In 1992, the IOM convened a Committee on Curriculum Development
   in Environmental Medicine which culminated in the report, Environmental Medicine:
   Integrating A Missing Element into Medical Education (Pope and Rail, 1995).

•  In  1993, the Institute of Medicine convened the Committee on  Enhancing
   Environmental Health Content in Nursing Practice. The committee's report, Nursing,
   Health and the Environment, recommended that environmental health concepts be
   incorporated into all levels of nursing education as well as nursing licensure and
   certification examinations (Pope et al., 1995).

•  Also in 1994, the American Medical Association adopted a resolution urging
   Congress, government agencies, and private organizations to support improved
   strategies for the assessment and prevention of pesticide risks (AMA, 1994).
 References
 American Medical Association. Report 4 of the Council on Scientific Affairs, Educational and
 Informational Strategies for Reducing Pesticide Risks (Resolutions 403 and 404), December, 1994.
 Blondell, J. "Epidemiology of pesticide poisonings in the U.S., with special reference to
 occupational cases." Occupational Medicine: State of the Art Reviews, Vol. 12.2. April-June, 1997.
 Burstein, J.M. and B.S. Levy. "The teaching of occupational health in US medical schools: little
 improvement in nine years." American Journal of Public Health, 84(5):846-849, 1994.
 Cullen, M.R. and L. Rosenstock. "The challenge of teaching occupational and environmental
 medicine in internal medicine residencies." Archives of Internal Medicine, 148(110):2401-2404,
 1988.

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Institute of Medicine. Role of the Primary Care Physician in Occupational and. Environmental
Medicine, IOM Report, 1988.

Levy, B.S. "The teaching of occupational health in US medical schools: five-year follow-up of
an initial survey." American Journal of Public Health, 75:79-80, 1985.

Litovitz, T.L., M. Smilkstein, L. Felberg, W. Klein-Schwartz, R. Berlin, and J. Morgan, 1996
Annual Report of the American Association of Poison Control Centers Toxic Exposure
Surveillance System. American Journal of Emergency Medicine, 15:447-500, 1997.

Pope, A.M. and D.P. Rail, eds. Environmental Medicine: Integrating a Missing Element into Medical
Education. Committee on Curriculum Development in Environmental Medicine, Institute of
Medicine, National Academy Press, Washington, DC, 1995.

Pope, A.M., M.A. Snyder arid L.H. Mood, eds. Nursing, Health and the Environment:
Strengthening the Relationship to Improve the Public's Health. Committee on Enhancing
Environmental Health Content in Nursing Practice, Institute of Medicine, National Academy
Press, Washington, DC, 1995.

U.S. EPA. Pesticides Industry Sales and Usage: 1994 and 1995 Market Estimates. Office of
Pesticides, Prevention,,and Toxic Substances, EPA #735-R-97-002, pp. 12-13, August, 1997.

U.S. EPA. Office of Pesticide Programs Annual Report for FY1997. Office of Pesticides, Prevention,
and Toxic Substances, EPA #735-R-97-003, January, 1998.
                                                                                                    m

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4.    Practitioner Perspectives:
       Lessons Learned and  Success Stories

    Three practitioners were invited to make presentations at the workshop. They offered
    the perspectives of a migrant worker, a university-affiliated pesticide specialist, and
a nurse practitioner, respectively. Their presentations are summarized in this section,
followed by a discussion of themes that emerged during the course of the workshop
and a sampling of comments from workshop participants.

Three Perspectives

Wilson Augustave, Case Manager, Finger Lakes Migrant Health Care Project, Rushville,
New York. Mr. Augustave has been a migrant farmworker for most of his life and has had
extensive exposure to pesticides himself. He has spent the last three years training migrants
regarding the dangers of pesticides and how best to protect themselves. He is a member of
DHHS' National Advisory Council on Migrant Health.

                      Mr. Augustave offered the perspective of farmworkers who
                      by and large are living "a life of immediacy" at poverty levels
                      and are dependent on their jobs to support themselves and
                      their families. Voicing an opinion on pesticide exposures
                      could cost a worker his or her job, "so some things you keep
                      your mouth quiet about, and just hope that it doesn't hurt
                      you severely or soon."


                       Typically, Mr. Augustave noted, when farmworkers go into
                       health centers for pesticide-related concerns, they are given
                       pills and told to come back in a few weeks. Rarely do providers
discuss pesticides or are pesticides seen as a problem for the larger community.
Nevertheless, he noted, there are plenty of opportunities for broader pesticide exposures.
For example, workers use laundry machines in town to wash their clothes which contain
pesticide residues.

Mr. Augustave related a case of pesticide poisoning that he encountered at a migrant
labor camp. Eight men had gashes on their arms which looked "as if they had just had

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                                                                           Practitiofier Perspectives
                                                                          MJSt!*'(!."'
  a tangle with a flesh-eating disease." The contractor was applying a bottle of solution to
  some of the worst cases, and telling the workers that it was poison ivy. Mr. Augustave
  brought in the public health officials, who sent the workers to an emergency room. A
  day later, though, when he received a call from public health, the workers had all moved
  on and follow-up was no longer possible. Mr. Augustave stressed the need tp find some
  way for migrant farmworkers to have continuity of health care.
 Dr. Mark Robson, Executive
 Director, Environmental and
 Occupational  Health  Sciences
 Institute, Piscataway, New Jersey.
 Dr. Robson has worked in the area of
 pesticides for 20 years,  having served
 as the Extension pesticide specialist at
 Rutgers University, and later working
 in the New Jersey Department  of
 Environmental Protection. He serves on
 numerous pesticide-related committees
 including recently chairing the peer
 review committee for the EPA portion
 of the agricultural health study. Dr.
 Robson is currently involved in a
 National  Institutes   of Health
 environmental justice grant looking at
 pesticide issues  on the  Texas-Mexico
 border.


•f
 One afternoon a physician called "I have this terrible
^problem right now, I need some advice. Yesterday a woman
    s'pushing a baby carriage down the street. A lawn care
 fellow was coming the other way spraying a herbicide on the
 lawn. As he came to the comer, so did mom. Mom and baby
 all got sprayed with 2-4-D. We sent them right away to the
 hospital, but I want some advice. I immediately asked for a
 ~ ^           ^  ~~                     j-
 Cholinesterase test, but it didn't show anything."
 , -      I said, "It is not going to identify anything;
 'cholinesterase tests are for organophosphorus insecticides.
 Had you found something, we could have published
 together!"
        He said, "You know, the only  thing I remember
 from my medical training was 'Pesticides equal
''cholinesterase test.'"
-               - ; '  „  ^         — Dr. Mark Rojt>sonv
 Dr. Robson presented a case study from his clinic in which pesticide exposure and health
 problems were solved through the cooperation of the growers and local Extension Service.
 Two New Jersey farmers in their fifties who had farmed all their lives were experiencing
 blurred vision, lack of concentration, and other health problems. A closer investigation
 diagnosed chronic organophosphate intoxication. The two farmers grew only one crop
 — some 550 acres of lima beans — and did most of the work themselves.

 That meant that every week from May through July, the farmers did successive planting of
' lima beans. The spray schedule began when they started to till the soil and continued
                                                          m

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         "until they harvested the last lima bean." Every eight passes in the field, they would dump
         in the fine granular insecticide (Diazinon 14-G) and get "a face full of it." Moreover, the
         pesticides were kept in the shop, not in a separate storage area, as required by law. So the
         farmers were literally exposed to some amount of pesticides 12 months of the year.

         Dr. Robson explained how the team  of Extension staff and health care providers
         encouraged the farmers to put up a separate storage area, put up a separate washing facility,
         launder their work clothes each day and change into fresh coveralls, and start using personal
         protective equipment. The team also made simple design changes to the farmers' equipment
         to reduce pesticide exposure. The outcome was that "they looked and felt better than they
         had in years. It was like a miracle cure," said one of the farmers. Dr. Robson attributed the
         success to the one-on-one assistance, the farmers' cooperation with everything the doctors
         asked them to do, and the cooperative working relationship of grower, Extension staff,
         and health care providers.
         Dr. Louise Rauckhorst, Professor, Philip Y. Hahn School of Nursing, University of San
         Diego, San Diego, California. Since 1990, Dr. Rauckhorst has served as the nurse practitioner
                                  track coordinator at the School of Nursing. Her faculty experience
                                  in schools of nursing spans over 15 years, including conducting
                                  research and teaching and advising nursing students. Dr. Rauckhorst
                                  serves as project director on programs to improve the preparation of
                                  nurses in gerontology and migrant health, and to meet the challenges
                                  of health care in the next century.

,   ,;;.. ...... i.p  .. , ;, ,   . , ., ., •,  ..... .
                         Dr. Rauckhorst reported on a recent survey of 57 clinics in
                         several California counties  conducted by the pesticide
                         management department at the University of California at
                         Davis. Each clinic reported seeing only one or two identified
                         pesticide poisoning cases a year,  which makes it
                         understandable why it is difficult to keep providers' attention
                         on pesticide poisoning. Primary care providers reported being
largely unaware of reporting requirements, especially the requirement to report by
telephone within 24 hours to the local county health officer. Cases were only picked up
if a doctor's first report or an occupational illness report was filed, which would delay
any investigation of the situation.

