New Directions (1986—2007)

Overview of the period

Dr. Merchant was appointed Head of the Division of Occupational and Environmental Health Section in the DPMEH in 1983.  He also became Director of the IAM taking over from Dr. Long, who retired in 1986. Merchant led changes in the IAM during the New Directions period.  These changes had their beginnings during the previous middle ages of the IAM. The major change was from a focused European-style research institute to a collection of several independent research centers. These changes continued in the New Directions period.  Further, the IAM was clearly broadening to a traditional occupational and environmental Health Department.  In 1989, the name IAM (which held for 32 years) was changed to the Institute for Rural Environmental Health (IREH).  The result was that the IAM became a division integrated into a more typical structure of a U.S. university academic department with faculty responsibilities for research, service and education. The name change reflected a broader vision for a portfolio of research, education and service from the original IAM conceptual focus on the occupational health and safety of farmers, their families, and workers.  However, research, teaching, and outreach in agricultural health and safety remained a strong component of the new division.

A new farmers’ occupational health clinical outreach network program was established. The Iowa State Legislature (fostered by David Osterberg, Iowa House of Representatives, Chair of the Agricultural Committee at the time) initiated a pilot grant to develop a model clinic. We parlayed this small grant by garnering additional resources to establish a network of 22 agricultural health and safety service clinics in Iowa. The network was named The Iowa Agricultural Health and Safety Service Network (IAHSN). These 22 clinics were scattered across Iowa providing occupational health and safety services to farmers. An expanded educational component of the Agricultural Medicine Training Program was established to train nurses and other health care professionals to serve in the outlying IAHASN network clinics.  The clinics were located in rural hospitals and county health departments. This activity evolved into further state legislation and funding to establish Iowa’s Center for Agricultural Safety and Health (I-CASH).   

In addition to the founding of I-CASH during this period, several other centers were founded during this period which had some aspect of agriculture or rural in their aims.  The following centers were founded by Merchant: The Great Plains Center for Agricultural Health (GPCAH), The Injury Prevention Research Center (IPRC), The Environmental Health Sciences Research Center (EHSRC), and the Center for International Rural and Environmental Health (CIREH). The original IAM concept of a highly focused and integrated enterprise in Agricultural Medicine research evolved to a collection of centers.

Later in this period (1987-1990), faculty and staff of the IREH conducted a policy process (Agricultural at Risk: The Policy Process) which led to the Surgeon General’s Conference on Agricultural Safety and Health and the NIOSH Agricultural Health and Safety Program with new funding from NIOSH for agricultural health and safety work ($24 million annually, $48 million in 2019 dollars).  NIOSH funding resulted in a new center at Iowa (The Great Plains Center for Agricultural Health and Safety) and 10 other such centers across the U.S.

During this period (in 1999) the DPMEH in the College of Medicine transitioned to the new College of Public Health (CPH). The Department of Preventive Medicine and Environmental Health was no more. 

Administrative arrangements (1986 – 2007)

The previous Department Head, Dr. Isaacson, terminated the former administrative arrangements of sections and section chiefs in the IAM. Although the trend in administration was moving away from the major focus on agriculture, a new position was developed to help retain a focus and coordination of agricultural health and safety activities. The position was called Associate Director for Agricultural Medicine.  Dr. Merchant developed this position circa 1990 and appointed Donham. The position continued with some modifications by Dr. Nancy Sprince (succeeding Merchant from 1997-1998) and then Craig Zwerling (succeeding Sprince from 1998 – 2008).  The basic charge of this position was the following: “The Associate Head for Agricultural Medicine will provide leadership for the Department of Occupational and Environmental Health in the area of Agricultural Health and Safety. This leadership role shall include the areas of research, education, and outreach.” (See the position as description in Appendix D).

Merchant was appointed Director of the Environmental Health Section in the DMPEH and Director of the Institute for Agricultural Medicine in 1983. Dr. Robert Wallace was department head from 1985 to 1994. Professor Leon Burmeister served as Interim Head in 1994-97.  In 1997, Dr. Robert Kelch, Dean College of Medicine, through a national search, appointed Merchant as DMPEH head and dean designee to lead the transition process moving the Department to the new College of Public Health (CPH), founded in 1999.  Subsequently, Merchant was appointed dean of the new CPH. To be an accredited college of public health, there must be a financial and administrative separation from other colleges. Further, an accredited college must have departments in all the following areas: 1) Occupational and Environmental Health (DOEH); 2) Epidemiology; 3) Biostatistics; 4) Health Management and Policy; and 5) Community and Behavioral Health. The DOEH already had the necessary Environmental Health, Biostatistics, and Epidemiology components. The former graduate program in Hospital and Health Management and Policy  became the new Health Management and Policy Department in the CPH in 2000. A new Department of Community and Behavioral Health was created in 2000. The agricultural health and safety programs were situated within the new DOEH in the CPH.  Donham remained the Associate Department Head for Agricultural Medicine in the new DOEH through this period.

Dr. William Popendorf PhD, CIH was hired during the latter stages of the prior period (1983).  However, his major professional impact began in this period of new directions. His base education was in chemical engineering.  He also was a certified industrial hygienist (CIH).  He was hired in part to take over the Industrial Hygiene training program which had been founded by Dr. Berry.  Popendorf worked with Donham on assessment of the working environment in intensive swine production buildings. Prior to coming to Iowa, he had formerly been on the faulty of the University of California at Berkley. There he had an active research program on human exposures to pesticides and the relationship of volatility of the chemicals to exposure risk.

Burt Kross PhD joined the faculty in 1997. He collaborated with Donham and Merchant on the Agriculture at Risk Project.  A civil and environmental engineer, he became the Director of the Center for International Rural Environmental Health (CIREH) in 1991.

Dr. Peter Thorne PhD was hired in 1988. He came from the University of Pittsburgh where he had conducted research on particulate respiratory exposures. Dr. Thorne had a degree in Chemical Engineering and PhD in Environmental Health (Toxicology).  He also was a Certified Industrial Hygienist (CIH).  His interests and background helped build expertise in occupational respiratory diseases. In 1990,  Merchant appointed him the Deputy Director for the Environmental Health Science Research Center. In 2009, he became the Director on that center. Thorne later became the department head for the DOEH in the UI College of Public Health.

Steve Reynolds, PhD came to the department in 1991, from his doctoral program at the University of Minnesota College of Public Health.  In his doctoral work, he studied respiratory hazards of workers in turkey confinement buildings.  Dr. Reynolds also held a CIH.  His prior experience suited him well to work collaboratively with the Iowa faculty who were researching the work environment in confined animal facilities.

Mustafa Selim PhD arrived in Iowa from Murray State University in Kentucky. Selim was an environmental chemist, and was interested in environmental health effects of aflatoxin, a product of certain types of mold that grows on grain.

Loren Will DVM, MPH was hired to work on occupational health research projects in intensive livestock housing.

Patrick O’Shaughnessy PhD CIH had base training in civil engineering from the University of Vermont.  He was hired (1997) to fortify the Industrial Hygiene training program and the EHSRC where his interest and experience in particle physics aided in exposure chamber research. His engineering background and experience also assisted the ongoing research on the work environment in swine confinement housing as well as outdoor emissions from these buildings.

Nancy Sprince MD MPH (boarded in occupational medicine) was recruited from Harvard University in 1990 and became the Director of the Occupational Medicine Residency Program. She contribute important agricultural and rural injury research. Dr. Sprince also founded Heartland Center for Occupational Safety and Health.

Dr. Craig Zwerling MD PhD MS MPH (1990), Dr. Sprince’s husband,  came to the IREH from his position as Director of Occupational Medicine for the Boston Post Office. He was also boarded in occupational medicine.  With a background in injury research, he served as Deputy Director of the Injury Prevention Research Center and became its director in 1994.   Sprince and Zwerling also contributed to agricultural health research with the IRPC and EHSRC centers. They published a number of articles from a large data set called The Farm Family Survey.  Zwerling became head of the Occupational and Environmental Health Section and Director of IREH in 1997 and served until his retirement in 2008.

Corine Peek-Asa, PhD, was recruited from UCLA in 2001 to become Deputy Director of the Injury Prevention Research Center. She became Director in 2004 and made important contributions to agricultural and rural injury prevention research. She became College of Public Health Associate Dean for Research in 2009.

Tom Cook, PhD MS was supported by the NIOSH Industrial Hygiene Training Grant to complete his PhD in bio-mechanical engineering and ergonomics in the University of Iowa College of Engineering. He then joined the Occupational and Environmental Health faculty where he taught and led ergonomics research. He was an active contributor to the Center for International Rural and Environmental Health and served as its director  1995–2012.

New developments and new programs in the New Directions Period (1986 – 2007)

This period was a time of immense growth in the Agricultural Medicine programs at Iowa. Four major developments occurred during this period: 1) formation of the AgriSafe Network, which led to, 2) founding of Iowa’s Center for Agricultural Safety and Health (ICASH), 3) The Agriculture at Risk Policy Process, which led to the NIOSH National Agricultural Health and Safety Program, and 4) the founding of the non-profit Farm Safety for Just Kids. These programs are defined in detail below.

