Performance audit, pesticide regulation, Department of Health Services

              B
DOUGLAS R NORTON, CPA
AUDITOR GENERAL
STATE OF ARIZONA
OFFICE OF ' THE
AUDITOR GENERAL,
LlNDA J. BLESSING. CPA
DEPLN AUDITOR GENERAL
November 30, 1990
Members of the Legislature
State of Arizona
The Honorable Rose Uofford
Governor of the State of Arizona
Mr. Ted Williams, Director
Department of Health Services
Transmitted herewith is a report of the Auditor General, A Performance
Audit of Pesticide Regulation: Department of Health Services. This
report is the f i f t h in a series of five reports on Pesticide regulation
and i s i n response to Chapter 162, Section 7, of the 1989 Session Laws.
The report addresses the Department of Health Services' responsibilities
for developing and maintaining a registry of pesticide poisonings. We
found that few cases have been reported to DHS, but this appears to be
more a function of underreporting rather than a lack of incidences of
poisonings. Some minor statutory revisions and greater out reach efforts
by DHS could help improve reporting.
Our report also notes that the Department has authority to monitor the
presence of pesticides in food, but is not funded to do so.
My staff and I w i l l be pleased to discuss or c l a r i f y items in the report.
D O ~ RS. N orton
Auditor General
DRN: Imn
STAFF : W i l l i am Thomson
Peter N. Francis
Arthur E. Heikkila
Dennis B. Uurphy
Shan D. Hays
Margaret U. Jackson
2700 NORTH CENTRAL AVE. 9 SUITE 700 0 PHOENIX, ARIZONA 85004 9 ( 602) 2554385
SUMMARY
The O f f i c e of the Auditor General has conducted a performance a u d i t of
the Arizona Department of Health Services' a c t i v i t i e s r e l a t e d t o
a g r i c u l t u r a l p e s t i c i d e s . This a u d i t was conducted i n response to Chapter
162, Section 7, of the 1989 Session Laws, which d i r e c t e d us to review the
S t a t e ' s p e s t i c i d e r e g u l a t o r y program administered by four State agencies,
i n c l u d i n g the Department of Health Services ( DHS).
Arizona Revised Statutes give DHS two primary r e s p o n s i b i l i t i e s r e l a t e d to
p e s t i c i d e s . A. R. S. $ 36- 606 d i r e c t s DHS to develop and implement a system
f o r r e p o r t i n g and preventing p e s t i c i d e poisoning that must include
medical education programs and a Statewide r e p o r t i n g network. DHS'
D i v i s i o n of Disease Prevention, O f f i c e of Risk Assessment and
I n v e s t i g a t i o n i s responsible f o r implementing these s t a t u t o r y
requirements. A. R. S. $ 936- 904 through 36- 910 give DHS the s t a t u t o r y
a u t h o r i t y t o embargo food and e s t a b l i s h tolerances f o r p e s t i c i d e
chemicals i n food.
DHS has a l l o c a t e d two f u l l - t i m e employees to perform i t s medical
education and r e p o r t i n g d u t i e s .
Significant Underreporting Reduces Usefulness
Of Pesticide Registry ( see pages 3 through 11 )
DHS' P e s t i c i d e Registry i s o f l i m i t e d value because, at the present time,
very few cases of p e s t i c i d e p o i s o n i n g a r e r e p o r t e d . Our research
i n d i c a t e s t h a t many cases are not reported to DHS, i n c l u d i n g such severe
cases as a c h i l d who was h o s p i t a l i z e d a f t e r p l a y i n g i n an area containing
i l l e g a l l y dumped, granulated p e s t i c i d e s , and a man who l o s t the use of
h i s hands a f t e r exposure t o h e r b i c i d e s . Many p e s t i c i d e poisonings are
not reported to DHS because v i c t i m s do not seek medical care and/ or
because of the d i f f i c u l t y i n making a confirmed diagnosis l i n k i n g the
i l l n e s s w i t h p e s t i c i d e s .
Although DHS i s s t a t u t o r i l y mandated to a l e r t heal thcare professionals to
the symptoms of p e s t i c i d e poisoning, DHS' e f f o r t s to t r a i n the medical
community have been l i m i t e d and l a r g e l y i n e f f e c t i v e . Further, because of
the d i f f i c u l t i e s faced by doctors i n making confirmed diagnoses,
s t a t u t o r y changes allowing p o t e n t i a l poisoning cases to be reported may
be needed.
Other Pertinent lnformat ion - Food Safety
( see pages 13 through 17 1
There i s p u b l i c concern about the safety of a g r i c u l t u r a l p e s t i c i d e s .
Although DHS has the s t a t u t o r y a u t h o r i t y to set tolerance l e v e l s f o r
p e s t i c i d e residues and embargo adulterated food, the Department does not
monitor the food supply. Arizona r e l i e s on the Federal Food and Drug
Administration ( FDA) to monitor the levels of pesticides i n food;
however, the FDA program i s l i m i t e d . The FDA, which t e s t s both foreign
and domestically grown produce throughout the country, t e s t e d o n l y 445
samples of produce grown i n Arizona i n 1989. The test r e s u l t s indicated
low v i o l a t i o n rates. C a l i f o r n i a , Oregon, and Washington supplement FDA
programs by t e s t i n g a d d i t i o n a l produce i n t h e i r own s t a t e labs.