-------
 n
 Primary care providers in the survey also reported being unaware of contact people and
 resources for pesticide-related cases. They also reported being reluctant to report a case unless
 they were 100 percent certain of the diagnosis, even though California law mandates reporting
 if a clinician suspects pesticide exposure to be the cause of a patient's health problems.

 Dr. Rauckhorst presented a likely scenario of a pesticide poisoning incident in San Diego
 County, and concluded with a discussion of gaps in coverage:

 •  Limited enforcement of federal and state laws regarding adequate training of workers,
    and provision and maintenance of required safety equipment and supplies.

 •  The need to focus training on local issues specific to local farmworker populations,
    the types of crops planted, the types of pesticides used.

 •  The need to tie these efforts with workshops, CME or CEU granting, written materials,
    Internet programs, staffed telephone support networks and consultation resources,
    to give providers ongoing access to pesticide information and referrals.

•  Opportunities to provide health profession students with field trips, especially if
    they intend to  practice in  rural areas, to give them first-hand knowledge of
    occupational risks.
Emerging Themes

Several themes emerged from the presentations and question and answer sessions among
the expert panel, presenters, and observers. They include:

•  Partnerships — the importance of developing a sense of partnership at multiple
   levels — among federal and state agencies, stakeholders, industry, community-based
   organizations, and professional associations; among growers, health care providers,
   Extension Service, and public health departments; between health care provider and
   patient, etc. Dr. Lynn Goldman of EPA noted that various agromedicine programs
   including the ones in Pennsylvania, North Carolina, South Carolina, and West
   Virginia, provide examples of successful partnerships and cooperation between key
   stakeholders. Dr. Roger F. Suchyta (American Academy of Pediatrics) noted the need

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Workshop zm Developing National Strategies
                   to consider how to bring industry into partnership on this issue. Teresa Niedda
                   spoke to the interest and expertise of community organizations as partners.

                   Diversity — the diversity of sectors affected by pesticides and the complex web of
                   interests, cultures, and populations involved (agricultural, non-agricultural, rural and
                   urban, family farms, migrant workers, children's exposures to residues, etc.). Dr. Mark
                   Robson (Environmental and Occupational Health Sciences Institute) noted that very-
                   little research has been conducted on women farmworkers, even though more than
                   half the work force are women. Rita Monroy (National Coalition of Hispanic Health
                   and Human Services Organizations) noted the need for sensitivity towards culture,
                   including language, beliefs, and values particular to the Hispanic community, or to
                   other communities with which health care professionals will be dealing. Chip Petrea
                   (University of Illinois/AshNet) noted that even from one Illinois county to the next,
                   dairy farmers would likely have a different frame of reference than grain farmers. In
                   addition, it is important to consider the literacy levels of all the sectors.

                   Multidisciplinary teamwork — the need to approach the issue  from a multi-
                   disciplinary framework which includes a variety of medical professions, departments
                   of agriculture, OSHA, departments of environmental quality, and  Extension. Dr.
                   Sheldon Wagner (National Pesticide Telecommunications Network) noted that in a
                   case of pesticide-related illness, it's not just a matter of a doctor analyzing the case
                   and making a diagnosis. Delbert Shelton (DuPont) pointed out that physicians need
                   follow-up support from others who will take on case investigations. He noted that
                   this type of multidisciplinary approach is used effectively in some of the agromedicine
                   programs.

                   Incentives — the importance of examining the incentives that influence health care
                   providers to address pesticide exposures in the larger context of the health care system
                   in which providers  operate. Among the issues  raised were the usefulness of state
                   reporting requirements in encouraging reporting of pesticide incidents, the high
                   turnover of primary care providers in rural areas, and the impact of managed care.
                   Dr. Rugh Henderson (Penn. State University/National Agromedicine Consortium)
                   pointed out that there are advantages to managed care which might enable reaching
                   and sensitizing health care providers to this issue;  on the other hand, the time
                   pressures in managed care make it less likely that a health care provider could pursue
                   pesticide-related health concerns. Joni Berardino (National Center for Farmworker

-------
   Health) noted that even if managed care were available in rural areas, farmworkers
   are generally not eligible to participate in such systems because they are uninsured.


Other Voices

A wide range of other subjects were touched on during the course of the workshop.
Following is a sampling of comments from participants gleaned from the question and
answer session during the first day of the workshop.

•  Surveillance programs: "Within the [Texas] Department of Health, part of our
   responsibility of being a surveillance program is to be available to take case reports
   from physicians when they call in. We follow-up in as much of a multidisciplinary
   way as we can, at least in Texas. That includes bringing in the Texas Department of
   Agriculture... They can use  their regulatory power to  fine growers if necessary, if
   there has been an inappropriate use of a pesticide. We use the skills that we have to
   look at health effects, and to follow up on a person after they have seen their physician.
 .  We look at them two and three days later, a week later, two months later. We complete
   full interviews with these people, looking at what they were exposed to, how they
   were exposed, what their occupation is. The majority  of our reports do not come
   from primary care physicians, they come from secondary sources, but the system is
   there." (Dr. Jackilen Shannon, Council of State and Territorial Epidemiologists)

•  Regional resources: "How can  we regionalize expertise in a specialized area like
   pesticide health and safely? In the Northwest we have a multi-state region that is
   served by the University of Washington Medical School. So we have what is called a
   medcon or medical consult that feeds calls from anywhere in Idaho, Montana, Alaska,
   and Washington. Anyone can call into the University of Washington, and then they
   get directed to specialists. It has  been done out of necessity in the region with only
 ,  one medical school, and I think it's a model that could also be used elsewhere."
   (Mary Miller, American Nurses Association)

•  Color coding of charts: "When  a provider has an opportunity to come face-to-face
   with a farmworker, they have to utilize that opportunity to its  fullest advantage.
   Color coding of charts is a simple tool that one of the health centers that we work
   with uses. The health centers are in an area where there are a lot of farmworkers so

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Workshop on Developing National Strategies
                  they simply changed the color of the chart for every farmworker. When they knew
                  that that patient did farm work, that patient got a red chart, so that it reminded the
                  provider to ask those important questions when they had the farmworker in front
                  of them." (Joni Berardino, National Center for Farmworker Health)

                  Movable health records: "How about developing a system for keeping records of
                  individuals' exposures that will move with them as  they move from one site to
                  another? Just as we have talked about in the migrant population—that there should
                  be school records, health records, etc., that can move with them—pesticide exposures
                  could be an important part of that movable health record." (Dr. Louise Rauckhorst,
                  University of San Diego)

                  "We have been working on trying to put together a comprehensive tracking database
                  for farmworkers... in the area of some very specific disease entities; for instance, we
                  have a binational tuberculosis tracking initiative. We find that there is a willingness
                  in those instances where they know there is going to  be high mobility, and  where
                  there is absolutely critical information that needs to be exchanged." (Karen Mountain,
                  Migrant Clinicians Network)

                  "The Association for Farmworker Programs has a series of service centers all over the
                  country. They have set up a program where they could link the computers between
                  all these service centers to see if it works as a way of tracking exposures to farmworkers
                  throughout the country." (Corlis Sellers, U.S. Department of Labor)

                  Grower Involvement: "The growers that I have dealt with historically in Hillsborough
                  County [Florida] have been very reluctant to issue any notice of job injury to farm-
                  workers who want to come and see us with a possible pesticide exposure. I'm talking
                  about something that is not life threatening. It may be dermatologic or ophthalmologic
                  or something along those lines. Most of our conversations with the growers are very
                  unyielding and unfruitful in terms of making them believe that something could have
                  happened that really is related to a pesticide exposure, unless the  person is actually
                  carried into us. I have had growers say to me things like, well, everybody in my family
                  has the flu now. Or, they must have picked it up from something in their house." (Dr.
                  Dennis Penzell, Suncoast Community Health Centers)

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                                                                     Practitioner; Perspectives
I  Need for Analytic Methods: "Of the thousands of pesticides that are out there,
  there are only a minority in which there is an analytical method in which you can
  go ahead and look and see what the patient was exposed to. There is a real need for
  that to be developed, or to get some way of finding out really what a patient was
  exposed to more than just bringing in a  label." (Dr. Sheldon Wagner, National
  Pesticide Telecommunications Network)

  Patient Involvement: "If we think we're going to solve this problem very easily by
  doing primary education through medical school or nursing school or residency
  training programs, I think we are deluding ourselves. One of the ways that probably in
  the long run may have the best success in this area is educating the potential patient.
  If the patient comes into the doctor's office and says, look doctor,  I'm exposed to
  pesticides on the farmland that stuff blew in my face yesterday, and now I've got this
  collection of symptoms, it is going to raise a flag for most physicians. But if they come
  in with nondescript symptoms like many mild to moderate OP poisonings are, and
  don't identify themselves as a farmworker or an agricultural worker, don't identify
  themselves that their apartment was sprayed with something the day before, the chances
  that that diagnosis is going to be made are minuscule. There isn't any laboratory test
  that most physicians can do that is quick and rapid and will make the diagnosis. It is
  based on symptomatology, which is non-specific, and it just isn't going to happen."
  (Dr. George C. Rodgers, American Association of Poison Control Centers)