Formation of the AgriSafe Network (1987)

In the early 1970s Sweden, Finland and later Norway developed programs to provide comprehensive preventive occupational health services to farmers. These programs operated a network of clinics scattered across the countryside offering services included medical screening and treatment for occupational illnesses and injuries, and on-farm technical consultation related to safety and industrial hygiene, aiming to identify and mitigate sources of injuries and illnesses. Services also included personal protective equipment supplies, including selection and fitting.  Further, the programs included safety, health, and wellness education programming to farmers and their families.  During my sabbatical year in Sweden (1984–1985) I worked with the Swedish version of this program (lantbrukshalsan, translated as farmers’ health).  On returning home from my sabbatical, I thought this concept had potential as an effective program for health and safety protection of Iowa farmers, their families and workers.  Action to institute this program in Iowa was put on hold until the “right soil and moisture conditions” were present to “germinate” the concept. The right conditions began in 1986, when Iowa State House Representative David Osterberg (Mount Vernon) Chair of the Agricultural Committee, consulted with me about his possible grant opportunity for an educational travel program to Sweden to investigate farm safety and agricultural chemical protection programs in that country. Osterberg was awarded the grant and spent several weeks in Sweden visiting various agricultural health programs and activities.  Excited about what he had seen in Sweden, upon his return, in consultation with me, he initiated legislation to establish a model agricultural health and safety clinic in Iowa, utilizing ideas from the Swedish program model. Legislation was passed in 1988, for the Agricultural Health and Safety Service Pilot Program (Iowa Code chapter 304, Division VII, Section 802). To start this pilot program, a legislative grant of $40,000 for two years was awarded to the agricultural medicine component of the IREH.  I was the PI of this award serving as the director and coordinator to recruit potential clinics and administer the sub-awards. The awards were made based on a competitive grant process to rural hospitals and county public health departments. The three original model clinics were established with principal managers at Marshalltown Hospital (Marsha Barrett BSN) Sartori Hospital in Waterloo (Pamela Delagardelle BSN), and Spencer Hospital (Carolyn Sheridan BSN). Expansion continued from the original three to six model programs over two years. Eventually 22 programs were established across Iowa.  This program was titled the Iowa Agricultural Health and Safety Service Network (IAHASSN).

Jane Gay BSN helped to design the protocols and recruit clinics. The various clinics in the network provided comprehensive occupational health, safety, and wellness services to farmers, their families, and workers. Details of available services included on farm safety and Industrial hygiene services, demonstration, consultation on selection and fitting of personal protective equipment, health and safety education to farmers and families, and agricultural medicine training for health care professionals who would staff these clinics (Gay, Donham, Leonard 1990, Donham, Venzke 1997).  This program was an outreach program from the University of Iowa somewhat analogous to the Extension Service from Land Grant Colleges, but focused on health and safety, rather than raising corn, livestock or other commodities.   This program was the first and only such program outside of the Scandinavian Countries. A map indicates the location of these clinics (Gay, Donham, Leonard,1990, Donham, Venzke 1997).

Later, the name IHASSN program was changed to The AgriSafe Network. This name was adopted from the network member program at Spencer Hospital (AgriSafe).  Interest and request for services in other states outside of Iowa emerged. As it would be incorrect to utilize Iowa funds to support out-of-state programs, in 2003, the program was spun off as a new non-profit company, the AgriSafe Network (AgriSafe 2019). Natalie Roy MPH, who formerly worked for ICASH as educational coordinator, became the Executive Director of the National AgriSafe Network program.  Carolyn Sheridan BSN, and Charlotte Halvorson BSN, managers of the respective Spencer, IA and Dubuque, IA AgriSafe programs, were retained as principal staff persons of the now national/international non-profit AgriSafe Network Company.  As of 2021, there are over 70 AgriSafe Affiliate members (but not all full clinics) in at least 27 states in the U.S., as well as members in Canada, Argentina, Australia, and India among other locations (AgriSafe 2019).

In summary, the IAHASSN program was the first program on the American Continent to provide comprehensive occupational health and safety services to farmers, their families and their workers.  IAHASSN also was a major event in building the vision and the momentum for a larger State – wide Center (the idea that led to Iowa’s Center for Agricultural Safety and Health) to manage and grow these clinics and develop a broader farm health and safety program.  Additionally, IAHASSN was the organization, which formed the international non-profit organization The AgriSafe Network.   

Iowa’s Center for Agricultural Safety and Health (ICASH) (1990)

The founding of Iowa’s Center for Agricultural Safety and Health (ICASH) developed as an extension of the IAHASSN/AgriSafe program described in the previous paragraphs.  With success of the AgriSafe program, we recognized that a larger center with more resources was needed to manage the network. Also, we recognized the need for additional general health and safety programing.  Further, we recognized the need for coordination of  the health and safety efforts and resources of Iowa State University, the Iowa Department of Public Health, and the Iowa Department of Agriculture and Land Stewardship. Therefore, an initiative was undertaken to establish a statewide center of agricultural safety and health.  Based on consultation with Representative David Osterberg, a bill was produced to establish such an organization.  Representatives Josephine Gruhn (D-Spirit Lake, deceased in 2015) and Wendell Pellett (R-Atlantic, deceased in 2017) were floor managers of the bill, along with co-author of the bill, David Osterberg.  In 1990, the Iowa State Legislature passed a bill forming a Center of Agricultural Safety and Health (Iowa Code, Section 262.78, and House File 2548).

A concurrent activity during the critical time period that assisted the passage of this legislation to form ICASH, was the Agriculture at Risk Policy Process.  That process will be described in detail later.  The critical aspect of the final report of the process (Agriculture at Risk, 1989) were proposed models for a federal and state agricultural health and safety programs. The legislation closely followed the model for a state organization.

Following passage of Iowa House file 2548, Section 262.78, Donham formed a statewide ad hoc committee to develop the rules, processes, and structure that would be adopted to implement and maintain the Center. Members of this ad hoc committee included representatives from Iowa State University Colleges of Agriculture and Veterinary Medicine, The University of Iowa, the Iowa Department of Public Health, the Iowa Department of Agriculture and Land Stewardship, and other at-large representatives.  This committee titled the center Iowa’s Center for Agricultural Safety and Health (ICASH). The term (Iowa’s) was used to reflect that the Center was not just a University of Iowa program, but a combination of state organizations (University of Iowa, Iowa State University, Iowa Department of Public Health, and the Iowa Department of Agriculture and Land Stewardship).  The legislation ordered that the center would be housed administratively at the University of Iowa where the Director would be located as a University of Iowa employee.

Some legislators and citizens questioned why ICASH was centered at the University of Iowa rather than Iowa State University (ISU) which has the College of Agriculture. My answer went something like the following.  “The missions of The University of Iowa and Iowa State Universities are common in their concern for the welfare of the farmer. However, they differ in that the University of Iowa focuses on medical research, health professions training, and clinical services regarding farmers’ health relative to their exposures to agricultural occupational hazards.  Iowa State University is primarily a production agricultural university concerned mainly with the economic health of the farmer.”  However, it should be acknowledged that Iowa State did have a history in agricultural safety. From 1947 through 1986, there was a position of Extension Safety Specialist at Iowa State University to generate informational programs and disseminate them throughout the state via the network of regional and county extension offices. Geographic separation and the difference in focus resulted in little interaction between the two institutions in this area in early years. In addition, the Extension Safety Specialist left ISU in 1986 and the position was not filled until 1990. Thus, ICASH filled in for what ISU had done previously in agricultural safety during that period.

These events helped justify the siting of ICASH at the University of Iowa. Initial funding for ICASH was recommended at $365,000 annually.  However, the final funding allocated by the Agricultural Appropriations Subcommittee was $250,000. Although not specified in the legislation, I-CASH was supportive in advocacy and financial support in reestablishing the Agricultural Safety Extension position at ISU.  We allocated $50,000 ($97,000 in 2019 dollars) per year out of the University of Iowa ICASH budget to support an Agricultural Extension Safety Extension Specialist.  Charles V. Schwab PhD was hired to fill the Agricultural Safety Specialist position in 1990. (Note: the funding to support the ISU safety specialist was withdrawn in 2002).

A major accomplishment of the ICASH  legislation was establishment of a working collaboration, coordination, and management of government agencies and private non-profit organizations that have an interest in agricultural health and safety activities in Iowa. The State agencies that became partners, as specified in the enabling legislation, included the University of Iowa College of Medicine, Iowa State University College of Agriculture, the Department of Agriculture and Land Stewardship, and the Iowa Department of Public Health.  ICASH helped develop several new private non-profit organizations in the state that became partners in ICASH.  (These organizations are listed and described below).  The I-CASH principal aim was to sustain and grow this collaboration with a focus on the common goal of saving lives and preventing injuries to farmers, their families, and their workers.  The motto was “Helping to keep Iowa’s farmers, their families, and workers, alive and well in agriculture”.  I-CASH was and remains today unique in that it is the only state-level legislative-based collaborative agricultural health and safety organization in the world.  Working among organizations with diverse cultures, funding streams, and alliances, some with inherent competition and barriers, I-CASH has done well to keep the organization functioning to meet the needs of the agricultural community. The 2010 annual report (ICASH 2010) which was the 20th ICASH anniversary, provides a review of the ICASH history, its formation, vision, goals, and progress. The following paragraphs describe some of the major I-CASH accomplishments during the period from its founding in 1990 to 2010 and beyond.

Programs and organizations spawned by ICASH

Founding of the Midwest Regional Agricultural Safety and Health Forum (MRASH) (1990)

During its middle ages of (1974-1985) the IAM modeled and facilitated the founding of several new national and international agricultural health and safety organizations that have been previously described. However, as the IAM was changed in structure and function, ICASH assumed the role as modeler, facilitator, leader of new programs and organizations.