TABLE OF CONTENTS
INTRODUCTION AND BACKGROUND. . . . . . . . . . . . . . . . .
Page
1
FINDING: SIGNIFICANT UNDERREPORTING REDUCES
USEFULNESS OF PESTICIDE REGISTRY . . . . . . . . . . . . 3
Pesticide Registry
Data Important . . . . . . . . . . . . . . . . . . . . . 3
Many Cases Are
NotReported . . . . . . . . . . . . . . . . . . . . . . 4
DHS Cou Id Provide More
Training And Education . . . . . . . . . . . . . . . . . 7
Statutory Changes May Be
Required To Enhance Reporting. . . . . . . . . . . . . . 9
Recommendations. . . . . . . . . . . . . . . . . . . . . 11
OTHER PERTINENT INFORMATION: FOOD SAFETY. . . . . . . . . . 13
AGENCY RESPONSE
TABLES
Page
TABLE 1 D i v i s i o n of Disease Prevention
l nves t i gat i ons Sect i on
Ful I- Time Equivalents ( FTEs) and
Pesticide- Related Expenditures
For Fiscal Years 1987- 88 through 1989- 90
( Unaud i ted)
INTRODUCTION AND BACKGROUND
The O f f i c e o f the Auditor General has conducted a performance audit of
the Arizona Department of Health Services' a c t i v i t i e s related to
agr icut t u r a l pest i c i d e s . The audi t was conducted i n response to Chapter
162, Section 7, of the 1989 Session Laws, which d i r e c t e d us to review the
State's p e s t i c i d e regulatory program administered by four State agencies,
including the Department of Health Services ( DHS).
Arizona Revised Statutes ( A. R. S.) d i r e c t DHS to assume two primary
r e s p o n s i b i l i t i e s related to p e s t i c i d e s . A. R. S. 936- 606 requires the
development and implementation of a system f o r r e p o r t i n g and preventing
p e s t i c i d e poisoning. The system must include medical education programs
and a Statewide r e p o r t i n g network. The Department has assigned
r e s p o n s i b i l i t y f o r implementing these s t a t u t o r y requirements to the
D i v i s i o n o f Disease Prevention, O f f i c e o f Risk Assessment and
Investigation.
In a d d i t i o n , A. R. S. 9936- 904 through 36- 910 allow DHS t o e s t a b l i s h
tolerances f o r pesticides i n a g r i c u l t u r a l commodities, and to embargo and
seek condemnat ion of produce containing unsafe p e s t i c i d e s . The D i v i s i o n
of Disease Prevention has requested funds for food monitoring programs,
but competing p r i o r i t i e s have eliminated these programs from the
Departmental budget request to the L e g i s l a t u r e .
Staffinq And Budget
DHS has assigned two epidemiology s p e c i a l i s t s to i t s P e s t i c i d e Registry
and medical education program. However, recent promotions w i t h i n the
D i v i s i o n of Disease Prevention have l e f t one of these p o s i t i o n s vacant.
DHS a n t i c i p a t e s changing the vacancy's c l a s s i f i c a t i o n to environmental
s p e c i a l i s t , i n order t o f i l l the p o s i t i o n w i t h someone who could take
samples for laboratory analysis and assume other d u t i e s t h a t would
enhance the Department's abi l i t y to i n v e s t i g a t e p e s t i c i d e cases.
Unti 1 1989, DHS received a s p e c i f i c a p p r o p r i a t i o n for i t s p e s t i c i d e
program. However, i n f i s c a l year 1990, the program budget was absorbed
i n t o the Department's lump- sum a p p r o p r i a t i o n .
TABLE 1
DIVISION OF DISEASE PREVENTION
INVESTIGATIONS SECTION
Full- Time Equivalents ( FTEs)
and Pesticide- Related Expenditures
For Fiscal Years 1987- 88 Through 1989- 90
( unaudited)
FTE Positions
Expend i tures
Source: Department of Health Services
Scope Of Audit
Our audit focused on the performance of DHS' I n v e s t i g a t i o n s Section i n
maintaining the P e s t i c i d e R e g i s t r y and educating the medical community.
We also examined the issue of food monitoring t o determine whether the
Department should t e s t food for the presence o f p e s t i c i d e s . The report
presents one d e t a i l e d Finding on the underreporting of p e s t i c i d e
i I Inesses. In addi t ion, we developed Other Pertinent lnformat ion on
monitoring food for p e s t i c i d e residues.
Our audit was conducted i n accordance w i t h generally accepted government
a u d i t i n g standards.
The Auditor General and s t a f f express appreciation to the D i r e c t o r and
s t a f f of the Department of Health Services for t h e i r cooperation and
assistance during the aud i t .
FINDING
SIGNIFICANT UNDERREPORTING REDUCES
USEFULNESS OF PESTICIDE REGISTRY
DHS' Pesticide Registry i s o f l i m i t e d value because very few cases of
pesticide poisonings are reported. Although designed to be an important
source of informat ion about pesticide- related i I Inesses, the r e g i s t r y ,
due to underreporting, lacks data on many cases. Underreporting appears
to occur, at least i n p a r t , because DHS has not e f f e c t i v e l y educated the
medical community to recognize and report pesticide poisonings. However,
statutory changes may also help to increase reporting.