-------

-------

v^  '•• x-,..'._  .  ,.,•   •-•"••y* •. i----T?---
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      •'•• _^ '    -

 xpert Panel
   1^         - "
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Workshop on Developing National Strategies
               5.    Findings
               The Broader Context

                   This initiative is set in the context of efforts taking place at the local, state, and federal
                   levels, including activities to educate health care providers, pesticide-related activities,
               and environmental/occupational health activities. The panel recognizes the importance
               of building upon efforts in the field to learn from other experiences and link resources
               together in the initiative. Specifically, the panel recognized the groundbreaking efforts
               by the Institute of Medicine, in its landmark reports, Environmental Medicine: Integrating
               A Missing Element into Medical Education and Nursing, Health and the Environment:
               Strengthening the Relationship to Improve the Public's Health. The panel chose to adopt
               (with slight revision) several overarching recommendations of the Institute of Medicine
               committees that developed these two publications. Over the course of the workshop,
               panelists identified national and regional resources, such as the National Pesticide
               Telecommunications Network, poison control centers, agromedicine programs, NIOSH
               agricultural health centers, and the Association of Occupational Clinics, that are vital to
               the initiative's success.

               Based upon the recommendation of the expert panel, the next stage of the initiative will
               include a thorough compilation of existing activities, resources, organizations, and materials
               aimed at educating primary care providers about pesticide exposures. An initial list of
               resources, including those suggested by the expert panel, is included in Appendix B. This
               list is not intended to be a comprehensive list, but rather a sampling of activity. A more
               complete listing will be carefully designed with participation from the expert panel.


               Targeting  Primary Care Providers

               For purposes of this initiative, the panel agrees  that the target audience  is the primary
               care provider. A primary care provider is defined as a physician, nurse, nurse practitioner,
               physician assistant, nurse midwife,  or community health worker specializing in one of
               the following areas: family medicine, internal medicine, pediatrics, obstetrics/gynecology,
               emergency medicine, preventive medicine, or public health.

-------
                                                                          Themes,arid Findings*
As the "gatekeepers" of our health care system, primary care providers need to be able to
identify a possible pesticide exposure. For this reason, the panel recommends that all
primary care providers possess basic knowledge and skills related to pesticide exposures.

The panel also recognized the need to ensure that sufficient specialists are trained and
available to primary care providers. Health care providers with specialized training in
occupational and environmental medicine serve as excellent  resources both for
purposes of this initiative and for primary providers. However, because such specialists
already have a higher awareness of pesticide issues, the majority of the panel agreed
that occupational and environmental health providers are not the initial target of this
initiative. A minority opinion was expressed at the meeting that occupational medicine
should be considered a part of primary care  and therefore be part of the initial
implementation of this initiative.


Current Training of Primary Care Providers

The panel agreed that primary care providers are not sufficiently trained at any stage of
their education about pesticide exposure, and as a consequence, adverse health effects
from pesticide exposures are often underreported. The panel recognizes, however, that
the lack of training reflects a larger gap in education on environmental and occupational
health. The panel briefly summarized the main concerns about provider knowledge of
pesticide exposures:

•  Providers do not receive training on recognition, diagnosis, and management of
    pesticide-related exposures during their formal education.

•  Pesticide exposures and associated  health conditions are difficult topics to teach
    because they require additional knowledge of toxicology and other topics often not
    included in the curriculum of health professional education.

•  Providers do not often see acute pesticide poisonings and do not possess enough
    knowledge to recognize chronic cases.

•  Health conditions associated with pesticide exposures are often misdiagnosed.
•  Providers often do not know how and where to report pesticide exposures; sometimes
    the reporting is considered burdensome given their demanding work environments.
•  Providers often do not know to whom patients can be referred.

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VfeislKilp	pr'pl||lppmjfRational Strategies
               Expected Outcomes for Primary Care Providers

               The panel discussed at length the general goals that should be expected of all targeted
               primary care providers. Agreement was reached that all primary care providers should:
               •  Demonstrate knowledge about pesticides and recognize health effects from pesticide
                  exposures as a health concern;
               •  Diagnose  and treat pesticide exposures at the earliest possible time and complete
                  the appropriate follow-up and referral (exposure management);
               •  Take preventive measures in both the clinical and community settings, including
                  anticipatory guidance and community education (prevention management);
               •  Report exposures and health outcomes of patients or communities to appropriate
                  public health or regulatory agencies; and
               •  Access the appropriate resources/specialists (local, regional, and national).


               Three Stages of Education

               The panel agreed that to achieve these expected outcomes, competencies should be
               articulated for three stages in the education of primary care providers:
               •   Basic Education — for purposes of this initiative, defined as education received in
                   medical schools and  associate or baccalaureate nursing schools (education leading
                   to Associate Degree Nurses, Bachelor of Science Nurses).
               •   Specialty Training — for purposes of this initiative, defined as education/training
                   received in residency (variable by specialty), graduate nursing education for advanced
                   practice nursing (e.g., clinical nurse specialist, nurse practitioner, nurse midwife),
                   and physician assistant training.
               •   Practice/Continuing Education — for purposes of this initiative, defined as the
                   education practitioners receive as part of continuing education or in their practice/
                   professional settings. This stage also includes community health worker training.
                   The settings in which primary care providers practice include but are not limited to:
                   emergency departments, community clinics, workplace settings, private offices, urgent
                   care facilities, schools, patient's homes, hospital clinics, and managed care settings.

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 6.    Preamble to Expert Panel
       Recommendations

    The expert panel agreed to adopt, as a preamble to its own recommendations, the
    themes and overarching, recommendations made by the Institute of Medicine's
Committee on Enhancing Environmental Health Content in Nursing Practice and
published in Nursing, Health and the Environment (National Academy Press, 1995). The
panel revised the recommendations to more broadly reflect primary care providers. The
preamble to the Expert Panel's recommendations is as follows:

1. Environmental health concepts should be incorporated into all levels of primary
   care provider education, specifically defined for purposes of this initiative as
   physicians, nurses, nurse practitioners,  physician assistants, nurse midwives, and
   community health workers, and office staff in the disciplines of family practice,
   pediatrics, internal medicine, emergency, obstetrics/gynecology, preventive medicine
   and public health.

2. Environmental health content should be included in licensure and certification
   exams.

3. Expertise in various environmental health disciplines should be included in the
   education of primary care providers.
4.  Environmental health content should be an integral part of lifelong learning and
   continuing education of primary care providers.

5 .  Professional associations, public agencies, and private organizations should provide
   more resources and educational opportunities to enhance environmental health in
   primary care practice.

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Workshop on Developing National Strategies
              7.    Recommendations of the  Expert  Panel

                  The expert panel developed four national strategies to reach the expected outcomes
                  defined in Section 5. For each of the strategies, the panel has specific
              recommendations that will form the basis for a future implementation plan.
              STRATEGY I:
              DEFINING  RECOMMENDED COMPETENCIES
              Essential Competencies Recommended
              for All Primary Care Providers

              The expert panel recommends that primary care providers be able to demonstrate specific
              competencies upon completion of their basic education and specialty training, and that
              practitioners demonstrate specific competencies in their practice settings. The following
              are the recommended essential competencies of providers:

              Epidemiology
              •  Sentinel Cases: Providers should understand that diagnosis of a pesticide overexposure
                 in one individual may be a sentinel case and often indicates that other individuals
                 may have been exposed. Identification is the first step towards preventive action.
              •  Surveillance: Providers should understand the importance of surveillance and should
                 be able to access and report data for local/regional/national surveillance programs.

              Basic Symptomatology
              •  Providers should be able to recognize the signs and symptoms of pesticide exposures
                 (both acute and chronic).
              •  Providers should be able to take a basic environmental history to determine if a
                 temporal relationship exists between exposure and symptoms.

              Management of Pesticide Exposure
              •  Providers should be able to effectively diagnose (through appropriate testing) and
                 treat health conditions associated with pesticide exposure, refer patients to
                 appropriate specialists and resources, and follow-up appropriately.

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                                                           Recommendations of the Expert Panel
Patient Counseling/Anticipatory Guidance:
•  Providers should ask specific environmentally-related questions in patient histories
    and provide guidance to patients on how to prevent pesticide exposures. The remedial
    guidance to patients should be conveyed in a sensitive and appropriate manner.

Community Environment of Patients:
•  Providers should possess a basic awareness of environments in which patients live,
    work, and play in order to anticipate possible encounters with exposure to pesticides.