In 1990, soon after ICASH was founded, we initiated a conference on Agricultural Safety and Health.  To form this conference, we brought together all the partners of ICASH to learn about new issues and programs in occupational health and safety on farms and to offer continuing education of our associated providers (e.g., nurses, physicians, and others who staffed the IHASSN clinics). This program grew rapidly. As the NIOSH Great Plains Center for Agricultural Health came on line, we invited them to become a partner of this conference.  Later the NIOSH Agricultural Center in Nebraska (Central Sates Center for Agricultural Safety and Health [CS-CASH] came on board as a partner. That collaboration provided additional resources and geographic reach, as the latter two NIOSH Agricultural Centers had responsibility to cover all the upper Midwest states. We retitled that program as the Midwest Regional Agricultural Safety and Health Forum (MRASH). This program occurs annually today, drawing circa 175 scientists, health providers, and producers from Iowa and the Midwest and Eastern states.

ICASH Facilitated and Promoted New Not-For- Profit Agricultural Health and Safety Organizations

In addition to founding MRASH, ICASH was active in promoting and developing new organizations that helped to disseminate the skills, resources, and human capital in agricultural medicine in Iowa, nationally, and internationally.  Faculty and staff of ICASH facilitated and promoted the development of 12 new non-governmental agricultural health and safety programs.  Contacts for opportunities to assist others in program development came by way of our nationally recognized service, outreach, and education programs.  Description of these programs follow.

The WW Kellogg Company Foundation Initiative in Agricultural Safety and Health

Early in 1990, Gene Graham of the Kellogg Company Foundation contacted me.  He reached out to us based on the national publicity generated ICASH programs and Kellogg’s history of funding the IAM.  Jane Gay BSN, a staff person in ICASH, took the lead working with Graham in developing this project.  Jane had been organizing our network of farmer occupational health clinics (AgriSafe Network).  The Kellogg Company Foundation allocated $11,000,000 for the program. Jane became a consultant to Graham and Kellogg.  The development of this program proceeded as follows:

• Organized an introductory conference held in San Diego, January 1991. Approximately 125 participants from around the U.S. attended.
• A consensus process was held to determine the critical hazards in agriculture to be addressed.
• A plan was developed to award competitive grants to address the issues identified.
• Jane Gay developed the RFP for the proposals.
• The review process included several experienced reviewers to score the proposals.
• Follow-on conferences were held in New York and Orlando to facilitate communication and understanding among awardees and between owner/operators and migrant worker employees.

The goals of the program were to seek and practice interventions that work and to bring together migrant farm workers and owner operators.  Eleven five-year projects were funded.  Projects included a novel mental health intervention in New York with an expansion to Iowa.  Farm worker health and safety networks were funded in New Jersey and Florida. Coalition/partnership projects were funded in Kentucky, Illinois, and Nebraska. A farmer sociological project was conducted in Eastern Washington.  Similar projects were funded in California, Louisiana, and Wisconsin.

Several of the projects/coalitions have had life after the end of the funding period. A detailed evaluation of the project by third party reviewers indicated a number of factors that made some projects successful and pointed out barriers that hindered progress in other projects (Petrea 1997, Jenkins, and Malenga 1998, Kukulka, Cheek, Jenkins 2008).  Synergy between the NIOSH and the Kellogg initiative (public and private) helped to bring a new age of resources, research, and outreach to address the formerly underfunded but important area of health and safety among farmers, their families and workers.

Farm Safety Camps (1995)

The Farm Safety Days Camps began circa 1995 as an ICASH project. The program was led by ICASH staff person Jane Gay BSN collaborating with Agrisafe Nurses Pam Dellegardelle BSN (Sartori Hospital in Waterloo) and Carolyn Sheridan BSN at Spencer, Iowa Hospital. They developed a manual for the camp program. The aim of Farm Safety Day Camps was to teach kids how to be safe on farms through demonstration and hands-on learning. A second aim was that the kids would take this information home to teach their parents about farm safety. This program became extremely popular and has been adopted by organizations in many states including the Extension Service, 4H, and FFA among other providers.  The largest organization that developed using this concept in programing is Progressive Agriculture Farm Safety Day (PASD 2019).  They provide over 300 programs yearly in the U.S. and Canada.

The National Education Center for Agricultural Safety (NECAS) (1997)

In and around 1995, I consulted with Sam Steel (Manager, Agricultural Health and Safety Division of the National Safety Council) about developing a “hands-on” farm safety campus in Iowa. The idea was that farmers could come and learn from models set up to demonstrate how accidents occur and how to prevent them. This program was to be a cooperative venture between the North East Iowa Area Community College, the National Safety Council, and ICASH.  The State of Iowa awarded $1,000,000, and the federal government awarded an annual appropriation for several years to develop and operate this learning campus.  NECAS was established in 1997 on the Peosta campus of Northeast Iowa Community College. Sam Steel was the founding director and continued in this position from 1997- 2002.  Dan Neenan succeeded Steel as Director and remains so as of this writing (2021).  This center emphasizes hands on training for EMT’s, fire fighters and first responders to address emergency hazards in agricultural environments.  This center is represented on the Board of ICASH (NECAS 2019).

North Carolina Agromedicine Institute

In 1987, I was contacted by Byron Burlingham MD, a pediatric physician in the College of Medicine at East Carolina University in Greenville, North Carolina (ECU).  He was the point person of a group of faculty that included Dr. Ernest Hodgson (Extension), Dr. Billy Caldwell (Toxicology Program), and Dr. Paul James MD (Department of Family Medicine).  They were interested in starting a program that combined Extension and Medicine to serve the health and safety needs of the farming population.  I served pro bono as a consultant over the course of 12 years on planning and promoting the development of their program.  Circa 1998, I met with Vice-Chancellor Tom Feldbusch of ECU to discuss developing the program.  In 1999, permission was granted by the University of North Carolina System Board of Governors to establish the North Carolina Agromedicine Institute (NCAI) to be modeled after ICASH.  The NCAI includes as partners the North Carolina Agriculture and Technology State University (NC A&T), and NC State University. The NCAI struggled in the early years to find its footing, having gone through several short-term directors.  In 2008, Robin Tutor-Marcom, a staff person at NCAI came to the University of Iowa to take the week-long Agricultural Health and Safety Core Course.  She returned to NCAI, and shortly was appointed director. She continued her academic education while serving as director, obtaining her Educational Doctorate and Master of Public Health degrees. She provided the program with energy and direction. Under her leadership, the NCAI has become one of the leading outreach agricultural medicine programs in the country.  She successfully imported and deployed the AgriSafe Network and the Certified Safe Farm programs in North Carolina, which were developed at the IAM/ICASH in Iowa.  In March of 2019, they celebrated their 20th anniversary (NCAI 2019).

Sharing Help Awareness United Network (SHAUN) (1999)

On or about 1998, Jeris Peterson, a farm woman in Southern Iowa, lost her young son Shaun to a farm injury.  She was devastated from this loss and found nobody who could help her overcome her grief and psychological stress.  She wanted to help other farm parents to manage grief and get back to some semblance of a normal life. At the time the Associate Director of I-CASH, Kendall Thu PhD, worked closely with Jeris to help develop an organization to meet this goal.  After Dr. Thu left the University of Iowa for a faculty position at the University of Northern Illinois, Michael Rosmann PhD, filled in as Associate Director for ICASH.  Rosmann is a clinical psychologist and a farmer.  He had previously worked as director of a local mental health center in Harlan, Iowa.  He also had a private practice counseling farmers with behavioral health issues that involved farm and family issues. Rosmann, worked with Peterson, developing the organization that Thu and Peterson initiated. A new non-profit organization founded in 1999 was the result – Sharing Help Awareness United Network (SHAUN).  ICASH donated extensive human resources and management to the development of this organization.  The primary aim of SHAUN was to develop a mental health training program to prepare farm people as “lay counselors” and to form a network of these lay counselors who could intervene with farm families who had lost a child or relative to an accidental injury. As this program grew, it was apparent that rural and farm behavioral health should have a broader mission.  Consequently, SHAUN was disbanded around 2001, and a new organization Agriwellness was formed to take on the mission of SHAUN, along with the broader issues of agricultural behavioral health.

Agriwellness

Rosmann left his position as ICASH Associate Director to focus on his new venture as Agriwellness Director, which he founded in 2001.  Donham was on the founding board of Agriwellness. The mission of Agriwellness is to promote accessible behavioral health services for rural and agricultural populations (Agriwellness 2019, Rosmann 2002).  This organization pulled together various personnel and resources from ICASH, Extension, public health, and the Federal Government (Dept. of Health and Human Services). The program Sowing the Seeds of Hope [SSOH] developed by Rosmann and Jeris Peterson for the organization SHAUN, was the key program of Agriwellness. This mission was carried out with funding from ICASH and a number of other state and federal resources. It served behavioral health educational efforts in Iowa, and six surrounding states. Further, several regional conferences on rural agricultural behavioral health were held in the Midwest. Agriwellness still exists as of this writing, with ad hoc individual consulting services and communication on the issues through the farm mass media. Dr. Rosmann is a syndicated columnist for various farm publications (e.g., Iowa Farmer Today) where he writes weekly articles on behavioral health issues. This work expands the reach of Agriwellness to a large farm audience.