In 1987, i n response to A. R. S. 936- 606, the Department of Health Services
created a Pesticide Registry to record incidences o f p e s t i c i d e
poisoning. Recording data on pesticide poisonings can provide both
imnediate and long- term b e n e f i t s . The information contained i n the
Pesticide Registry can assist researchers studying the chronic or delayed
effects of long- term pesticide exposure. Farmworkers and pesticide
appl icators are r o u t i n e l y exposed to pesticides at varying l e v e l s .
Pesticides have been implicated i n heightened incidences o f r e s p i r a t o r y
ai Iments, dermatitis, eye problems, cancer, and b i r t h defects among
farmworkers. In view of the number of children exposed to a g r i c u l t u r a l
pesticides, research into the long- term e f f e c t s o f pesticides i s
especially important. In 1984, a Texas study reported t h a t 36 percent of
the State's farmworkers were under the age of 16, and many workers
brought young children to the f i e l d s .
In Arizona and C a l i f o r n i a , r e g i s t r i e s of pesticide- related illnesses have
also provided more immediate b e n e f i t s . For example, one pesticide
product caused a number of reported i l lnesses s h o r t l y a f t e r i t was
introduced i n Arizona. In a review of the r e g i s t r y , DHS noticed the
problem, i d e n t i f i e d the product, and worked with other agencies to
persuade the manufacturer to improve safety precautions on the product
label. Cal i f o r n i a ' s r e g i s t r y showed that equipment ma1 functions caused
many p e s t i c i d e poisonings. Cal i f o r n i a ' s r e g i s t r y also showed other
farmworker poisonings could be i d e n t i f i e d or avoided by monitoring
farmworker c h o l i n e s t r a t e l e v e l s to determine the l e v e l o f exposure to
pesticides, or extending the amount of time r e q u i r e d b e f o r e r e e n t e r i n g a
sprayed f i e l d .
Many Cases Are
Not Reported
DHS' Pesticide Registry l i s t s few cases of i l l n e s s caused by a g r i c u l t u r a l
pesticides. However, our research indicates many cases are not reported
to DHS. Given the reasons cases a r e n ' t reported t o DHS, i t i s unl i k e l y
Arizona w i l l ever achieve 100 percent r e p o r t i n g . However, i f the
r e g i s t r y i s to have any p r a c t i c a l value, more e f f o r t can and should be
made to increase r e p o r t i n g .
Few cases have been reported - Between Apr i I 1987 and June 1989, DHS'
P e s t i c i d e R e g i s t r y recorded 27 cases or suspected cases of a g r i c u l t u r a l
pesticide poisoning. In a d d i t i o n , 21 i l l n e s s e s i n v o l v i n g a g r i c u l t u r a l
pesticides were brought to the Department's a t t e n t i o n , but were
c l a s s i f i e d as " no case."(') In r e l a t i o n to the number of people
p o t e n t i a l l y exposed to a g r i c u l t u r a l p e s t i c i d e s , the number o f cases
reported i s very small. By the most conservative estimate, Arizona
employs at least 11,000 migrant workers each year.(*) I n a d d i t i o n , an
unknown number of people work f o r p e s t i c i d e a p p l i c a t o r s , or l i v e i n areas
where schools and residences are close to a g r i c u l t u r a l land.
Although we found no method for accurately i d e n t i f y i n g the number of
unreported cases o f p e s t i c i d e - r e l a t e d i l l n e s s e s , we d i d learn o f a number
of cases that were not reported to DHS. For example, Mexican health
o f f i c i a l s t o l d a comnunity services worker i n San Luis of 35 cases
( 1 ) DHS categorizes events based on reports from healthcare professionals: i f an
i n d i v i d u a l does not seek medical care o r if the healthcare p r o v i d e r does not both
diagnose and r e p o r t the i l l n e s s as e i t h e r a " case" or a " suspected case", DHS records
the event as " no case."
treated by healthcare providers i n Mexico, although the poisonings
occurred i n Arizona. Our review of complaint f i l e s a t the Commission of
Agriculture and H o r t i c u l t u r e i d e n t i f i e d 49 complaints of
pesticide- related health e f f e c t s that d i d not appear on DHS' Pesticide
Registry. I n 1988, the Poison Control Center at the U n i v e r s i t y o f
Arizona rece i ved 1,051 ca I I s about pest i c i de exposures, i nc I ud i ng ca I l s
about s t r u c t u r a l and h o r t i c u l t u r a l p e s t i c i d e s . Perhaps few of these
illnesses could have met DHS' c r i t e r i a for c l a s s i f i c a t i o n as a " case" or
" suspected case." However, they do provide an i n d i c a t i o n that the extent
of pesticide- related i l l n e s s i s greater than the P e s t i c i d e Registry shows.
Even when victims of p e s t i c i d e poisoning sought medical care, t h e i r
healthcare providers d i d not always report the i l lnesses to DHS.