Recommended Competencies
Specific to  Basic  Education

The panel recommends that training during basic education emphasize:

•  Raising awareness about the connection between pesticide exposures and health
    outcomes;

•  Medical/nursing principles relevant to environmental/occupational medicine
    (including toxicology and epidemiology); and

•  The importance of interdisciplinary efforts—within medicine, agriculture, and
    environmental sciences—to address complex health issues such as those involving
    pesticides, and the network of resources available to the primary care provider.

Students who complete their basic training should be able to:

•  Identify and recognize a pesticide, with a basic understanding of toxicology (e.g.,
    integrate into pharmacology course);

•  Recognize signs and symptoms of health effects associated with pesticide exposures
    (e.g., integrate into pathophysiology course);

•  Demonstrate an understanding of principles of environmental/occupational health;

•  Identify risk factors  (e.g., occupation, location of home, susceptible populations
    such as children);

•  Demonstrate an understanding of concepts of epidemiology and population-based
    health;

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 Workshdp On Peveldpfng Natidn^l Strategies
                   Ask patients 2-3 screening questions that would elicit possible exposure to a number
                   of environmental factors (including but not limited to pesticides); and
                   Advise patients and provide basic education about pesticide exposure.
                Recommended Competencies
                Specific to Specialty Training

                The panel recommends that training at this stage emphasize:
                •  Specific pesticide exposures and associated health conditions;
                •  Clinical experiences dealing with pesticide exposures; and
                •  Environmental history taking.
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In addition to the competencies achieved in basic education,
residents, advance practice nurses  (e.g., nurse practitioners,
dinical nurse specialists, and nurse midwives) and physician
assistants who complete their basic training should be able to:

H   Diagnose pesticide-related illness using appropriate
    testing procedures and treat pesticide  overexposures;
•   Identify environmental factors that may possibly be
    linked to patient illness to ensure that chronic pesticide
    exposures are addressed;
•   Take an environmental health history with questions
    regarding where the patient lives, works, and plays;
•   Understand temporal relationship between exposure and
    symptoms;
                    Demonstrate the use of epidemiology and population-based health principles;
                    Provide patients with education and guidance regarding prevention of pesticide
                    exposures;

-------
•  Access and utilize resources at a local, regional, and national level; and

•  Demonstrate an understanding of case reporting requirements for pesticide exposures.
Recommended Competencies
Specific to Practice Settings

The panel recommends that training at this stage emphasize:

•  Specific pesticide-related issues in the practice area or region;

•  Links to important resources relevant to the provider's specific environment; and

•  Reporting requirements and recommendations.

In addition to the competencies demonstrated after basic and specialty education,
practicing providers should be able to:

•  Demonstrate knowledge about the environment in which they practice, with specific
   understanding of communities that may be at-risk for pesticide exposures;

•  Identify exposures related to pesticides used in the region;

•  Recognize possible sentinel cases;

•  Demonstrate an understanding of the legal responsibilities of providers and ethical
   implications of activities related to pesticide exposures;

•  Utilize the local and regional resources available, such as: local or state public health
   department, poison control center, occupational/environmental clinic, department
   of agriculture, department of environmental quality, agriculture extension,  and
   occupational health and safety agency; and

•  Report concerns about pesticide exposures to  the appropriate authorities, such as
   local or state public health departments, OSHA or state department of labor, or
   department of agriculture.

-------
Workshop on Developing National Strategies
STRATEGY II:
IMPACTING  EDUCATION AND TRAINING

A key recommendation by the expert panel is to make the issue of pesticide exposures and
environmental/occupational health relevant and interesting to students. Wherever possible,
material should be integrated into the existing curriculum. Given the differences in the
three stages of education, the panel recommends the following strategies for each stage:


                               Basic Education

                              The panel recommends that in basic education (medical
                               school, associate/baccalaureate nursing) students receive
                               the key building blocks necessary to understand the role
                               of environmental and occupational factors on health.
                               Specific recommendations are to:
                               •  Integrate overviews of environmental/occupation
                                  health information into general courses in order
                                  to place the concept on the radar screen of students;
                                  emphasize the cutting edge issues in the field for
                                  students;
                               •  Identify key courses into which environmental/
                                  occupational concepts can be integrated (i.e.,
                                  physiology, pharmacology). The panel recommends
                                  that a subgroup of the expert panel develop the
                                  implementation plan for this recommendation;

                               •  Ensure that  clinical experiences  include
                               opportunities to work with pesticide exposures and
    environmental health by partnering with local resource organizations  (e.g., area
    health education centers, poison control centers, clinics, occupational health and
    safety agencies);
    Develop appropriately-tailored case studies to be used in coursework as part of the
    trend towards problem-based learning;
              :ing mat go outsit
              i",,. ii HHii'i!'!::!!!1" 'i'liji	niiiniiiKiiiiuw;,rfc,, m	nt 'iimii;;
       '!|!''i!i'»!|!'«p	s;1!!!'!!^    	"ISII'I	"l|!"	""	IIT'FIPW! W	IT I1 'I "I ' f f'"  '
       ents thai I know, if you give them a
       i	m	is^^^^^  	!i	m	',	m	si	\	M.'- .
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           Ire anxious to have something
       :	that is 'outside. 'They are enthusiastic
       S	!:::	!!S!!~	:	11!	g*SH	iiS	*£	!'	*	t:=	'".
                 curriculum wici we are
                      eorge C. Rodgers

-------
                                                            Recornmendations of the Expert, Panel
•  Integrate environmental/occupational health components into distance learning
    and telecommunication technologies (on-line materials, CD-ROM educational
    materials, video training conferences);

•  Develop mechanisms to teach topics with interdisciplinary faculty teams; and

•  Identify the decision-making bodies that influence curricular changes at the
    institution, state and national levels.
Specialty Training

The panel recommends that in specialty training (i.e., residencies; graduate nursing
training such as education leading to clinical nurse specialists, nurse practitioners, and
nurse midwives; and physician assistant training) residents/students focus on more
specific aspects of pesticides and address cases of pesticide exposures with patients and
in communities. Specific recommendations are to:

•   Integrate questions and educational objectives into Board certification and licensure
    exams;

•   Develop case studies for appropriate specialty areas that demonstrate a team approach
    by the providers, emphasizing the interdisciplinary nature of the field and the
    increasing use of problem-based learning techniques;

•   Research and assess the appropriateness to primary care of curricular materials already
    developed in occupational/environmental health;

•   Design rotation experiences in environmental/occupational health that build upon
   ' the lessons learned from other specialties;

•   Include  pesticide exposure scenarios and cases in residency/student seminar
    discussion topics;

•   Identify ambulatory settings where pesticide exposure issues occur, and which could
    provide appropriate experiences for residents/students;

•   Invite experts, including primary care providers, to give Grand Rounds to residents
    or similar teaching lectures for nurse practitioner or physician assistant students;

•   Develop effective distance learning and telecommunication materials and programs;

-------
Workshop OH Developing National Strategies
               •   Link pesticides/environmental health conditions to research courses taken by
                   students;
               •   Ensure that pesticide exposures and other environmental hazards are part of
                   differential diagnosis and history taking; and
               •   Create opportunities for "teachable moments" - opportunities for faculty to
                   demonstrate real cases of pesticide exposures, or to simulate cases.


               Practice  Settings

               The panel recommends that practitioners be reached through continuing education, in-
               service training, professional meetings, and the Internet. The key to success is the
               communication of a dear and coordinated message to practicing primary care providers.
               Specific recommendations include:
               •   Assess, develop, and evaluate distance learning and telecommunications approaches;
               •   Disseminate a dear message through a number of different modes, induding journals
                   and professional newsletters (see Raising Awareness);
               •   Build effective linkages between primary care providers and resource people (e.g.,
                   poison centers, emergency departments, AOEC clinics, NIOSH agricultural centers,
                   NPTN);
               •   Design optional continuing education courses or components to be integrated into
                   required continuing education courses with evaluation mechanisms;
               •   Involve specific stakeholders and populations in outreach efforts (e.g.,  industry,
                   farmworkers, agricultural extension, etc.);
               •   Build environmental health/pesticide knowledge into recertification of primary care
                   providers as an incentive for them to educate themselves about the issue; and

               •   Identify and make available to practitioners references to ready resources for support/
                   treatment guidance.

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                                                           RecommendatfoilS of the: Expert Papef
 STRATEGY III:
 RAISING AWARENESS

 The expert panel recognizes that this initiative needs to raise the awareness and attention
 of professionals in the health care arena about pesticide-related health conditions as
 well as other occupational and environmental health conditions. A primary component
 of this strategy is to give primary care providers a clear message about the importance of
 knowing a patient's occupational and environmental background. The message could
 be  conceived of as "Think Pesticides" or more broadly, "Think Environmental/
 Occupational Connection."

 Another element of the strategy is to raise the visibility of the issue by developing a
 strong marketing effort, complete with "attention grabbers." To catch the attention of
 primary care providers, marketing efforts must be relevant, include statistics, be keyed
 to major events, and convey a message appropriately targeted to the audience.

 The panel generated a set of ideas for raising awareness, from which more specific plans
 can be developed.