Rural Health Initiative

RHI is a non-profit health screening organization founded in 2004 and located in East-Central Wisconsin.  Rhonda Strebel is the founding director of this program and remains so as of this writing.  Headquartered in the Town of Shawano, it is connected to the Theda Care Health Network which operates primarily in the counties of Shawano, Outagamie and Waupaca (RHI 2019).  I was on the founding board of this organization, serving as a consultant and advisor establishing this organization. They used the ICASH AgriSafe Network and the ICASH program called Certified Safe Farm (CSF) as models for their organization.  The key difference in this program compared to the CSF, is that there was a single focus on basic health/wellness screening. The nurses travel to the farm and conduct the health screenings and health coaching at the client’s kitchen table. Finding any adverse health issue, the clients are referred to an appropriate health care professional.

Australian National Center for Farmer Health

In 2006, Susan Brumby RN, PhD (from Hamilton, Victoria, Australia) was awarded a travel scholarship to attend the Agricultural Medicine Core Course in Iowa.  Following this training and experience, she returned to her home and began developing the ideas for an agricultural medicine center. Susan was a farmer married to a veterinarian which gave her knowledge and a cultural connection to the farming population.  Coming from a farm background, she was aware of and concerned about the health and safety of “her people.” She trained to become a nurse and midwife with the Western Australia Health District.  Later, she completed a PhD.  She became the founding Director for the National Center for Farmer Health in 2008 (ANCFH 2018). In 2010, she developed the plan to have a national conference that would bring attention to the center and the issues in Australia and set the tone for future development in the field.  I presented a keynote speech to help set the goals and directions for the center. In 2021, the NCFH is the premier program in Australia that aims to help keep farmers and their families healthy.  She started a program called “Sustainable Farm Families” that focused on health screening and health promotion of farm families.  She returned to Iowa in 2013 on a sabbatical program. During that time, we worked on a plan to establish the Agricultural Medicine Core Course in Australia, modeled after the Iowa Agricultural Health and Safety Core Course, which she had attended in 2006.  Upon returning to Australia, she initiated an education program and graduate certificate program based on the ICASH model. Together we published an article describing the translation of our core course to Australia (Brumby, Rudolphi, Rohlman, and Donham 2017).  The NCFH has gained international recognition with their programs in research and outreach.

Vermont Farm Health and Safety Coalition

Jean McCandless MSW, LICSW was a social worker in the Vermont Department of Public Health. Her interest in farmer health began with a program she developed on an arthritis management and prevention for rural and farm people. She had started working with the Vermont Farm Health Task Force, which later became the Vermont Farm Health and Safety Coalition (VFHSC 2018).  In 2008, McCandless traveled from Vermont to Iowa City, IA to attend our Agricultural Health and Safety Core Course. Upon returning to Vermont, her interest expanded to general farm health and safety issues. She was one of the partners in our Building Capacity Program, which was designed to help other organizations around the country to plan and initiate the Agricultural Health and Safety Core Course in their regions. The VFHSC consists of a group of organizations collaborating to provide training and services to help improve the health and safety of Vermont’s farmers, farm family members, and farm workers. Members of the coalition include the University of Vermont, the Vermont Department of Agriculture, various health provider groups, farm groups and agribusiness groups. The organization is modeled after Iowa’s Center for Agricultural Health and Safety.

The Rural Health and Safety of Eastern Iowa

The Rural Health and Safety of Eastern Iowa was established in 2011 (RHSEI 2019).  During my tenure as ICASH Director, we established 22 Agricultural Occupational Health clinics around the state of Iowa (The AgriSafe Network mentioned above).  However, we were unable to establish one in the regional area of the University of Iowa (Eastern Central Iowa). Having been a board member of the Johnson County Public Health Department for many years, I advocated to them for such a clinic for many years. In 2005, I suggested to to the ICASH Board re-institution of the AgriSafe clinic startup grants program.  In 2008, this resulted in instituting a special ICASH competitive grant process to develop a new AgriSafe clinic to provide preventive services to farmers and their families and workers. An independent review committee chose our ICASH grant to establish a farm occupational health clinic, modeled after the AgriSafe Clinics in existence in other regions around the state. The aim of our funded proposal was to establish the program in conjunction with Johnson County Public Health Department and the Regional Iowa State University Extension. In 2008, a prominent farm couple of Johnson County, Roger and Sally Stutsman (Image 32) lost their only child to a farm injury. That event created a greater awareness and concern in the Johnson County Health Board and the Johnson County Supervisors in regard to farm safety.  County Supervisors, supported by Johnson County Extension, allotted an annual grant of $15,000 to help fund our proposed RHSEI program. With these funds in hand, the RHSEI was founded in 2011 as a non-profit organization.  Roger Stutsman was the founding Board Chair. He currently (2021) remains the Chair; Donham Vice Chair; Nyle Kauffman MD, treasurer; and Stephanie Leonard MS CIH, Secretary.  Other prominent board members as of April 2018 include farmer representatives Loran Steinlage, Rob Stout, and Keith Marshek.  College of Public Health Professor Diane Rohlman PhD also joined the board.  This is a working board, as the programs are operated by volunteer board members.

The initial clinic goal was to establish a full occupational health service for farmers that would include safety and health education, as well as health promotion and safety services.  In the current format, the emphasis has focused on education, especially for youth, including ATV safety, Farm Safety Day training, and safety training for Amish children and their parents.

In 2019, the organization established a partnership with Mercy Hospital of Iowa City, an eastern Iowa regional hospital with outlying clinics in eight surrounding rural communities. Working together with Mercy, The Rural Health and Safety Clinic teams up to provide mobile health screenings and health and safety education to the rural and farm populations in their service areas. During the time of the COVID 19 pandemic, the clinic provided free COVID testing out of its mobile clinic in rural counties of Eastern Iowa.

Agricultural Health and Safety Alliance (2017)

This organization arose from the AgriSafe Network Organization, described earlier in this document as originating as an ICASH program.  Carolyn Sheridan BSN, one of the principal staff of the AgriSafe network, left to develop the Agricultural Health and Safety Alliance in 2017 (AHSA 2019).  In essence, the Agricultural Health and Safety Alliance is a “grandchild” of ICASH.  AHSA focuses on training students in agricultural production programs at universities and colleges in the U.S., Canada, and Australia.

Other Significant Programs and Activities of ICASH

Surveillance of Farmer Illnesses and Injuries

ICASH worked with the Iowa Department of Public Health (IDPH) from 1990 – 2013 to establish and promote continuation and advancement of agricultural health and injury surveillance. The Administrative Code of Iowa requires health care providers to report any farm-related illness or injury. A special reporting form, “The Iowa Farm Injury Report,” (https://idph.iowa.gov/Portals/1/Files/BETS/farm_injury_report_form.pdf) was developed for health care providers to report to the IDPH when they had encountered a farm injury or illness. However, the IDPH devoted little resources to collect and analyze the data. Therefore, ICASH worked with the IDPH to develop a surveillance system of reporting through the State Emergency Medicine system records, which had software to make recording and analysis easier. However, the system lacked coverage of the total farm population as only level four trauma centers (located mainly at tertiary care facilities) were required to report. Thus, as the bulk of farm illness or injury events occur in rural areas where only level one, two, or  three trauma centers are present, many farm injuries and illnesses are not counted. Surveillance has continued in current times and has advanced following the ICASH effort as the Iowa NIOSH Great Plains Center for Agricultural Health and Safety and the Iowa Injury Prevention Center have developed programs to supplement the IDPH effort.

The Agricultural Occupational Health Nurse Certificate Program

Mentioned earlier, in 1990 we developed an educational program to train nurses and other health care providers to serve in the AgriSafe Clinics located around the state of Iowa (Gay, Donham, Leonard 1990, Donham and Venzke 1997).  This 40-hour course led to the three-hour graduate course “Rural Health and Agricultural Medicine” 175:209, and the 40-hour summer graduate and continuing education course, “Agricultural Health and Safety: The Core Course” (ASH Core Course 2019).  This program exists today and as of 2021, this course has resulted in the training and certification estimated at over 1240 nurses and other health care providers, and public health professionals in agricultural occupational health (Rudolphi, Donham 2015, Fisher, Donham 2011). Many of the agricultural health and safety programs mentioned above, were initiated by former students of our Agricultural Health and Safety Core Course, including the programs in Vermont, North Carolina, Alabama, Illinois, Texas, Nebraska, Australia, Turkey, Sweden, and Argentina.  Diane Rohlman PhD assumed direction of this course in 2014 and remains director as of 2021.

Visiting professor to Family Practice Residency programs

ICASH operated an extensive outreach program.  For example, from 1985 – 2013, I traveled the state delivering a series of lectures on Agricultural Medicine to the network of ten Family Practice Residency Programs in Iowa. This program was aimed at family medicine residents and house staff. The programs were presented on a rotational basis so that the entire agricultural medicine core course would be presented over a four-year period—the length of the residency.

The Farm Safety Walkabout Program

This program was developed in 1992 by ICASH staff person Jane Gay BSN, Director Donham and Cheryl Hawk DCM, PhD, a graduate student at the time. This program aimed to work with youth and their families on their farms to identify and remove safety hazards. This initiative led to one of the components of the Certified Safe Farm Program (to be discussed later in this manuscript).  Several other programs around North America have adopted this program. An operations booklet was produced to facilitate parents to implement this program with their children at the farm level (Hawk 1992).  Dr. Hawk also developed other youth programs in her tenure at Iowa, including childcare options for farm kids (Hawk, Donham, and Gay 1994).