A chi Id was h o s p i t a l i z e d a f t e r playing i n an area where an i I legal l y
dumped bag of granulated p e s t i c i d e had burst open. DHS learned of
the case from a farmworkers' legal a i d o f f i c e , not from the h o s p i t a l
o r physician.
A 36- year- old b r o c c o l i worker, and mother o f f i v e , v i s i t e d a doctor
f o r r e s p i r a t o r y problems. The doctor sent her t o a lung s p e c i a l i s t
who found severe scarring i n her lungs which he a t t r i b u t e d t o chronic
exposure to p e s t i c i d e s . DHS received no report of t h i s case. We
discovered i t when we interviewed s t a f f at the U n i v e r s i t y o f
Arizona's Rural Health O f f i c e . One o f t h e i r s t a f f , known for her
e f f o r t s i n a s s i s t i n g farmworkers, had been contacted by h o s p i t a l
s t a f f for help i n l o c a t i n g s o c i a l services for the p a t i e n t .
A pressurized hose attached to a p a i l c o n t a i n i n g p e s t i c i d e s came
loose and drenched a worker. The man was treated at an emergency
room and released, but has continued to have h e a l t h problems. The
case was not reported to DHS. A community l e g a l s e r v i c e s Outreach
worker, who had been asked for help i n o b t a i n i n g Worker's
Compensation for the p a t i e n t , t o l d us about t h i s case.
Two recent newspaper columns described the problems o f a man who can
no longer work w i t h h i s hands as a r e s u l t of exposure t o herbicides
while p u l l i n g weeds from an i r r i g a t i o n d i t c h . DHS s t a f f t o l d us they
learned o f the case by reading about i t i n the newspaper.
Another man's feet and legs were badly damaged by a herbicide he was
using to clean a d i t c h . Since he can no longer work, he r e l i e s on
d i s a b i l i t y payments from Social S e c u r i t y . DHS had no record o f t h i s
case. The Comnunity Legal Services Outreach worker who helped t h i s
man obtain h i s d i s a b i l i t y income, informed us of the case.
Many factors c o n t r i b u t e t o underreporting - There are probably many
reasons why pest i c i d e - r e l a t e d i l lnesses are not reported to DHS. Two key
reasons are that some people may not seek medical care, and those that do
may not be diagnosed as having an i l l n e s s related to p e s t i c i d e s . Even
when a diagnosis i s made, physicians may be r e l u c t a n t t o report t h e i r
diagnosis.
Many pest i c i d e - r e l a t e d i l lnesses do not r e s u l t i n a v i s i t to a heal thcare
provider. When symptoms are mi Id or go away by themselves, even people
concerned enough to complain to State agencies may not see a doctor. A t
the Arizona Commission of A g r i c u l t u r e and H o r t i c u l t u r e ( ACAH), we found
eight instances of pesticide- related health complaints i n which
complainants stated they did not plan to v i s i t a doctor.
I n a d d i t i o n , a h i g h - r i s k group -- farmworkers -- are less l i k e l y than the
general population to seek medical care. We interviewed physicians,
c l i n i c and h o s p i t a l s t a f f , social and legal service providers, and health
o f f i c i a l s both i n Arizona and other states to learn why. We were t o l d
that unless symptoms i n t e r f e r e w i t h t h e i r a b i l i t y to work, farmworkers
seldom seek medical care. Most farmworkers have no health insurance, and
time away from work means loss of income. In some cases, farmworkers
fear that r e p o r t i n g a work- related i l lness may make trouble for t h e i r
employer and r e s u l t i n loss of work. ( I n f a c t , a farmworker advocate
t o l d us of one case i n which a farmworker was threatened w i t h loss of
work by h i s employer, i f he sought medical care.) When farmworkers do
seek medical care, some v i s i t doctors i n Mexico because costs are lower
and language and c u l t u r a l b a r r i e r s are removed.
Even for those who do seek medical care, physicians and c l i n i c s t a f f t o l d
us that i l lnesses r e l a t e d t o pesticides may not be diagnosed as such.
Our review of medical a r t i c l e s and studies performed i n o t h e r s t a t e s
confirmed t h i s . Except i n severe cases, the symptoms of
p e s t i c i d e - r e l a t e d i l lnesses are simi l a r to those of a number of common
complaints such as f l u , g a s t r o e n t e r i t i s , and a l l e r g i e s . D e r m a t i t i s , the
most common p e s t i c i d e - r e l a t e d ailment, has many causes. Tests t o confirm
diagnosis are o f t e n expensive and uncertain, and for some types of
pesticides, no lab t e s t e x i s t s . Diagnosis may be even more d i f f i c u l t for
heal thcare professionals who don' t of ten encounter these cases. Doctors
who work regularly with fieldworkers, said mi ider cases of
pesticide- related i l l n e s s may be ' misdiagnosed i f a healthcare
professional i s not a l e r t to the p o s s i b i l i t y , and does not ask enough
questions t o obtain a thorough occupational history from the p a t i e n t .
F i n a l l y , some physicians and healthcare o f f i c i a l s suggest that cases may
not be reported because heal thcare professionals fear becoming involved
in a lawsuit or occupational injury claim i n which they might have to
defend an uncertain diagnosis i n court. Our review of l i t e r a t u r e on the
subject corroborated t h i s statement.