 Professional Meetings
 •   Develop a portable exhibit for national/regional meetings of targeted professionals;
 •   Develop educational sessions for same targeted meetings with the organizations
    represented by the expert panel and other stakeholders;

•   Target the residency or student sections of professional associations at their national
    meetings; and

•   Involve residents and students in  developing papers/posters.
Marketing/Outreach
•  Develop briefing materials that reflect sound science principles and clearly articulate
   the issues from the perspective of primary care providers;

•  Effectively market and package messages and materials that are clearly designed for
   the target audiences. Make them newsworthy!
                                                                                          m

-------
                •  Identify ways to build coverage in the media and television arenas (quick response
                    to newsworthy events, media advocacy projects, influencing television shows,
                    seasonal public service announcements).

                Materials and Resources for Providers
                m  Design effective and appropriate patient brochures (or revise what already exists)
                    for providers to give to their patients;
                •  Develop informational/teaching communication tools (CD-ROM, audio tapes, etc.)
                    for providers; and
                •  Utilize effective distance learning and tele-communications tools.
     Ul* have to remember to target our
     message to the audiences we are trying to
     reach. Ordinarily I am sitting in a
     primary care office not waiting for a
     imijor event to happen and hoping that it
in iii "Hill
III	li!
                            Journal Articles
                            •   Design a mechanism  to  strategically place
                                journal/newsletter articles on pesticides and on
                                the initiative. Several strategies are recommended:
                                   •   Publish peer-reviewed journal article with
                                       scientific  data  (e.g.,  results  from
                                       surveillance data in Texas that document
                                       the incidence and case reports);
                                   •   Publish professional piece on the initiative
                                       to be published in a multitude of journals
                                       (commentaries);
                                   •   Publish supplement/monograph on the
                                       topic with series of articles, for example,
                                       a joint effort on primary care provider/
                                       epidemiology perspectives;

     •  Publish  a series of articles throughout the year so as to ensure repetition
        and consistent message.
Target a wide list of appropriate journals. An initial list of targeted journals developed
by the expert panel will be supplemented with additional research. The initial list
includes:
       •   American Association of Occupational Health Nurses Journal
       •   American Journal of Emergency Medicine
.,,,-•
isn t going to happen...If you want to get
                             11      I
me to modify my day-to-day behavior in
the office, you are going to have to focus
    message to the reality of my clinical
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     ;ce.
            — Dr. Hugh Henderson,
     National Agromedicine Consortium

-------
              American Journal of Nursing
              American Journal of Public Health
              Annals of Emergency Medicine
              Annals of Internal Medicine
              Archives of Internal Medicine
              Contemporary Pediatrics (general issue)
              Family Practice Journal
              Graduate Medicine
              Journal of American Medical Association
              Journal of Emergency Nursing
              Journal of Family Practice
              Journal of Nursing Education
              Journal of the American Academy of Nurse Practitioners
              Journal of the Board of American Family Practice
              New England Journal of Medicine
              Nurse Midwife Journal
              Nurse Practitioner Forum
              Nurse Practitioner World
              PA Journal
              Patient Care
              Pediatrics
              Public Health Nursing
              State journals
              The Nurse Practitioner
Build Partnerships/Gather Models
•   Gather models of how specific health care disciplines or localities have raised
    awareness on pesticides (the expert panel is an important source of models);

•   Learn from and collaborate with the successes and lessons learned in the
    agromedicine and agricultural health and safety field;

•   Involve additional partners in the initiative, including industry, departments of
 ,   agriculture, departments of labor, and cooperative extension service at the local and
    state levels;

•   Research other effective outreach models (e.g., "Models that Work" - an effort by
    the Bureau of Primary Health Care at HRSA);

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Workshop Oil Developing National Strategies
               •  Explore possible ways to  integrate environmental medicine requirements into
                   national requirements of primary care providers (e.g., through a possible effort at
                   the Health Care Financing Administration); and
               •  Collaborate with professional associations and societies to develop position papers.

               Support Network
               •  Establish peer networks and support group for providers by locality or region;

               •  Establish consultation and referral resources;
               •  Develop Internet site for initiative that includes linkages from/to/between sites;

               •  Educate the general public and providers about the necessity and value to them of
                   surveillance systems; and
               •  Establish and design a clear mission and purpose of a "listserve"; link with other
                   listserves that already are resources for providers (e.g., OEM Duke List-serv).

               Evaluate Provider/Faculty Awareness
               •  Survey both  faculty  and providers on their knowledge, skills,  and attitudes on
                   pesticide exposures and environmental health issues.

               Disseminate Proceedings
               •  The expert panel generated a list of organizations, professional associations, and
                   credentialing bodies that should be informed of this initiative. This is an initial list;
                   the subgroup on resources will develop a more complete list and dissemination
                   plan. The distribution list includes:
                          •   Accreditation Council for Continuing Medical Education and
                              equivalents for nursing and physician assistants
                          •   Accreditation Council for Graduate Medical Education and
                              equivalents for nursing and physician assistants
                          •   Alliance for Continuing Medical Education (CME)
                          •   American Association for Colleges of Nursing
                          •   American Association of Occupational Health Nurses
                          •   American Board of Occupational Health Nurses
                          •   American Chemical Society
                          •   American Nurses Association

-------
                                              Recommendations, of tKe:l:kjpert?|pAiii£r
American Nurses Credentialing Center
American Public Health Association
Area Health Education Centers
Association of American Medical Colleges
Emergency Nurses Association
Federation of Associations of Schools of the Health Professions
Liaison Council for Medical Education
National Association of Emergency Medicine Technicians
National Council of State Nursing Boards
National League for Nursing (NLN)
Nurse Midwifery
Osteopathic Medicine
Residency Review Committees
Society of Toxicology
Specialty areas including but not limited to: Occupational Medicine,
Pharmacists, Podiatrists
State Offices of Rural Health.

-------
WbMtshop on
               STRATEGY IV:
               MAINTAINING AND DEVELOPING RESOURCES

               The panel discussed the urgent need to maintain and increase resources which currently
               are often subject to uncertain funding and viability. The panel concludes that there is a
               strong need to consider centralizing resources in this area in order to avoid duplication
               of effort and make information and resources more widely available and publicized to
               a wider audience. Specific recommendations of the panel include:
Centralize the resources available to primary care
providers on pesticide-related health concerns.
Resources could be centralized nationally or in a
network of regional and local centers. Such centers
would provide a combination of referral information,
specialists, Internet materials,  case studies, and
surveillance services; and
       e is a lot ofiflfonnation out
       	._	„	:	||	;	 -,.. ,.	
       . Their clinical toxicolosv on
       -RQli is great, and I think
       I	||V.nj||	;:	/Jj	*;|	"jnn	iJUj	iij i. I'llll'lij1 7 r' i • '•, '"j,1' i, '
                   to do is get the
              ession to  now tat
                 "
                     don, Wagner,
     !•	js	;l	t	ij-=	=	=|- JNatioriai Pesticide
     mi	!	|j|ji|i|||||||j|||||||||||||||||l
       lecommunications Network
                                  	:	"1
Strengthen the link of the pesticides and health care
initiative with resources already in existence, such as
poison centers, agromedicine programs, agricultural
health and safety centers, and land grant universities.

-------
 8.    Recommended  Next Steps
T
I he panel discussed the implementation of these strategies and the challenges that
would be encountered by this initiative.
 Challenges Facing the Initiative

The expert panel recognizes that there are significant barriers to changing the awareness
and training of primary care providers on pesticide issues. Therefore the expert panel
recommends that this initiative be integrated in the broader context of other national
initiatives in occupational and environmental health. This integration will also avoid
any duplication of effort. A few of the challenges that this initiative will need to grapple
with were identified:
General Challenges
• Ensuring an interdisciplinary approach;

• Coordinating varying definitions of pesticide exposures and environmental health;

• Developing a consistent and clearly stated message;

• Increasing the level of importance of this issue among health science faculty; and

• Assisting faculty in teaching a challenging technical topic.

Reaching Primary Care Providers
• Getting information to practitioners in a digestible and implementable form;

• Encouraging primary care providers to let go of old habits and learn new ones;
                                               /
• Convincing primary care providers and health science faculty that pesticide exposure
   is relevant and important;

• Improving the understanding  of the use of diagnostic tests (e.g., cholinesterase
   testing); and

• Developing a link between the provider's clinical role and community involvement.

-------
 Workshop an Developing National Strategies
m
                Institutional Barriers
                •  Barriers in curriculum committees and Board exam decisions;

                •  Perceived weak link between primary care providers and occupational and
                   environmental specialists and resources; and

                •  Tenuous future support for resources and services for primary care providers.

                Involving All Stakeholders
                •  Involving industry in this effort;

                •  Determining best role for growers, agricultural extension, and relevant agencies;

                •  Involving community-based organizations; and

                •  Involving worker representatives.

                Environmental/Occupational Health Field
                •  Lack of data;

                •  Limited resources for research and technical assistance.