Tractor Risk Abatement and Control Program

Tractor Risk Abatement and Control (TRAC-SAFE) prevention intervention was developed in 1994 by Drs. Merchant and Donham. It was developed in response to the high number of fatalities related to tractors. TRAC-SAFE was designed as a community-based program to be carried out by local health and safety professionals along with community volunteers and farm groups working together with farm machinery dealers. The program aimed to reduce injuries and fatalities from tractor overturns and other tractor-related injuries. Carol Lehtola PhD, post-doctorate student at the time, was the primary manager of Iowa counties where there was a high risk of tractor-related fatalities. The local Future Farmers of America (FFA) chapters in those counties took the lead.  (FFA is a popular high school agricultural training program found in many rural school districts). FFA students visited farms to review and audit their tractor fleets for safety, encouraging them to install safety devises according to a safety checklist, e.g., rollover protection structures (ROPS), power take off (PTO) shields, and safe marking and lighting for tractors moving on roadways. If the farmers installed the recommended safety features prescribed by the FFA students’ audit, they received incentives from community businesses. These included gift certificates from grocery stores, farm stores, and machinery dealers. If a ROPS was to be installed, the machinery dealer would pick up the tractor and transport it to their shop and install the ROPS at cost.  While the tractor was in the shop, the machinery dealer would also conduct a horsepower rating on the tractor free of charge. Several of the features of this program (community-based, checklist driven, and incentives) were models for the Certified Safe Farm Program, which is discussed later in the manuscript. CDC-NIOSH saw the TRAC-SAFE program as an important and effective program. They promoted the program and produced and distributed hundreds of operational manuals provided free to communities to implement the program. The TRAC-SAFW manual is described in the references and can be downloaded from the referenced web site (Donham, Lehtola, and Merchant 1996).

Tractor Risk Abatement and Control: The Policy Conference

An extension of theTRAC-SAFE program, this policy conference was held in 1997 in Iowa City.  Invited participants represented a broad spectrum of stakeholders (farmers, policy makers, public health professionals, and industry people). This conference followed a consensus process, which led to a model policy document aimed to reduce the risk of tractor related fatalities in farmers, their families, and workers. Proceedings were published by the University of Iowa in booklet format, and distributed widely (Donham, Osterberg, Meyers, Lehtola 1997, TRAC-SAFE 2019).  The authors of the proceedings were Kelley Donham, David Osterberg, Mel Myers, and Carol Lehtola.  This conference enhanced national attention on the issue, helping to spawn policy and programs in other states. For example, the New York Center for Agricultural Health and Medicine (NYCAHM) advocated to their state legislature to establish a rollover protection structure assistance program.  Further, NYCAHM, with NIOSH support initiated the National ROPS Rebate Program, which works with states to facilitate farmers installing ROPS by reducing the cost of ROPS installation. Also, Robert Aherin PhD, a farm safety specialist at the University of Illinois, was able to encourage the state legislature to establish standards on lighting and marking for farm vehicles operating on the public roads.

The First and Subsequent Follow-on Conferences on Worker and Environmental Health Consequences of Confined Animal Feeding Operations

The USDA and EPA defines Animal Feeding Operations with 1000 animal units or more (an animal unit is 1000 lbs. of live weight) and houses them for 45 days or more, as a confined animal feeding operation (CAFO).  A swine facility with 2,500 animals equals 1000 animal units and is therefore a CAFO.  Since the late 1980’s the CAFO style of livestock production has emerged as the primary method of raising livestock in Iowa and other states. CAFO production saves labor and increases productivity.  However, CAFO production created a great deal of environmental concern mainly from rural neighbors who did not like the odors and feared health problems that emissions might cause. The ICASH center along with other centers and key faculty at Iowa became state and national leader in addressing this issue. Several state, regional and national conferences on this subject were designed and led by Iowa faculty and staff. These events made important advances in policy aimed at addressing the environmental and worker health concerns of CAFO livestock production.  

Conference on Understanding the Impacts of Large-Scale Swine Production

In 1995, the first conference in the U.S. on the CAFO issue was held in Iowa. This single-issue conference was designed, led, and managed by ICASH faculty and staff together with Drs. Merchant and Thorne. Iowa State University faculty also participated in the planning and conduct of this conference. The Proceedings of this conference were published (Donham, K.J., and Thu, K., 1995).  As this was the first conference globally held on this issue, it opened the door to two other follow-on conference in Iowa held in 2002 and 2007, and two in North Carolina held by Duke University and by the U.S. Public Health Service.

The Iowa Concentrated Animal Feeding Operation Air Quality Study

Public controversy on the CAFO issue became so strong that in 2002, Iowa’s Governor (Tom Vilsack) wrote to the Presidents of Iowa State University and the University of Iowa requesting that faculty from both universities jointly address air quality (primarily odor) arising from CAFOs. The former Dean of the ISU College of Veterinary Medicine then Interim Dean of the College of Agriculture, Dean Richard Ross, and Dean Merchant of the U.I. College of Public Health were designated by the respective presidents of the two universities to co-chair this study group of 24 interdisciplinary faculty; half from ISU and half from UI. The working group was tasked in a letter from DNR director Jeff Vonk to provide guidance regarding the impacts of air quality surrounding CAFOs on Iowans and to recommend methods for reducing and /or minimizing emissions. Other UI faculty and staff contributing to this effort included Donham, Peter Thorne, Carol Hodne, Keri Horbuckle, Joel Klein, Shannon Marquez, Patrick O’Shaughnessy, David Osterberg, Stephen Reynolds, Jerald Schnoor, and Kendall Thu.  This joint UI-ISU effort resulted in a consensus multi-authored 221-page report (Merchant J.A., and Ross R. 2002). The report spurred a DNR air quality study and then rule making which extended set-back distances for CAFOs to better protect the public and establishment of the DNR “Master Matrix” system for citing of CAFOs.  UI faculty who contributed to the DNR rule making process included Donham, O’Shaughnessy, Thorne, Osterberg, and Merchant. These DNR rules have remained essentially unchanged since its passage in 2003. The report published with support from the UI Vice President for Research and the Environmental Health Sciences Research Center was widely disseminated and remains a valuable EHSRC reference document.

The National Institute for Environmental Health Sciences Conference on CAFO’s 

A 2007 conference, funded by the National Institute for Environmental Health Sciences, was held at UI and was organized by Dr. Thorne, Director of the Iowa Environmental Health Sciences Research Center (EHSRC).  Nearly 30 scientists with expertise and experience in this field participated in the conference. This was a one health study (multidisciplinary approach) that provided evidence-based science on physical, environmental, economic, and social hazards associated with CAFO production. The results of this conference were published in the Journal Environmental Health Perspective (Thorne, P.S. 2007).

Certified Safe Farm Program 

This novel program was established in 1996 in Iowa as a total farmer health program. The program was funded in part by a grant from NIOSH, in addition to support from the Iowa Farm Bureau, Monsanto, Blue Cross Insurance and the Central States Center for Agricultural Safety and Health at the University of Nebraska.  The program is unique among farm safety and health programs. The program had five major components: 1) In-depth and specific farm-focused health and safety education, 2) health and wellness screening, 3) referral to a higher level of care if so indicated, 4) an on-the-farm safety audit by a trained safety person with the aid of a safety check list, and 5) performance incentives if the producer brought the safety aspects up to a defined level. Incentives included $200 cash and the potential for discounts on insurance costs, and discounts on farm services and supplies. Over 600 Iowa farms are certified.  This program was adopted in North Carolina, with components of the program established in Wisconsin and New York.  Results have shown reductions in severe injuries, certain respiratory illnesses, increased use of PPE, and a 47% reduction in occupational health and injury medical expenses. Over 20 articles have been published on this “total worker health” incentivized program.  Examples of the publications include the following (Donham, K.J., Rautiainen, R., Lange, J., and Schneiders, S. 2007). This program has been extensively evaluated and has shown reduction in farm injuries, illnesses, and medical care costs.

 ICASH Strategic Planning Process of 2000

 The year 2000 was the 10-year anniversary of ICASH. During this year, an in-depth strategic planning process was carried out to look back, evaluate, and look ahead to prepare I-CASH to meet the demands of the next decade. The results of that effort are documented in the 2000 annual report (Donham, K.J. 2000). One of the conclusions of that planning session was a diagram and review of the mission and vision of ICASH.  The attached figure was designed and approved by consensus of the Board. The diagram represents a sunflower with the petals as collaborating partners and the center bringing these “petals” (partners) together for coordinated work to benefit the health of the agricultural population. 

Achievement of goals to reduce agricultural injuries and illness

The National Safety Council reported an estimated 2,428 farm fatalities per year in the U.S. from 1940 – 1945. This number would likely be similar for the period in the early days of the IAM. There has been a decline in the number of fatalities on farms over the years. However, farm injury statistics are not as reliable as we would like. Also, the total number of fatalities does not estimate risk, as there is no denominator.  For the ICASH 2010 annual report, we attempted to compare risk rates over the period of time. We obtained NIOSH/CFOI data for two years (1999 and 2008). We compared agricultural fatalities for these two years using number of farms in the state as the denominator.  During that time, total agricultural fatalities declined from 75 to 25, or from 78 fatalities per 100,000 down to 30 fatalities per 100,000 farms. This 48% observed reduction in fatalities (rates per number of farms) could be attributed (at least partially) to the totality of efforts of ICASH, its State and private non-profit affiliates, and the Great Plains Center for Agricultural Safety and Health (Donham 2010).  Over this nine-year period a tremendous amount of continuing education, intervention, and research focused on health and safety of the farming community. However, likely other factors contribute to this decrease as well.  Such factors may include newer and safer farm equipment, better educated and prepared work force, better health care, and emergency preparedness.

The graphs above indicate total fatalities and rates of fatalities per 100,000 farms in 1999 and in 2008.