DHS Could Provide More
Training And Education
DHS' e f f o r t s to t r a i n the medical community have been l i m i t e d and largely
ineffective. Even with limited resources, DHS could do more.
MIS has provided some t r a i n i n g and education - A. R. S. 936- 606 requires
DHS to provide medical t r a i n i n g to a l e r t healthcare professionals t o the
symptoms, diagnosis, treatment, and reporting o f p e s t i c i d e poisoning.
DHS has made some e f f o r t s to inform the medical community. In 1987, when
the reporting law took e f f e c t , DHS d i s t r i b u t e d information about
pesticide poisoning to a l l physicians, and a number of c l i n i c s , doctors'
o f f i c e s , and hospitals i n the State. Shortly a f t e r the Pesticide
Registry was established, DHS also contracted with a t o x i c o l o g i s t t o
present seminars to physicians. These seminars were reportedly very we l l
done; however, attendance was very low. In f a c t , a t the seminar in
Tucson, aside from two s t a f f members of the University of Arizona Poison
Control Center, only one or two people attended.
More recent e f f o r t s by the Department have been somewhat l i m i t e d . A
representative from DHS has spoken about pesticides at events organized
by other groups ( including a school nursing conference, a medical
conference sponsored by the Colegio de Medicine of San Luis, Mexico, and
a symposium on migrant health sponsored by Federally funded c l i n i c s i n
Yuma). Department s t a f f also provide, v i a a t o l l - f r e e number,
c o n s u l t a t i o n to physicians and advice to the p u b l i c . ( ' ) In a d d i t i o n , DHS
continues to provide wal l charts on p e s t i c i d e poisoning, EPA pub1 i c a t ions
i n both English and Spanish, and other m a t e r i a l s t o the health care
community. DHS o f f i c i a l s s t a t e that lack of resources prevents them from
doing more.
DHS can do more - From our survey of county health departments, c l i n i c s ,
h o s p i t a l s , other s t a t e s , and community service groups, we discovered a
number of ways i n which to educate the medical community and farmworkers.
C l i n i c and county health personnel suggested g i v i n g b r i e f
presentations about pesticides to c l i n i c s during medical s t a f f
meetings. ( Heal th department s t a f f i n Oregon and Washington present
short t a l k s on pesticides during h o s p i t a l " rounds".)
Some healthcare providers i n o u t l y i n g parts of the State suggested
o f f e r i n g seminars i n r u r a l areas.
Community Legal Services s t a f f and other s o c i a l s e r v i c e p r o v i d e r s
suggested g i v i n g b r i e f t a l k s and d i s t r i b u t i n g basic l i t e r a t u r e on
safety and hygiene to migrant workers at t h e i r bus pickup p o i n t s .
DHS could also include more information about pesticides i n i t s
newsletters. DHS publishes a bimonthly b u l l e t i n which i s sent to health
care providers throughout the State. DHS used t h i s b u l l e t i n i n 1988 to
pub1 i c i z e the newly formed Pesticide program and to s o l i c i t comments on
proposed rules, and i n 1989 to a l e r t health care p r o f e s s i o n a l s t o
i n c i d e n t s of p e s t i c i d e poisoning among pet groomers. With l i t t l e impact
on current resources, DHS could increase i t s use of t h i s b u l l e t i n to
promote the r e p o r t i n g o f informat ion on the symptoms, diagnosis, and
treatment of i l l n e s s e s caused by p e s t i c i d e s . Oregon's semimonthly
Communicable Disease B u l l e t i n presents such information; recent issues
contained a r t i c l e s e n t i t l e d " Monitoring Pesticide Workers for Subacute
Organophosphate E f f e c t s , " and " Pesticide A l e r t : Poisoning from Flea
Control Products Containing Phosmet." In a d d i t i o n , DHS might be able to
place information i n newsletters and b u l l e t i n s published by other
organizations such as the Arizona Board of Medical Examiners and other
( 1 ) Although DHS does not maintain records of c a l l s t o t h i s number, a DHS o f f i c i a l
estimates t h e Department receives six to ten c a l l s per week on the t o l l - f r e e l i n e .
This includes follow- up c a l l s from people who are seeking further assistance or advice
regarding pesticide problems previously reported.
8
medical associations, or funnel information through community services,
legal aid, and other public service organizations that offered assistance
to us throughout our a u d i t .
Outside money and resources may also be avai lable to supplement DHS'
budget. For example, we found t r a i n i n g i s available and could be brought
to Arizona at l i t t l e or no cost to the State. Using funds from the
Nat iona1 lnst i t u t e f o r Occupational Safety and Health ( NIOSH), a group
from a C a l i f o r n i a university developed pesticide seminars for Washington
and Hawaii, and has expressed interest i n developing a seminar for
Arizona. These seminars u t i l i z e local experts as much as possible and
cover topics such as the basics of toxicology, the health e f f e c t s as a
result of exposure to di f ferent types o f p e s t i c i d e s , emergency medicine,
reporting requi rements, nonemergency pat ients, r i s k assessment, chronic
health e f f e c t s , and working with farmworkers. As these seminars meet the
standards for continuing education credit for healthcare professionals
there i s an incentive to attend. DHS' assistance in i d e n t i f y i n g needs
and providing r e f e r r a l s to Arizona resources and experts would cost very
i i tt le or nothing.