                •  Need for improved reporting procedures; and

                •  Need for increased enforcement.
                Implementation  Plan

                Developing an effective implementation plan for the initiative is the next step for the
                planning committee and expert panel. The implementation plan is expected to build
                on the recommendations coming out of the workshop, to specify in more detail the
                next steps in implementing each of the strategies, and to include timetables, schedules,
                and responsibilities for each task.

                To develop this implementation plan, the  panel decided to create three subgroups
                comprised of expert panel members and additional experts. The three subgroups are:

                •  Primary Education Content (curriculum specialists) — covering Strategy I.

-------
                                                                       Reco rn m en d ed. M§%^'.?tgpS
•  Dissemination to Practicing Primary Care Providers — covering Strategies II and III,
    as well as the marketing/dissemination effort related to Strategy I.
•  Resource Development/Dissemination/Centralization — covering Strategy IV.

As part of the implementation plan, the subgroups will build on the network of
stakeholders involved in this initiative. A key part of the initiative is a strong,  effective
outreach effort to involve as many stakeholders and target groups as possible at an early
stage, and to maintain their interest and participation over time. The subgroups will
help launch this outreach effort, compile a complete list of participating organizations,
and determine which organizations and agencies will carry out which responsibilities.

The implementation plan will also include a comprehensive list of resources related to
pesticides and health care, including model programs, scientific research on pesticides,
medical journal articles, and Internet sites for state and community-based programs.

-------

-------
Appendices

-------
Workshop OH Developing National Strategies
                Appendix A:  Who's Who
                FEDERAL INTERAGENCY
                PLANNING COMMITTEE

                U.S. Environmental Protection Agency

                Kevin Keaney
                Acting Branch Chief
                Certification & Worker Protection Branch
                Field & External Affairs Division
                U.S. Environmental Protection Agency
                401 M Street, SW (7506C)
                Washington, D.C. 20460
                Phone: 703-305-5557
                Fax: 703-308-2962
                keaney.kevin@epamail.epa.gov

                Ameesha Mehta, MPH
                Project Lead
                Certification & Worker Protection Branch
                Field & External Affairs Division
                U.S. Environmental Protection Agency
                401 M Street, SW (7506C)
                Washington, D.C. 20460
                Phone: 703-305-6448
                Fax: 703-308-2962
                mehta.ameesha@epamail.epa.gov

                Delta Valente, MPA
                Project Manager for Farmworker Health
                Certification & Worker Protection Branch
                Field & External Affairs Division
                U.S. Environmental Protection Agency
                401 M Street, SW (7506C)
                Washington, D.C. 20460
                Phone: 703-305-7164
                Fax: 703-308-2962
                valente.delta@epamail.epa.gov

                Belen Revilla
                Certification & Worker Protection Branch
                Field & External Affairs Division
                U.S. Environmental Protection Agency
                401 M. Street, SW (7506C)
                Washington, D.C. 20460
                Phone: 703-308-8734
                Fax: 703-308-2962
                revilla.belen@epamail.epa.gov
Ana Maria Osorio, MD, MPH
Medical Officer
Certification & Worker Protection Branch
Field & External Affairs Division
U.S. Environmental Protection Agency
401 M Street, SW (7506C)
Washington, D.C. 20460
Phone: 703-305-7666
Fax: 703-308:2962
osorio.anamaria@epamail.epa.gov

Frank Davido
Pesticide Incident Response Officer
Public Information & Records Integrity
Branch
Information Resources & Services Division
U.S. Environmental Protection Agency
401 M Street, SW (7502C)
Washington, D.C. 20460
Phone: 703-305-7576
Fax: 703-305-4646
davido.frank@epamail.epa.gov

Jerome Blondell, PhD
Health Effects Division
U.S. Environmental Protection Agency
401 M Street, S.W. (7509C)
Washington, D.C. 20460
Phone: 703-305-5336
Fax: 703-305-7775
blondell.jerry@epamail.epa.gov
U.S. EPA Regional Liaisons

Jane Horton
U.S. EPA, Region 4
Pesticides Section (4APT-PS)
61 Forsyth St, SW
Atlanta, GA 30303
Phone: 404-562-9012
Fax: 404-562-8972
Horton.Jane@epamail.epa.gov

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                                                                                         Appendices
Don Baumgartner
U.S. EPA Region 5
Pesticides Program Section (DRT-8J)
77 West Jackson Boulevard
Chicago, IL 60604-3590
Phone: 312-886-7835
Fax: 312-353-4788
baumgartner.donald@epamail.epa.gov

Allan Welch
U.S. EPA Region 10
Pesticides Section (AT-083)
1200 Sixth Avenue
Seattle, WA 9 8101
Phone: 206-553-1980
Fax: 206-553-8338
Welch.Allan@epamail.epa.gov
U.S. Department of Health and
Human Services

D.W. Chen, MD, MPH
Deputy Director
Division of Associated, Dental, and
Public Health Professions
Bureau of Health Professions
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
5600 Fishers Lane, Rm-8-101
Rockville, MD 20857
Phone: 301-443-6853
Fax:301-443-1164
dchen@hrsa.dhhs.gov

Jack Egan
Acting Director
Migrant Health Branch
Division of Community and Migrant Health
Bureau of Primary Health Care
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
4350 East West Highway
Bethesda, MD 20814
Phone: 301-594-4301
Fax: 301-594-4997
jegan@hrsa.dhhs.gov
Ruth Kahn, D.N.Sc.
Health Professions Education Specialist
Office of the Director
Division of Medicine
Bureau of Health Professions
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
Parklawn Building Room 9A-27
5600 Fishers Lane
Rockville, MD 20857
Phone: 301-443-6823
Fax: 301-443-8890
rkahn@hrsa.dhhs.gov

Cassandra Lyles
Program Analyst
Office of Rural Health Policy
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
5600 Fishers Lane, Rm 9-05
Rockville, MD 20857
Phone: 301-443-7321
Fax: 301-443-2803
slyles@hrsa.dhhs.gov

Madeleline Hess, Ph.D, RN
Acting Branch Chief
Nurse Education and Practice Branch
Division of Nursing
Bureau of Health Professions
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
5600 Fishers Lane, Rm 9-35
Rockville, MD 20857
Phone: 301-443-6336
Fax: 301-443-8586
mhess@hrsa.dhhs.gov

Mark Nehring, DMD, MPH
Senior Program Management Consultant
EMC/Maternal and Child Health Bureau
Health Resources & Services Administration
U.S. Dept. of Health and Human Services
5600 Fishers Lane, Rm 18A-30
Rockville, MD 20857
Phone: 301-443-3449
Fax: 301-443-1296
mnehring@hrsa.dhhs.gov

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Workshop on Developing National Strategies
                Karen Pane, RN, MPA
                Nurse Consultant
                Nurse Education and Practice Branch
                Division of Nursing
                Bureau of Health Professions
                U.S. Dept. of Health and Human Services
                5600 Fishers Lane, Rm 9-36
                Rockville, MD 20857
                Phone: 301-443-6334
                Fax: 301-443-8586
                kpane@hrsa.dhhs.gov

                Sherry Baron, MD
                Medical Officer
                National Institute for Occupational Safety
                and Health
                U.S. Dept. of Health and Human Services
                4676 Columbia Parkway, MS R-10
                Cincinnati, OH 45226
                Phone: 513-458-7159
                Fax: 513-458-7105
                slb8@cdc.gov
                U.S. Department of Agriculture

                Peter S. Wood
                USDA-AMS
                Pesticide Records Branch
                8700 Centreville Rd., Suite 202
                Manassas, VA 20110
                Phone: 703-330-7826
                Fax: 703-330-6110
                peter_s_wood@usda.gov

                John Impson
                National Program Leader
                USDA CSREES
                AG Box 2220
                Aero Space Building, Room 330M
                901 D  Street, SW
                Washington, D.C. 20250-2220
                Phone: 202-401-4201
                Fax: 202-401-4656
                IIMPSON@REEUSDA.GOV
U.S. Department of Labor

Mike Hancock
Leader, Farmworker Labor Team
Wage and Hour Division
200 Constitution Ave., NW
Rm S-3510
Washington, D.C. 20210
Phone: 202-219-7605
Fax: 202-219-5122
jtc@fenix2.dol-esa.gov

Rosemary Sokas, MD, MOH
Director of Office of Occupational Medicine
OSHA/DOL     :
RoomN3653
200 Constitution Ave, NW
Washington, D.C. 20210
Phone: 202-219-5003
Fax: 202-219-9053
rosemary.sokas@osha-no.osha.gov
Association of Teachers of Preventive
Medicine

Barbara }. Calkins, MA
Executive Director
ATPM
1660 L St, NW, Suite 208
Washington, D.C. 20036
Phone: 202-463-0550
Fax: 202-463-0555

Mary V. Davis, DrPH
Programs Director
ATPM
1660LSt, NW, Suite 208
Washington, D.C. 20036
Phone: 202-463-0550
Fax: 202-463-0555
mvd@atpm.org