Agriculture at Risk Policy Process (1985 – 1990)

The Agriculture at Risk Policy Process resulted in pivotal advances to the field of Agricultural Safety and Health in Iowa, the Nation, and internationally as well. Prior to 1955, little national attention was paid to the issue of agricultural health and safety by the medical and public health professions. There was no national program.  It was the Cooperative Extension Service at the Land Grant Universities that carried most of the load, focused on safety information dissemination about acute agricultural injuries. The US Department of Agriculture provided $20,000 per year to several land grant colleges to help carry out farm safety programs. That amounted to less than a half-time person for an entire state, regardless of the size and extent of their agricultural enterprises. Very little funding was available to support research and training for the medical and public health professionals to carry out this important work.

The Agriculture at Risk Policy Process Changed All of This!

The results of this process was arguably one of the most important events in the history of Agricultural Health and Safety in Iowa and the Nation.  The developments that led up to this process began in early 1980s.  Prior to this event, a growing national awareness of the issues of Agricultural Safety and Health was boosted by a series of six articles A Harvest of Harm written in 1984 by Tom Knudson (Knudson, T.A. 1984).  Knudson, a journalist for the Des Moines Register, consulted with several faculty of the IAM, who assisted him in his research as advisors and resource experts. Knudson requested contacts with farmers and farm families who had had injuries or illnesses from their farm work exposures. Because he could not provide that information due to privacy protection issues, Merchant suggested that he research the Des Moines Register clipping files for farm injury stories, which would be a public record, free from privacy protection issues.  Knudson returned with a file of newspaper clippings. Merchant introduced Knudson to  other IAM faculty who discussed at length the cases reported in these clippings and the issues of farm safety and health generally. We also provided Knudson with several of our research papers among other references that provided a scientific basis to enhance and back up his oral interviews. Knudson’s A Harvest of Harm appeared as a series of six articles published in the Des Moines Register and as a separate newspaper magazine publication. The series was reviewed with critical acclaim by other journalists, and the public as an outstanding work of investigative journalism. Knudson and the Des Moines Register received a Pulitzer Award for A Harvest of Harm, which propelled the issue of agricultural health and safety to national attention.  The series served to raise awareness as to the frequency and severity of farm-related injuries, illnesses, and deaths, not only in Iowa, but nationally as well.

This publicity helped induce the IAM faculty and staff to develop an idea leading to a policy process to attract resources to attack the agricultural health and safety problem. The plan led to the successful deployment of a five-year long strategic policy process which resulted in the CDC/NIOSH national farm health and safety research, education, and outreach program for medical and public health entities.

In addition to Knudson’s A Harvest of Harm series, additional events followed that added force to move the “Agriculture at Risk” policy process forward. That event began in 1983 following the publication of the book Medical Practice in Rural Communities (Mutel, C.F. and Donham, K.J. 1983).  This book led to a relationship with Pioneer Hi-Bred International, a large Iowa-based seed production company. That connection resulted in a long-term relationship with Pioneer, which funded many programs and centers at the University of Iowa. The first program Pioneer supported was the Agricultural at Risk Program. (Follow-on relationships that occurred will be described later in this document).  LuJean Cole, Community Investment Manager at Pioneer, contacted us after reading Medical Practice in Rural Communities.  She was interested in improving health care access in rural communities. Cornelia Mutel and I proposed to Pioneer a project to train Pioneer’s plant managers across the state on how they could facilitate health care services in their rural communities. Pioneer funded the project— the first Pioneer-funded project (circa 1985) at the University of Iowa. Following successful completion of that project, Pioneer (Cole) returned to discuss an expansion of that effort. We (Donham, Mutel, and Merchant) met with Cole to discuss further cooperative projects. Initially, Cole proposed the idea of an agricultural health and safety conference. I suggested that conferences in and of themselves often have little effect in making progress toward a larger goal – such as making policy that would affect agriculture toward a more safe and healthful place to work. Based on my experience with the success of the Skokloster consensus conferences on agricultural respiratory diseases (described earlier in this manuscript), I suggested that a multidiscipline consensus process be developed and designed to create policy leading to long-term resources aimed at improving health and safety on farms. Over the following weeks, Donham and Kendall Thu (then Associate Director of ICASH) developed details of such a strategy in collaboration with Merchant and Kross.  Merchant and Kross proposed that rural environmental health issues be added as a focus area of policy process in addition to agricultural health and safety. Merchant presented the proposal to Cole and Pioneer CEO Charles Johnson and secured initial funding of $50,000 ($117,753 in 2020 dollars).  Pioneer added additional support in kind by printing the policy document, Agricultural at Risk.  Donham, Thu, and Dr. Keith Long applied for additional funding, including successful proposals to the Northwest Area Foundation, Iowa Farm Bureau Federation, the Farm Bureau Family of Financial Planning Services, Land O’ Lakes Inc., and the John Deere Foundation. The total funding for the project was $250,000 ($588,766 in 2020 dollars).

A conference steering committee was convened and chaired by Donham and included Merchant and Kross from the University of Iowa, Carol Bolen from Pioneer, and three professors from Iowa State University (Joel Coats, Gary Osweiler, and Michael Stahr).  Further, a 13-member farm advisory panel was formed that include representatives from farm commodity organizations including Farm Bureau, Iowa Farm Bureau Federation, and other relevant farm organizations. The steering committee and its farm advisory panel developed a unique and comprehensive strategic policy development process that I believe remains today one of the most successful advances in the history of agricultural safety and health. The details of the process are included in the references, and the program guide presented in Appendix E. The following points highlight the essence of this plan (Donham 1989, Donham 1990A, Donham 1990B, Donham and Storm, 2002).

1. Substantial efforts were conducted in 1987, a year before beginning the conference to obtain information on farm health and safety from famers and transmit that information to health and safety professionals, policy makers, and the public. The results of this inquiry were disseminated through various media outlets and published in peer-reviewed journals. This information was also a key component to inform the participants of the farm health and safety issues from the farmers’ viewpoint in the three follow-on conference series scheduled in this strategic policy process. The pre-conference activities included the following:
   • A large mail survey of farmers was, designed and conducted by Thu and Donham—The Farm Family Survey. The aim was to discern farmers concerns around health and safety on their farms and farming in general.
   • Video interviews (managed by Thu) of a selection of farmers and their families that participated in the Farm Family Survey were conducted.
2. The results of these events above were brought into a series of three strategic conferences which included: 1) a technical workshop to establish the science basis of the farm health and safety situation, 2) a policy work group to transition the information to science-based policy, and 3) a public forum to present the results to the public and gather their input.
   • The technical workshop was held September 18 – 21, 1988 at the University of Iowa, consisting of over 100 national experts in agricultural health and safety. A consensus was established on the major health and safety issues and state-of-the-art in agricultural safety and health.
   • The policy work group was held in Des Moines, September 27 – 29, 1988, and consisted of 50 persons, including representatives from the technical workshop plus additional policy makers from the Midwest and the nation.
   • The Public Forum was also held September 29 – 30, 1988 in Des Moines and was town hall style meeting open to anyone interested. In attendance were farmers, farm group representatives, policy makers, scientists and a large contingent of the media. Input from the attendees was recorded and included in the final documents.
   • The results of the technical workshop and the detailed description of the entire process was published in one entire issue of the American Journal of Industrial Medicine. (Donham, 1990 A., Donham 1990 B, Donham C).
3. The primary results for public and policy makers were recorded in the groundbreaking policy document entitled Agriculture at Risk—A Report to the Nation which summarized the state-of-the-art in agricultural health and safety, and listed 86 policy recommendations for farmer health and safety. Further, the document contained model legislation for the nation as well as the states. Authors on Agriculture at Risk included Jim Merchant (Editor), Burton Kross, Kelley Donham, and David Pratt.  Cornelia Mutel served as technical editor for the final version (Merchant, J.A., Kross, B.C., Donham, J. J., and Pratt, D.S., eds. 1989.  Donham, K.J., Kross, B., Merchant, J.A., and Pratt, D.S. 1990) (images 34).  Dr. Antonio Novello, Surgeon General was the leader of the pinnacle event of this effort— the Surgeon General’s Conference on Agricultural Safety and Health.
4. A new national organization was formed, “The National Coalition for Agricultural Safety and Health” (NCASH), that included many of the principal persons and organizational representatives present at the national conference. Directed by Donham, the ad hoc aim of NCASH was to be the point organization to establish consensus and to lead and represent all individual stakeholders and organizations in bringing forward the policy process to the public and policy makers.
5. We retained Tom Slater, CEO of State Public Policy Group to help refine and deploy a strategy to engage federal policy makers.
6. NCASH with the help of Tom Slater, organized a U.S. Joint House and Senate hearing in Washington D.C. on the issue. Derek Willard, UI government relations, helped in these arrangements. Senator Tom Harkin and Congressman Jim Leach were also important facilitators of this process. NCASH members made educational visits to U.S. Congressmen, Senators, and leaders in their respective districts. They also made visits to the following agencies: NIH, ECD, EPA, USDA, Kellogg, and other foundations and agribusinesses. A joint House-Senate hearing was held on agricultural health and safety for NCASH to present the results of Agriculture at Risk Process.  Merchant and Donham provided testimony bringing forth the results of the policy process. Additionally, Marilyn Adams provided testimony describing her loss of her 10-year-old son who drowned in a gravity-fed grain wagon.
7. Distribution of Agriculture at Risk was targeted to several hundred policy makers and stake holders.
8. A national media dissemination effort was deployed to regional and national newspapers, radio, and TV outlets.
9. Finally, a Surgeon General’s conference on agricultural health and safety was held in Des Moines, Iowa, April 30 – May 3 1991. Antonia Novello MD was the Surgeon General at the time. This was the first Surgeon General’s Conference in over 50 years (CDC 1992) . It was an international conference with participants from Canada and Western European countries.  The results of the conference were published in a 645-page hard-cover book format (Papers and Proceedings of the Surgeon General’s Conference on Agricultural Safety and Health (CDC 1992). This conference established a firm commitment from the highest level of the U.S. government to address long-term, the health and safety issues of farmers, their families and their workers. President George H.W. Bush signed a proclamation in the preface to the proceedings documenting his commitment to the issue. The final paragraph in the proclamation established the first full week of September as National Farm Safety Week.  This proclamation continues and strengthens the Farm Safety Week originally proclaimed in 1944 by the National Safety Council.