Grant money, similar to the NIOSH grant that funded a Texas program to
encourage reporting through active surveillance, may also be available to
Arizona. Under that program, the state agency telephoned selected
healthcare providers on a regular basis t o determine whether they had any
possible cases of pesticide- related illnesses to report. F l o r i d a also
obtained a grant from the Agency for Toxic Substance and Disaster
Registry to develop a reporting system. A representative of the
Environmental Protection Agency t o l d us he had submitted a request for
funds t o a s s i s t states, including Arizona, that had asked f o r help i n
addressing underreporting.
Statutury Changes May Be Required
To Enhance Reporting
Some actions to improve the r e p o r t i n g o f i l l n e s s e s r e l a t e d to pesticides,
would require changes i n the statutes or regulations. Arizona's present
statute on reporting pesticide poisoning may actually discourage some
reporting. In addition, at least two states have statutes that impose
penalties on physicians who f a i l to report pesticide- related incidents.
Wording could be changed - Arizona's statute requi res heal thcare
professionals to f i le "... incident reports of pesticide poisoning which
they diagnose or reasonably believe, based on their professional
judgment, to be pesticide poisoning ." As previous Iy discussed,
diagnosis, except in severe cases, is often uncertain. Healthcare
providers may feel their professional reputation is at risk if they
report cases that are not definitely related to pesticides. Arizona
re1 ies on physicians to classify each incident as a " case," " suspected
case," or " no case." In contrast, California places the burden of
categorization on the government investigators who follow up on each
reported case.
Changing statutory language to include cases in which the physician is
uncertain of the diagnosis, but has a reason to believe pesticides may be
involved, could result in a higher rate of reporting. It would also
remove the burden of classification from healthcare professionals, who
may rarely encounter pesticide- related i I Inesses. The DHS staff who
study pesticide poisonings daily, would then have the responsibility of
categorization, perhaps using California's categories of " possible,"
" unlikely," and " unrelated" to replace Arizona's " no case" where a
physician did not diagnose the case as definite or probable.
Penalties could be imposed - The Legislature could consider changing the
reporting requirement to impose a penalty for nonreporting. DHS
officials believe this would have a significant impact on the number of
cases reported. In Cal i fornia, heal thcare professionals who fai l to
report pesticide- related incidents are subject to a civil penalty of up
to $ 250.(') In Utah, failure to report a pesticide poisoning is a
misdemeanor, punishable by a fine and/ or jail sentence. The actual
effect of these laws is unknown, but officials in California and Utah
believe the laws have encouraged reporting.
( 1 ) C a l i f o r n i a also has a unique system t h a t allows any worker t o see a physician a t no
cost for a work- related i l l n e s s or i n j u r y . The physician f i l e s a " Doctor's F i r s t
Report of Work I n j u r y " , and i s compensated by the insurance company o r t h e s t a t e ,
regardless of whether or not the diagnosis confirms t h a t the i l l n e s s o r i n j u r y was
actual1 y work- related. Since payment i s contingent on reporting, i t i s considered an
incentive to r e p o r t .
RECOMMENDATIONS:
1. DHS should do more to educate the medical cornmuni t y to recognize and
r e p o r t p e s t i c i d e - r e l a t e d i l lnesses.
2. The L e g i s l a t u r e should consider amending the s t a t u t e to encourage
r e p o r t i n g of cases where p e s t i c i d e s may be involved, but confirming
the diagnosis i s impossible.
OTHER PERTINENT INFORMATION
FOOD SAFETY
During our audit, we compiled information about testing food for the
presence of pest i c i de residue.
Public Concerned
About Food Safety
Although a g r i c u l t u r a l pesticides are widely used and contribute to
healthy, high- yield produce, there are public concerns about their
safety. Pesticides protect our food from insects, weeds, and microbial
contamination at a reasonable cost. A d d i t i o n a l l y , the use of pesticides
also ensures the a v a i l a b i l i t y of fresh produce year- round. However,
there i s concern about the p o t e n t i a l l y harmful e f f e c t s o f p e s t i c i d e s .
Chemicals found i n c e r t a i n pesticides present oncogenic ( tumor- producing)
or carcinogenic ( cancer- produc ing) r i sks. The Envi ronmental Protect ion
Agency ( EPA) has found 53 active ingredients i n pesticides to be either
oncogenic or p o t e n t i a l l y oncogenic.
DHS Has The Authority
To Embargo And Set Tolerances
A. R. S. 536- 905 gives DHS the authority to set tolerances f o r p e s t i c i d e
residues, while A. R. S. 936- 910 allows the Director to embargo adulterated
food, including food with excessive amounts o f p e s t i c i d e chemicals. In
conjunction with the Department's a b i l i t y to embargo produce, i t can also
monitor produce. A t the present time, DHS works with the Federal Food
and Drug Administration ( FDA) to embargo food found to contain levels of
pest i c ~ des unacceptable by FDA standards. However, DHS does not mon i tor
the food supply, nor has the Department established tolerances d i f f e r e n t
from those set by the EPA.