-------
Andrea B. Smith
Projects Assistant
ATPM
1660 LSt, NW, Suite 208
Washington, D.C. 20036
Phone: 202-463-0550
Fax: 202-463-0555
abs@atpm.org
EXPERT PANEL

American Academy of Family Physicians
Elisabeth Spector, MD, MPH (could not attend);
17 Sherwood Court
Flemington, NJ 08822
Phone:908-284-1730
Fax: 908-788-6111
elspecto@umdnj.edu              '

American Academy of Pediatrics
Roger F. Suchyta, MD
Associate Executive Director
141 Northwest Point Blvd.
Elk Grove Village, IL 60007
Phone: 847-981-7101
Fax: 847-228-5027
rsuchyta@aap.org

American Academy of Physician Assistants
Greg P. Thomas, PA-C
V-P, Clinical Affairs and Education
950 North Washington St.
Alexandria, VA 22314
Phone: 703-836-2272 x3107
Fax: 703-684-1924
greg@aapa.org

American Association of Colleges of
Nursing
Andrea R. Lindell, PhD
Dean, University of Cincinnati
College  of Nursing
PO Box 210038
Cincinnati, OH 45221
Phone: 513-558-5200
Fax: 513-558-7523
andrea.lindell@uc.edu
American College of Emergency Physicians
/. Ward Donovan, Jr,, MD, FACEP
Director of The Pennsylvania University
Poison Center
University Hospital-MS
Hershey Medical Center
500 University Drive
PO Box 850
Hershey, PA 17033-0850
Phone: 717-531-7057
Fax: 717-531-4441
wdonovan@nursing.hmc.psghs.edu

American Association of Poison Control
Centers
George C. Rodgers, Jr, MD, PhD
Professor of Pediatrics and
Pharmacology/Toxicology
Professor of International Pediatrics
University of Louisville School of Medicine
4250 Georgetown-Greenville Rd.
Georgetown, IN 47122-8816
Phone: 502-852-8630
Fax: 502-852-3998
gcrodgers@pol.net

American College of Occupational and
Environmental Medicine
Joe Fedoruk, MD, DABT, CIH
Diplomat of American Board of Toxicology,
Certified in Industrial Hygienist
(Toxicology Aspects)
333 South Anita Drive, Suite 640
Orange, CA 92868
Phone: 714-456-2124
Fax: 714-456-2143
mjfinc@aol.com

American Nurses Association
Mary Miller, MN, ARNP
Occupational Health Nurse Practitioner
Washington State Department of Labor
and Industries
PO Box 44610
Olympia, WA 98504-4610
Phone: 360-902-5666
Fax: 360-902-5438
mmdr235@lni.wa.gov

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Workshop on Developing National Strategies
                Council of State and Territorial
                Epidemiologists
                Jackilen Shannon, PhD
                Epidemiologist, Texas Department of Health
                1100 W. 49th St
                Austin, TX 78756
                Phone: 512-458-7269
                Fax: 512-458-7699
                jackilen.shannon@tdh.state.tx.us

                Migrant Clinicians Network
                Karen Mountain, MBA, MSN, RN
                Executive Director
                PO Box 164285
                Austin, TX 78716
                Phone: 512-327-2017
                Fax: 512-327-0719
                MCN@onr.com

                National Center for Farmworker Health
                Joni Berardino, MS, LSW
                Director of Public Affairs and
                Resource Development
                1515 Capitol of TX Hwy. South, Suite 220
                Austin, TX 78746
                Phone: 512-328-7682
                Fax: 512-328-8559
                berardin@ncfh.org

                National Organization of Nurse
                Practitioner Faculties
                Candace M. Bums, PhD, ARNP
                University of South Florida
                College of Nursing
                HSC 22 12901 Bruce B. Downs Blvd.
                Tampa, FL 33612
                Phone: 813-974-9160
                Fax: 813-239-3653
                cburns@coml.med.usf.edu
National Pesticide Telecommunications
Network
Sheldon Wagner, MD
Professor of Clinical Toxicology
Oregon State University
1007 Agricultural and Life Sciences
Corvallis, OR 97331-7301
Phone: 541-757-5086
Fax: 541-757-5085
wagners@ucs.orst.edu

National Rural Health Association
Michael Hodgman, MD
Bassett Healthcare/NY Center for
Agricultural Medicine and Health
1 Atwell Rd
Cooperstown, NY 13326
Phone: 607-547-3981
mrunt@aol.com

Pennsylvania State University/National
Agromedicine  Consortium
Rugh Henderson, MD
Associate Professor
College of Medicine
Dept. of Family and Community Medicine
PO Box 850
Hershey, PA 17033-0850
Phone: 717-531-8753
Fax: 717-531-5024
RHENDERS@family.fcm.hmc.psu.edu

Suncoast Community Health Centers, Inc.
Dennis Penzell, DO, FACP
Medical Director
2814 14th Ave,  SE
Ruskin, FL 33570
Phone: 813-645-4681 x315
Fax: 813-645-9240
DRSTACI@pol.net

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SPEAKERS AND
FACILITATOR

Wilson Augustave
Case Manager
Finger Lakes Migrant Health Care Project
2 Rubin Drive
Rushville, NY 14544
Phone: 716-554-6617
Fax: 716-554-4402
mighealth@aol.com

Louise M. Rauckhorst, EdD, MSN
Professor, Philip Y. Hahn School of Nursing
University of San Diego
19 51 Azure Way
Encinitas, CA 92024
Phone: 619-260-4575

Mark G. Robson, Ph.D., MPH
Executive Director
Environmental and Occupational Health
Sciences Institute
681 Frelinghusen  Rd.
Piscataway, NJ 08854
Phone: 732-445-0201
Fax: 732-445-0131
robson@eohsi.rutgers.edu

Susan T. West, Facilitator
Senior Director,
Health and Environment Programs
National Environmental Education and
Training Foundation, Inc.
734 15th Street, NW, Suite 420
Washington, D.C. 20005
Phone: 202-628-8200 x20
Fax: 202-628-8204
west@neetf.org
LIST OF OBSERVERS

Sheila Arbury, RN, MPH
Association of Occupational and
Environmental Clinics
101 Vermont Avenue, Suite 513
Washington, D.C. 20005
Phone: 202-347-4976
Fax: 202-347-4950

Margarita Benitez(
Equity Research Corp
5 Thomas Circle, NW
Washington, D.C. 20005
Phone: 202-387-3331
Fax:202-797-1344.

Sue Bernstein »
HRSA/ORHP
5600 Fishers Lane, Rm 9-05
Rockville, MD 20857
Phone: 301-443-0612

Stephen W. Borron
International Poison Center
1215 17th St, NW
Washington, D.C. 20036
Phone: 202-588-0620
Fax: 202-478-0444

Barry Brennan, PhD
Extension Pesticide Coordinator
University of Hawaii
1800 East-West Road
Honolulu, HI 96822
Phone: 808-956-9208
Fax: 808-956-9675
barry@hpirs.stiph.hawaii.edu

Janet Byron
Pesticide and Toxic Chemical News
1435 Auston Way
Berkeley, CA 94702
Phone: 510-848-4008
Fax: 510-848-4002

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Workshop on Developing National Strategies
                Lennie Carter
                Department of Veteran Affairs,
                NJ Health Care System
                385 Tremont Avenue
                East Orange, NJ
                Phone: 973-676-1000 ext. 1641
                Fax: 973-672-7636

                David Crow
                D.C.LR.S.
                1100 New York Avenue, NW, #520E
                Washington, D.C.
                Phone: 202-331-8181
                Fax: 202-331-8173

                Sue Darcey
                Pesticide Report
                3918 Oglethorpe St
                Hyattesville, MD 20782
                Phone: 301-864-3088
                Fax: 301-864-3089

                Shelly Davis
                Farmworker Justice Federation
                1111 19th St., NW
                Washington, D.C.
                Phone: 202-776-1575
                Caroline Whitehead Doherty
                North  Carolina Farmworker Health Program
                311 Ashe Avenue
                Raleigh, NC 27606
                Phone: 919-715-7210
                Fax: 919-733-8300

                Linda Durkee
                U.S. EPA
                401 M  Street, SW #7101
                Washington, D.C. 20460
                Phone: 202-260-6873
                Fax: 202-260-1847

                Florence Feinberg
               Migrant Legal Action Program
                Phone: 301-417-7067
 Scottie Ford
 West Virginia Department of Agriculture
 1900 Kanawha Blvd.
 E. Charleston, WV 25313
 Phone:304-558-2209
 Fax: 304-558-2228

 Scott Hirsch
 Association of Farmworker Opportunity
 Programs
 1611 N Kent Street #910
 Arlington, VA 22209
 Phone: 703-528-4141 ext 120
 Fax: 703-528-4145

 Rick Kingston
 International Poison Center
 8009 34th Avenue
 Suite 1050
 Minneapolis, MN 55425
 Phone: 612-814-7107
 Fax: 612-814-7101

 Bryon Little
 American Farm Bureau
 600 Maryland Ave, SW
 Washington, D.C. 20032
 Phone: 202-484-3614 x3604

 Paulo Mendonca
 The Virginia Justice Center
 PO Box 197
 105 4th Street SE
 Charlottesville, VA 22902
 Phone: 804-977-0553
 Fax: 804-977-0558

Terry Miller
 Oregon State University
Ag Chemistry
 Corvallis  OR 97331
 Phone: 541-737-1811

Rita M. Monroy
National  Coalition of Hispanic Health
and Human Services Organizations
 1501 16th St, NW
Washington, D.C. 20036
Phone: 202-797-4334
Fax: 202-797-4353

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                                                                                      Appendices
Teresa Niedda
Farmworker Health and Safety Institute
PO Box 510                 '
Glassboro, NJ 08028,  '    .
Phone: 609-881-2507
Fax: 609-881-2027

Steve Olenchock
NIOSH'          ;
1095 Willowdale Road
Morgantown, WV 26505
Phone: 304-285-6271
Fax: 304-275-6126

Chip Petrea
University of Illinois/Ash.Net
1304 W. Pennsylvania .
Urbana, IL 61801          •    •     •
Phone: 217-333-5035
Fax:  217-244-0323   .