Dr. Merchant was very effective in advancing the policy effort. He presented to CDC calling agricultural health and safety the “last frontier in occupational health.” He urged CDC to expand its injury prevention research centers to include rural injuries. NIOSH Director Don Millar then recommended that NIOSH develop a National Agricultural Health and Safety Program to include intramural and extramural research and a network of regional agricultural health and safety centers. The agriculture-at-risk process overall resulted in Congress charging the National Institute of Occupational Safety and Health (NIOSH) to take up this issue. Instrumental in funding this effort was Senator Harkin who chaired the Agricultural Committee and the Health Education Pension and Labor Sub-appropriations Subcommittee.  He authored a bill that resulted in new appropriations to CDD/NIOHS to fund a national program in agricultural health and safety as well as funds to CDC for rural injury research.

In summary, the Agriculture at Risk Policy Process spanned a five-year period (1985 – 1990). It resulted in national legislation to appropriate $24 million yearly ($48 million in 2019 dollars) to NIOSH to develop the National Agricultural Health and Safety Program begun in 1990. Additionally, the Agricultural at Risk Process induced other agencies and private companies (including NCI, NIEHS, EPA, USDA, Pioneer, and Kellogg Foundation) to add over $100 million annually in 1990 dollars to fund activities in agricultural health and safety.

1. These resources led to a robust intramural and extramural research program in NIOSH.
2. The NIOSH-funded program at Iowa, named the Great Plains Center for Agricultural Safety and Health, was one of the first programs to be funded (1999) along with the New York Center for Agricultural Health and Medicine (NYCAHM).   

The amount of resources put into agricultural safety and health based on Agriculture at Risk, is not matched in any other country. The flagship program resulting from this policy process is the NIOSH extra mural Centers Program for Agricultural Safety and Health. Eleven centers were developed and have been maintained from 1990 to the present time of this paper (NIOSH 2019).  Each of these centers has been funded for five-year periods for approximately $1.5 million each. These centers have conducted research, outreach, and education to address farm health and safety issues in their respective regions. The following map indicates the location of these centers as of March 2, 2018.

These centers collectively have substantially built the research and prevention-based outreach for a positive effect on the health and safety of famers in America.

The Great Plains Center for Agricultural Health

The Great Plains Center for Agricultural Health, founded and directed by Merchant, was one of two inaugural NIOSH-funded centers for agricultural health. Donham directed the outreach and training functions while Merchant directed the administrative and research functions. Particularly substantive research from GPCAH is the Keokuk County Study. See Appendix G for collaborators and Appendix H for the final report of this research.

Farm Safety for Just Kids (1987)

Marilyn Adams, a farm wife from Earlham, Iowa, lost her 10-year-old son due to suffocation in a gravity flow grain wagon in 1987.  Buoyed by her grief to save other families from this tragedy, Marilyn became an advocate to help prevent injuries and fatalities in farm kids. During this time, an average of 101 youth on American farms died from agricultural and environmental exposures. A slogan used during this time was “101 no more.”  Marilyn had been an effective participant in the Agriculture at Risk Policy Process.  The outcomes of that process facilitated her advocacy efforts. While Marilyn was working full time at the Firestone Tire Factory in Des Moines, in her free time, she and her two daughters, at their own expense, began a three-woman campaign to inform children and their parents of the risk of playing in and around flowing grain. Adams became actively involved with the IAM Agriculture at Risk Policy development process. She was an important member of NCASH that presented testimony to the joint House-Senate conference on this issue; she also lobbied U.S. House and Senate legislators, and heads of relevant agencies. These efforts helped to create synergy with other initiatives and a critical mass of policy makers that spawned the Surgeon Generals Conference and the CDC/NIOSH National Agricultural Health and Safety Program.  At the end of that process the organization that managed the Agriculture at Risk Policy Process, (NCASH) had a positive budget balance of $35,000 ($68,000 in 2018 dollars). Donham as Director of the Agricultural at-Risk Process and Chair of NCASH, with encouragement from Burt Kross, recommended that money be granted to Marilyn and her effort to prevent injuries to farm children. The NCASH committee accepted that recommendation. This money allowed her to leave her job at Firestone to concentrate on farm youth safety efforts. Marilyn founded a new non-profit organization, Farm Safety for Just Kids (FS4JK). Burt Kross PhD, an IAM faculty person and a principal member of the Agriculture at Risk Process, became a member and chair of the founding board of  Farm Safety 4 Just Kids. Kross led the growth of that organization with dedicated effort and entrepreneurial expertise. Kross and Merchant approached Pioneer Hi-Bred International and advocated for funding for the fledgling organization.  Pioneer did contribute, and that money combined with the donation from NCASH provided sufficient resources to hire staff, purchase supplies and facilities that enabled the organization to grow to become a force for safety of farm kids, nationally, and internationally. From 1990 – 2016, led by Adams, the organization grew and became the most important educational program for advocacy and prevention of injuries and illnesses to farm children. Over 150 chapters were formed with over 2,500 individual members over the 25 years of Adams’ leadership. The chapters and their members engaged over 2.5 million farm children and their parents.  Marilyn retired in 2014. In 2016, the organization ended, passing its remaining resources and mission to Progressive Agriculture Safety Days (PASD 2019). That organization provides training to potential staff and children through numerous programs today in U.S.A., and Canada . Marilyn Adams and FS4JK created a national and international awareness of the issue of farm youth injuries and fatalities and helped to create a new NIOSH-funded center focused on farm youth safety. That Center is one of 11 NIOSH Agricultural Health Centers that grew out of the Agriculture at Risk Policy Process and Marilyn Adam’s advocacy.  The National Children’s Center for Rural and Agricultural Health is located at the Farm Medicine Center in Marshfield, Wisconsin. The Center was founded by and is as of this writing, directed by Barbara Lee BSN, PhD.

Besides the eleven NIOSH Agricultural Health and Safety program funded centers, national awareness created opportunities for other federally funded centers that have components of activity that address agricultural health and safety issues. The Agriculture at Risk Process combined with Iowa’s history of work in the field, along with expertise of new faculty recruited to the department and collaboration with other university faculty, helped the University of Iowa College of Public Health to obtain federal funding to create several new centers and activities. The centers listed below all have components in their mission that deal with agricultural health and safety.

• The Injury Prevention Research Center (IPRC) – funded by CDC;
• Environmental Health Research Center (EHSRC) – funded by the National Institute of Environmental Health Sciences;
• Center for International Rural and Environmental Health (CIREH) – Initial Funding from Pioneer Hi-Bred International;
• Agricultural Health Study (AHS) – Funding from NIOSH, National Cancer Institute, and the Environmental Protection Agency;
• The Pioneer Chair in Agriculture and Rural Health – funded by Pioneer Hi-Bred International;
• The Great Plains Center for Agricultural Health – funded by NIOSH;
• Iowa’s Center for Agricultural Safety and Health – Funded by the State of Iowa;
• The Heartland Center for Occupational Health and Safety – Funded by NIOSH;
• The Healthier Workplace Center – Funded by NIOSH.

Education and Training 1986 -2006

Academic and continuing education in agricultural safety and health during this period was directed by Donham, in his dual roles as Director of ICASH and Education and Training Core Director of the GPCAH,  with assistance from various PMEH/CPH faculty and staff. These positions and funds, in addition to his faculty position as the IREH Associate Director for Agricultural Medicine, provided him interlocking staffing and funding to provide continuing education and conference support in Iowa, nationally, and internationally. Funding for Occupational Safety and Health made this integration of the  educational and outreach programs very productive. At its peak from 2000 to 2006, ICASH and the GPCAH combined to provide over 100 presentations per year. Additionally, five new graduate courses in agricultural health and safety were developed. Also, a graduate certificate academic graduate degrees (MS, and PhD) in Agricultural Health and Safety were developed. The “building capacity” program resulted in establishment of the 40-hour Core Course in Agricultural Medicine in ten states (including Iowa)  in the US and internationally in Sweden, Australia, and Turkey. Also, we trained Dr. Marcos Grigioni, Program Coordinator for Health and Safety for the Family Farm for Argentine Federated Farmers; he is the leader in agricultural safety and health in the country.

Development of graduate and continuing education in Agricultural Medicine

In 1999, the College of Public Health applied for and was awarded from NIOSH an Occupational Health and Safety Educational and Research Center. This Center was titled “The Heartland Center for Occupational Health and Safety.”   This center provided for student support, educational development for agricultural health and safety education for occupational physicians, occupational nurses, and ergonomists. The first director of the center was Dr. James Merchant. Following directors included Dr. Nancy Sprince, and as of this writing Patrick O’Shaughnessy PhD directs the center. The Heartland Center has a training track in agricultural health and safety which allows graduate training and continuing education programs to grow and prosper. As of 2018, the following number of students matriculated in the field:  15 certificate students, 11 MS students, and 4 PhD students. The graduates have gone on to expand the field of agricultural medicine in different practice and academic situations.