FDA Monitors
Arizona's Food Supply
Although s t a t u t o r i l y authorized to conduct i t s own program, Arizona, l i k e
most other states, re1 ies on the FDA to monitor the levels of pesticides
i n food. Whi i e the EPA r e g i s t e r s p e s t i c i d e s and s e t s a l l o w a b l e l e v e l s of
tolerance for them, i t i s the FDA's responsibi l i t y t o monitor and
enforce those tolerance l e v e l s . The FDA t e s t s both domest i cal ly- grown
and imported produce nationwide, and has found a v i o l a t i o n r a t e of 1.0 to
3.5 p e r c e n t . ( ' ) However, the FDA program i s l i m i t e d i n both s i z e and
scope.
The FDA estimates t h a t they t e s t less than 1 percent o f imported and
2 percent of a l l d o m e s t i c a l l y grown produce i n d i s t r i c t labs across the
country. Produce grown i n Arizona i s tested a t the FDA l a b o r a t o r y i n Los
Angeles. Produce imported i n t o Arizona and C a l i f o r n i a from Mexico and
produce grown i n Southern C a l i f o r n i a i s a l s o tested a t the FDA- Los
Angeles lab.
Sample s i z e i s l i m i t e d - Although Arizona r e l i e s on the FDA t o p r o t e c t
i t s food supply, the q u a n t i t y of food t h a t i s a c t u a l l y t e s t e d i s
l i m i t e d . I n 1989, the FDA tested 445 samples of produce grown i n
Arizona, or l e s s than one percent of the f r u i t and vegetables grown i n
the State l a s t year. Samples of Arizona produce are selected according
t o a sampling plan by the FDA's methodologist i n Los Angeles. The plan
i s designed to encompass a diverse group of crops, based on the
mix- by- volume of produce grown and problem crops t h a t tend t o have a
higher occurrence o f v i o l a t i o n s . Crates of selected produce grown i n
Arizona were shipped t o Los Angeles where the e n t i r e q u a n t i t y of f r u i t s
or vegetables was ground and then t e s t e d f o r harmful l e v e l s of
p e s t i c i d e s . Approximately 40 samples of produce grown i n Arizona,
C a l i f o r n i a , and Mexico a r e t e s t e d each day i n the Los Angeles lab. An
FDA representative i n Phoenix said that the capacity o f the lab i n Los
Angeles l i m i t s the amount of samples t h a t can be t e s t e d . I n a d d i t i o n ,
the FDA estimates t h a t i t costs approximately $ 90 t o t r a n s p o r t and t e s t
each sample.
Imported produce too i s tested at a low r a t e by FDA. Testing produce
imported from Mexico i s important because p e s t i c i d e s t h a t the EPA has
( 1 ) When a v i o l a t i o n i s found, the FDA embargos the shipment. They also then require the
grower to demonstrate compliance on his future shipments by having his shipments
tested at a p r i v a t e l a b o r a t o r y .
banned i n the United States have been found on that produce.
Additionally, not a l l Mexican farmers are aware of EPA tolerance levels
for pesticides. In the winter when most produce can be grown only in
southern climates, approximately 800 trucks enter Arizona each day
carrying Mexican produce. From those trucks, approximately ten samples a
day are taken. The FDA estimates that 2 percent of al l produce imported
into Arizona and C a l i f o r n i a from Mexico i s tested annually. Although in
1989 the FDA devoted three- fourths of i t s pesticide testing resources for
testing imported food, n a t i o n a l l y , only 10 percent of a l l produce sold
was imported .
Although testing i s l i m i t e d , the results of FDA t e s t i n g show low
v i o l a t i o n rates. Violations occur for one of two reasons, e i t h e r the
level of pesticide residue exceeds EPA tolerances, or the pesticide
residue, while in the legal range, may be from a chemical that has not
been approved by the € PA for use on that p a r t i c u l a r crop. For example, a
pesticide that i s approved f o r l e t t u c e but not for spinach would
constitute a v i o l a t i o n i f i t were found on spinach, even at low levels.
FDA testing in Los Angeles shows that Mexican produce general ly has a
v i o l a t ion rate of 3 to 4 percent, whi le the v i o l a t ion rate for Arizona
produce ranges from 3 to 5.7 percent. The FDA says that i t cannot
monitor a i l food, nor can i t test food for a l l pesticides i n the
marketplace.
Problems with FDA testing - The screening method used by the FDA to
detect residues on produce samples i s limited and, can detect only some
of the many pesticides sold. FDA chemists note that they test for
chemicals previously found on produce and for harmful pesticides that are
of p a r t i c u l a r concern such as DDT and Aldicarb. The FDA t r i e s to detect
the presence of additional pesticides using single- and multi- residue
testing methods. However, FDA chemists note that with routine
multi- residue testing they s t i I I cannot detect a l I of the pesticides
currently being used. At the present time, there i s concern about
whether the tolerance levels set by the EPA are adequate to protect
certain subgroups of the population. Researchers say that low v i o l a t ion
rates are meaningless i f tolerance levels f a i I to protect sensitive
segments of the population such as children.