PatPhibbs
Environmental Health Letter
951 Pershing Drive
Silver Spring, MD  20910-4464
Phone: 301-587-6300 x3022
Fax:301-587-1081

Telisport Putsaviage
Neuberg, Hargrave, Rambiave
 1225 Eye St, NW #500
Washington, D.C. 20005
Phone:202-312-2010
Fax:202-289-8781

Maryann Ramos
 OSHA
200 Constitution  Ave, Rm 3457
Washington, D.C.     •        •
 Phone: 202-219-5003
 Fax: 202-219-9053

 Lori Rectanus
 GAO
 441 Connecticut St NW
 Washington, D.C: 20548
 Phone: 202-512-9847
 Fax:202-512-8696
Cindy Lynn Richard
Achieva
5570 Sterrett Place
Suite 208A
Columbia, MD 21044
Phone: 410-964-9900
Fax: 410-964-0008

Robert I. Rose
EPA, Office of Pesticide Programs
401 M Street SW (7506C)
Washington, D.C. 20460
Phone: 703-305-6708
Fax: 703-305-2962

Roger Rosenthal
Migrant Legal Action Agency
PO Box 53308
Washington, D.C. 20009
Phone: 202-462-7744
Fax: 202-462-7914

Kyla Sell
Sunkist
50 F St NW
Suite 1100
Washington, D.C. 20001
Phone: 202-879-0256
Fax: 202-628-8233          ,

Omar Shafey
Pesticide Poisoning Surveillance
Florida Department of Health
 1317 Wimewood Blvd.
Tallahassee, FL 32399
 Phone: 850-488-8921
 Fax: 850-922-8473

 Delbert Shelton
 DuPont
 3750 Banyon Lane
 Alphareta, GA 30022
 Phone: 770-740-1313
 Fax: 770-740-1314

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Workshop OH Developing National Strategies
                Judy Smith
                EPA
                401 M Street SW
                Washington, D.C. 20460
                Phone: 703-305-5621
                Fax: 703-308-2962

                Monica F. Spann
                EPA, Office of Pesticide Programs
                401 M Street SW (7509C)
                Washington, D.C. 20460
                Phone: 703-305-6459

                Julia Storm
                North Carolina State University
                Toxicology, Box 7633
                Raleigh, NC 27695-7633
                Phone: 919-515-7961
                Fax: 919-515-7169

                John Tacelosky
                Chief, Division of Health and Safety
                PA Department of Agriculture
                2301 N. Cameron St
                Harrisburg, PA 17110
                Phone: 717-772-5217
                Fax: 717-783-3275
 Dorothy Tibbetts
 Ag. Chem. Extension
 Oregon State University
 Corvallis, OR 97330
 Phone: 333-737-6123

 Katinka Van der Jagt
 JSC
 1525 Wilson Blvd.
 Arlington,VA
 Phone: 703-312-8523
 Fax: 703-527-5477

 Jennifer Weber
 University of California at Davis
 IPM Education and Publications
 One Sheilds Ave.
 Davis, CA 95616
 Phone: 530-752-5930
 Fax: 530-952-9336

 Lawrence Worthington
 Maryland Governor's Commission
 311 W. Saratoga St,
 Baltimore, MD  21201
Phone: 410-767-7631
Fax: 410-333-3980

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                                                                                     ApperuHces
Appendix  B: Selected  Resources
Please note: The materials listed in this appendix are provided for information purposes only.
NATIONAL RESOURCES

National Pesticide Telecommunications
Network (NPTN): partially funded by EPA
and maintained at Oregon State University,
this toll-free telephone service (1-800-858-
7378) provides pesticide information to
callers in the U.S., Puerto Rico and the Virgin
Islands.
Web site: http://ace.orst.edu/info/nptn/.

EPA Office of Pesticide Programs:
401 M Street SW (7506C)
Washington DC 20460
Tel: 703-305-5017
Web site: http://www.epa.gov/pesticides/.

NIOSH Agricultural Health Centers

High Plain Intermountain Center for
Agricultural Health and Safety
154B Environmental Health Bldg
Colorado State University
Fort Collins, CO 80523
Director: Roy Buchan, DrPH
Tel 970-491-6151

Pacific Northwest Agricultural
Safety and Health Center
Box 357234
University of Washington
Seattle, WA 98195
Director: Richard Fenske,  PhD, MPH
Tel 206-685-8962

University of Texas Health Center at Tyler
PO Box 2003
Tyler, TX 75710
 Director: Arthur Frank, MD, PhD
Tel 903-877-7250
Northeast Center for Agricultural Medicine
and Health
One Atwell Road
Cooperstown, NY 13326
Director: John May, MD
Tel 607-547-6023

Southeast Center for Agricultural Health and
Safety Prevention
Department of Preventive Medicine
University of Kentucky
1141 Red Mile Road, Suite 102
Lexington, KY 40504
Director: Robert McKnight, ScD, MPH
Tel 606-323-6836

Great Plains Center for Agricultural Health
100 Oakdale Campus, #124 AMRF
University of Iowa
Iowa City, IA 52242
Director: Stephen Reynolds, PhD,  CIH
Tel 319-335-4212

National Farm Medicine Center
1000 North Oak Avenue
Marshfield, WI 54449
Director: Paul Gunderson, PhD
Tel 715-389-3415

UC Agricultural Health and Safety Center at
Davis
Old Davis Road
University of California at Davis
Davis,'CA 95616
Director: Marc Schenker, MD,MPH
Tel 916-752-5676

Association of Occupational and Environ-
mental Clinics: Established in 1987, the As-
sociation of Occupational and Environmen-
tal Clinics (AOEC) is a non-profit organiza-

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Workshop OH Developing National S&afelSeS
                tion committed to improving the practice of
                occupational and  environmental health
                through information sharing and collabora-
                tive research. AOEC has grown to a network
                of 55 clinics and more than 250 individual
                members, and is funded primarily through
                cooperative agreements with the Agency for
                Toxic Substances and Disease Registry (ATSDR)
                and the National Institute for Occupational
                Safety and Health (NIOSH). AOEC members
                develop curriculum materials in occupational
                and environmental health and provide train-
                ing programs for primary care practitioners. A
                lending library of course outlines, handouts,
                slides and videotapes has been established to
                assist members in this effort. A quarterly news-
                letter, an Occupational/ Environmental Medi-
                cine Listserver and an AOEC web site are part
                of the overall outreach and training strategy.
                Executive Director: Katherine Kirkland, MPH,
                Tel: 202-347-4976.
                AOEC Web site: http://occ-env-
                med.mc.duke.edu/oem/aoec.htm/.
                MATERIALS

               Environmental Medicine: Integrating A Missing
               Element into Medical Education (1995) and
               Nursing, Health and the Environment (1995),
               Institute of Medicine

               Case Studies in Environmental Medicine,
               Agency for Toxic Substances and Disease
               Registry
 Pennsylvania State University, Agromedicine
 Program video and materials.

 Ag-Med: Rural Practitioner Guide to
 Agromedicine. American Association of
 Family Physicians, Health Resources and
 Services Administration, Medical University
 of South Carolina, Clemson University

 Environmental Epidemiology for the Busy
 Clinician, Medical University of South
 Carolina

 Case Studies on Skin Disease and Respiratory
 Disease, University of California at Davis

 American College of Occupational and
 Environmental Medicine materials/trainings.

 Core Guidelines on Occupational Health and
 Allergy/Immunology, American Academy of
 Family Physicians

 Handbook on Children's Environmental Health
 (under development), American Academy of
 Pediatrics

 Draft Faculty Training Module on Pesticides
 (under development), Children's
 Environmental Health Network

Recognition and Management of Pesticide
Poisonings, Dr. Donald Morgan, MD, PhD,
ed. March 1989, EPA 540/9-88-001,
available in English and Spanish (new
edition coming out soon) Web site with full
text:  http://gnv.ifas.ulf.edu/~firstweb/text/
pp/19729.html/.

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