Continuing Education in Agricultural Medicine expanded during this period.  In 1988, I recognized that  a more detailed and comprehensive course in agricultural medicine would benefit practicing nurses and other health care providers who were providing occupational health services to farmers in our growing network of agricultural occupational health clinics in Iowa (later to become the AgriSafe Network).  Providers practicing in the AgriSafe Network were required to take and pass by examination the 40-hour course called Agricultural Health and Safety for Health Care Providers. This course was offered as a day-long, week-long-course during the summer. Students could take this course for three-hours graduate credit or 40-hour CME, CNE credits.  The three-hour graduate credit course was offered in the evenings during the spring semester. The graduate students in this course were those in the Preventive Medicine and Environmental Health, Medicine, PA, Nursing, Nurse Practitioner, Pharmacy and Veterinary Medicine programs.  The summer course averaged 40 students per class. Note this course continues today (2021) and is offered in summers as the “Agricultural Health and Safety Core Course,” directed by Dr. Rohlman (ASH Core Course 2019).  This course was supported with resources from Iowa’s Center for Agricultural Safety and Health (ICASH) and the Great Plains Center for Agricultural Health (GPCAH).

The number of attendees to this course grew over the years. We found that additional health care and non-clinical health students and practicing professionals were attracted to the course including respiratory therapists, mental health professionals, public health professionals, veterinarians, EMT’s, and safety specialists.  This course became an example of the concept of a “One Health Course.”  Surveying nationally and internationally for agricultural medicine training, we found no other such training anywhere else in the U.S. or internationally.

Research at IAM 1986- 2007

The research portfolio in Agricultural Medicine during the period from 1986 – 2000, was dominated by four major research areas: 1) Occupational and Environmental Health Effects of Intensive Hog Production Facilities, 2) The Keokuk County Rural Health Study, 3) The Certified Safe Farm Program  and 4) the Agricultural Health Study.

Large Scale and Intensive Animal Feeding Operations (AFO’s) and Resultant Worker, Residential, and Environmental Health Effects

The first peer-reviewed paper on the subject of worker health in confined swine feeding operations was published in 1977 by IAM faculty (Donham), graduate students (Thedell and Rubino) and allergist Dr. John Kammermeyer  (Donham, Rubino, Thedell, and Kammermeyer 1977).  This research initiative at Iowa continued and progressed through the years to present time (2021) beginning at the IAM, and later the College of Public Health at Iowa.  This foundational research led to investigations on the topic at other institutions in North American, and in Europe. The major research results on this subject include 1) a definition of the source and characteristics of dusts and gases in AFOs, 2) worker health effects of acute and long term exposure to these dusts and gases, 3)  recommended exposure limits to dusts and gases in AFOs, 4) engineering and management methods to reduce worker exposures, 5) and methods to reduced emissions to the outdoor environment (Von Essen, Donham 1999, Donham 2000C, Donham 2000D).  Over 30 peer-reviewed publications on the subject have been produced by UI researchers. A sample of these presentations are presented in the bibliography; 6)four major policy processes were conducted with reports that were widely disseminated:

• 1995: Understanding the Impacts of Large-scale Swine Production
• 2002: The Iowa Concentrated Animal Feeding Operation Air Quality Study
• 2007: The National Institute for Environmental Health Sciences Conference on CAFOs
• 2008: Putting Meat on the Table: Industrial Farm Animal Production—A report of the Pew Charitable Trust and Johns Hopkins. Merchant was an important participant in this process and report.

The Keokuk Rural Health Study

Led by Dr. Merchant (Principal Investigator [PI]) and funded by the NIOSH Great Plains Center) the Keokuk Rural Health Study (See Appendix H) was a population-based research investigation of the farming and rural populations of residents of Keokuk County in Iowa.  This was a prospective study, monitoring people, their hazardous exposures, and resultant health complaints from 1990 – 2014.  Over 23 peer-reviewed publications were published from this 24-year study.  Sanderson and Kelly (2009) reported on the design and operation of this study.  A representation of the papers published from this study are presented in the bibliography (Stromquist, Merchant, Zwerling et. al. 2009). Collaborators are listed in Appendix G.

 The Certified Safe Farm program (1999 – 2006)

NIOSH, Wellmark Blue Cross, Farm Bureau, and Monsanto (now Bayer) funded this research and demonstration project, beginning in 1996, and ending in 2006. The Certified Safe Farm Program (CSF) was designed by borrowing ideas from some of the concepts of the agricultural health clinic systems in Scandinavia, as well as our prior prevention projects “The Farm Safety Walkabout” and “Respiratory Illnesses Prevention in Swine Producers.”  Kendall Thu, Risto Rautiainen, Aaron Kline, and LaMar Grafft were critical staff in working on this project. The project was designed as a random controlled intervention, with randomly selected representative intervention group and a matched comparison group. This program worked in cooperation with the 22 AgriSafe Network of clinics scattered across Iowa. This was a program that fit with the concept of the NIOSH Total Worker Health program (NIOSH TWH) in that it was designed to improve and maintain both basic wellness as well as occupational health and safety.  However, the program was designed and implemented 15 years before NIOSH introduced the total worker health concept. The program had an incentive component to help attract and retain participants.  There were four basic components of the program: 1) a wellness health screening; 2) an on-farm safety audit (a score of 85% resulted in designation of “Certified Safe Farm”); 3) a cash incentive if certified; 4) wellness and occupational health and safety education.

There were several positive outcomes of this study.  Severe injuries and certain respiratory conditions were reduced in the intervention group. Use of personal protective equipment (e.g., respirators, hearing protection) increased in the intervention group. Incidence of organic dust toxic syndrome (a common agricultural respiratory condition in farmers) was reduced.  A 47% reduction in medical care costs was realized (Donham, Rautiainen, Lange, and Schneiders 2007).  The references listed represent just a sample of the 15 peer-reviewed articles published on the Certified Safe (Donham, Lang, Kline, Rautiainen, Grafft, and Schneiders 2011, Donham Kline, Kelly, Lange, and Rautiainen 2013)   This program has since been offered in North Carolina, and components of the program are offered in Wisconsin, and New York (Schiller, Donham, Anderson, Dingledein, and Strebbel 2010).  A more complete reference list is available in the references.

The Agricultural Health Study

In 1993, the ambitious Agricultural Health Study (AHS) research project was initiated by four cooperating federal agencies: The National Cancer Institute, The National Institute for Environmental Health Sciences, the Environmental Protection Agency, and the National Institute for Occupational Safety and Health (AHS 2019).  This study was launched by Drs. Aaron Blair and Michael Alevanja, both participants in the Agriculture-At-Risk policy process where this study was recommended. As of 2021, the study continues with no specified end date. The study includes nearly 90,000 persons and their spouses living in Iowa or North Carolina who have taken the Pesticide Applicators Training (99% of them are farmers). This training is required by EPA and USDA for workers  to obtain and apply restricted-use pesticides, i.e., those that may have a human or environmental health effect. The IAM was not the lead in the overall project, but Charles Lynch MD PhD, Department of Epidemiology in the College of Public Health, has been the Principal Investigator from the beginning on the Iowa component of this program. The study’s primary aim is to investigate possible relationships to the use of pesticides and the health of those using them. However, other aspects of the agricultural population are studied relative to occupational health and wellness (Starks, Gerr, Kamel, Lynch et. a. 2012).  As of 2021, the study has resulted in well over 300 published peer-reviewed papers. Faculty form the College of Public Health have contributed to several of these papers.The web site provides a summary of the findings, and a list of all published papers (AHS 2021).

Summary of Critical Advances in the New Directions Period (1986- 2007)

This was a period of critical changes in the IAM and immense growth in agricultural health and safety activities and programs in Iowa, in the nation, and internationally. Dr. Merchant was Department Head during this time. Donham was appointed to a new position (Associate Director for Agricultural Medicine).  Merchant became Dean of the new College of Public Health in 1999.

The following summarizes some of the major accomplishments during the New Directions period.

1986 – Development of Iowa’s Agricultural Health and Safety Service Network (Gay, J., Donham, K. J., Leonard, S. 1990)—22 networked farmer occupational health and safety clinic scattered across Iowa).

1988 – Nurse training program in agricultural medicine was established. This training program led to the Agricultural Health and Safety Core Course and the Building Capacity Program (expansion of the core course to 9 states, and 4 other countries).

1989 – The name Institute of Agricultural Medicine was changed to the Institute for Rural Environmental Health.  The focus of the activity expanded from agricultural medicine to a variety of different issues, operated by several different federally funded centers.

990 – Iowa’s Center for Agricultural Safety and Health  was founded.

1990 – The Agricultural and Risk Policy Process resulted in the Surgeon General’s Conference on Agricultural Safety and Health, and the Founding of the National NIOSH Agricultural Safety and Health Program.

1990 – The Great Plains Center for Agricultural Health

1990 – The Kellogg Agricultural Health and Safety program was established in conjunction with Iowa’s Center for Agricultural Safety and Health.

1990 – 2014 – The Keokuk Rural Health Study

1993 – Transition of the Iowa Agricultural Health and Safety Service Program to the new non-profit AgriSafe Network

1999 – Ending of the Department of Preventive Medicine and Environmental Health and Founding of the New College of Public Health.

To: Modern Times (2008—2013)