Other s t a t e s ' programs - To supplement the t e s t i n g done by the FDA,
several states have i n s t i t u t e d food t e s t i n g programs. Due t o concern
from l e g i s l a t o r s and the p u b l i c , these states have increased the amount
of food being tested, and work w i t h the FDA t o t e s t the maximum amount of
produce possible. C a l i f o r n i a , the leader i n food s a f e t y , spends twice
the amount the Federal government spends each year t o monitor produce.
Oregon and Washington have implemented less c o s t l y t e s t i n g programs.
C a l i f o r n i a - Cal i f o r n i a has a $ 40 mi l I ion a year food t e s t i n g program
w i t h seven elements i n c l u d i n g s t r i c t e r tolerance regulations than the
EPA, and four programs f o r p e s t i c i d e residue sampling. In the past
three years, C a l i f o r n i a ' s v i o l a t i o n rate has dropped from 2 percent
( which i t had been for 17 years) to 0.70 percent. F i f t e e n thousand
food samples are tested i n C a l i f o r n i a each year. C a l i f o r n i a ' s branch
chief i n charge of the Pesticide Regulation Program a t t r i b u t e s the
drop i n v i o l a t i o n s to the strong county r e g i s t r a t i o n programs that
s t r i c t l y monitor p e s t i c i d e sales and use. In a d d i t i o n , C a l i f o r n i a has
an agreement w i t h the FDA that enables the s t a t e to coordinate
t e s t i n g and test r e s u l t s .
Rashington - Washington spends $ 1.5 mi I l ion annual l y on food t e s t i n g
programs, not a l l of which involves p e s t i c i d e residue t e s t i n g . The
state has a contract w i t h the FDA t o t e s t 150 produce samples
annually for them. As a p a r t of the s t a t e ' s own t e s t i n g program,
Washington samples approximately 800 pieces of produce, and has a
p e s t i c i d e v i o l a t i o n rate of less than 0.50 percent.
Ore on - Oregon's Pesticide Residue Testing Program costs the state
& 00 annually. The program includes an informal work- sharing
program w i t h the FDA. Together, they t e s t approximately 1,600
samples of produce annual I y . Sharing planning and t e s t r e s u l t s
e s s e n t i a l l y doubles t h e i r capacity to monitor the s t a t e ' s produce.
The program a d m i n i s t r a t o r s t a t e d t h a t 2 percent o f the food tested
contains i l l e g a l levels o f p e s t i c i d e residue.
DHS Has Considered
Re- implementing A State Program
From 1981 to 1985, the Department of Health Services operated a l i m i t e d
food monitoring program that was managed by one person who had a d d i t i o n a l
r e s p o n s i b i l i t i e s . I n mid- 1985 when the former food t e s t i n g manager was
transferred, DHS chose not to continue the program. The D i v i s i o n of
Disease Prevention has recently given food monitoring more a t t e n t i o n and
has raised the issue during the preparation o f i t s D i v i s i o n a l budget
request. The D i v i s i o n notes the need for increased monitoring and
survei l lance of produce grown i n Arizona as we1 l as imported produce.
However, the D i v i s i o n thus far has not developed a proposed budget f o r
food monitoring, and the issue has never been included i n DHS' budget
request to the L e g i s l a t u r e .
' ROSE MOWORD. COVCRHOR Tt* WII. LIkUI. III, tI~,'~ IOL November 26, 1990
Mr. Douglas R. Norton
Auditor General
2700 North Central, Suite 700
Phoenix, At 85004
SUBJECT: COMMENTS ON REVISED PRELIMINARY REPORT DRAFT OF THE
PERFORMANCE AUDIT OF PESTICIDE REGULATION
Dear Mr. Norton:
Thank you for allowing me the opportunity to review the revised preliminary report draft
of the performance audit of Pesticide Regulation: Department of Health Services. I
believe the revised document accurately reflects the comments we made to members of
your staff during our meeting on November 16, 1990,
The Arizona Department of Health Servlces ( ADHS) is comm~ tted to pesticide regulation,
My staff has been directed to consider all the recommendations listed in the report, and to
implement those that are cost effective and which are likely to result in improved
reporting of pesticide related illnesses. To demonstrate our commitment, ADHS staff will
immediately seek to revise the Memorandum of Understanding now in place with the
Commission of Agriculture and Horticulture to assure that all citizens who believe they
have been made iil from pesticides are contacted by ADHS staff.
ADHS staff will continue to participate in efforts to educate medical professionals
regarding the recognition and management of pesticide poisonings, as well as the duty to
report those illnesses to the Department. I am convinced the pesticide poisoning reporting
registry cur be improved, and have conveyed that conviction to staff.
We agree that revision of A. R. S. 36- 606 to place on ADHS staff the responsibiiity of
determining whether M undiagnosed illness or complaint of illness is associated with
exposure to pesticides may benefit surveillance and reporting. However, this may require
substantial additional resources for the pesticide registry.
I would Iike to take this opportunity to commend your staff on a job well done. We
appreciate their professional and cooperative attitude.
Sincerely, -
Ted Williams
Director
The Dtpartwunt of Health &? vicar u An Equal Oppottunrty Aff~ rmatiuc Action Empbyer.
State Health Building 1740 West Adams Street Phoenix, Arizona 85007