Estimating of the costs of nonfatal occupational injuries and illnesses in agricultural works in Thailand

This is the first report on the number and medical treatment costs of occupational injuries and illnesses in the Thai agricultural sector. Other reports on OIIs have used data from the Workers Compensation System, which are only available for formal sector employees. This study is unique in using UCHS data to identify 1,704,655 occupational injuries among agricultural workers for 2017 (Table 1), different than the 17,481 agricultural injuries (16.9% of all injuries) reported to the National Injury Surveillance System of Thailand from 2002 to 2010 [25]. Clearly, Thailand sorely needs a robust system of OII data collection and surveillance for all informal sector workers.

Occupational injuries in Thai agriculture

The ISCO sub-code of 6111 (Field, Crop, and Vegetable Growers) had the largest number of visits and medical costs for occupational injuries (Table 1). The risks of injury among small family farmers growing crops such as rice, sugarcane, fruits, vegetables, and other field crops, result from the wide range of activities and equipment used during land preparation, planting, cultivation, and harvesting [26, 27]. Animal producers and livestock handlers suffered more severe injuries, as evidenced by higher per visit medical costs for injuries (Table 1). Others have also identified animal handling for its high health and safety risks [28, 29].

Occupational illnesses in Thai agriculture

Musculoskeletal Disorders (MSDs) have previously been reported as a common problem in Thai agriculture [26]. This, however, is the first study to estimate the annual medical costs attributed to MSDs (over $11.8 million), or about 28% of the total medical cost of all agricultural OIIs. In the U.S., MSD cases accounted for 31% of all worker injury and illness cases reported by U.S. Bureau of Labor Statistics [30].

Hearing loss has also been identified as a hazard in Thai agriculture, with a prevalence of up to 88% in some farming populations [31]. Exposures to ototoxicants such as pesticides may also play a role in the high prevalence of hearing loss [32]. The 15,182 cases identified in 2017 (Table 2) highlight the need for education about hearing protection and the provision of hearing protection devices to Thai farmers.

Although others have reported the problem of pesticide poisoning among those who mix or apply pesticides in Thai agriculture [8, 26], it appears that, like the imports of pesticides into Thailand [33], poisoning cases are increasing. In 2015, the estimated number of pesticide poisoning cases was 10, 177 [19] compared to the 13,995 cases we reported (Table 3). This is the first study to estimate the annual medical treatment costs attributable to pesticide poisoning (over a quarter of a million USD). We do not know the reason that the medical treatment costs for herbicide and fungicide poisoning are higher per case than for other pesticide poisoning cases. However, on June 1, 2020 the Thai government put in place bans on the use of the highly toxic herbicide paraquat and the insecticide chlorpyrifos and restricted the use of the herbicide glyphosate.

The UHCS rely on the primary care staff (most often a bachelor’s level nurse or public health officer) to identify occupational illnesses. The difficulty in diagnosing occupational illnesses without more extensive training may be reflected in the low number of occupational illness visits (3%) relative to injuries (97%) in our data. In addition, it is difficult to link occupational exposures to illness with a latency period between exposure and illness [25]. In the U.S., Occupational Safety and Health Act recordable occupational illnesses are also a small fraction of all OIIs and are believed to be under-reported [34].

Addressing the Medical Costs of Treating occupational injury and illness (OIIs)

Establishing the cost associated with OIIs is essential for strategic planning by governments to enable them to allocate scare resources and put in place adequate prevention measures. The cost estimates for OIIs available for this paper are based solely on medical treatment costs.

In the economies of high resource countries in the West, the most important cost element for OIIs is not the medical treatment cost, but the immediate lost work time and productivity, plus the “lost return on investment in human capital” when a fatality or disability results in the inability to continue the job [35]. Such information is not available in Thailand for the informal sector, although some of it is available for the formal sector from the Workers Compensation system. Nevertheless, the medical cost estimates presented here do reflect a cost shifting of occupationally related healthcare costs to the national healthcare system.

Prevention strategy

Thai farmers are currently covered under the Ministry of Labor’s Department of Labor Protection and Welfare “Guidance on Occupational Safety, Health and Environment for Informal Workers, 2013” [36]. Under this guidance, all informal workers, must promote safety and health at their own workplaces and meet all applicable standards. The government does not have a mechanism for the effective enforcement of this guidance nor a means to provide occupational safety and health support services to the informal sector. Thai regulations do not require the government agency or farmers to implement comprehensive OIIs prevention programs in agriculture.

Currently, the UHCS budget mainly covers medical treatment costs rather than prevention programs for OIIs. We recommend a re-allocation of a portion of the OII treatment costs enumerated here to providing agricultural workers with the critical components of prevention programs: hazard identification and remediation, training, and personal protective equipment. The Ministry of Public Health and the Ministry of Labor might develop safety programs that provide incentives for subsidizing the use of safely guarded machinery for farmers; training in sustainable and organic alternatives; subsidized personal protective equipment and additional training requirements before licensure for pesticide purchase. Outreach agricultural occupational safety and health training programs need to be set up around the country, in every district and sub-district, to reach agricultural workers in the remote rural areas. Prevention programs and subsidized using medical treatment funds could reduce OIIs and improve productivity.

Limitations

Our study used Health Data Center data from 2017 resulting in an underestimate of current OII costs, as Universal Health Care System (UHCS) costs have increased over time. Due to the lack of adequate training and limited interest from the UHCS, many OIIs may not have been put into the proper Diagnostic Related Group. The determination that an illness was work related was not verified by the Bureau of Occupational and Environmental Disease and might be an over or under estimate. With regard to OII medical costs, our study assumed that the costs of medical treatment for most occupational illnesses were the same as the most frequent DRG category claim (DRG 04520: respiratory infection or inflammation without important cost and clinical complexity). Due to lack of data, these OII cost estimates represent only direct medical expenses. Because the number of days away from work or the number of days of job transfer or restriction is not available for informal workers, we do not include the other costs to workers and the economy due to daily lost productivity or income.

Future direction

The U.S. Bureau of Labor Statistics conducts an annual Survey of Occupational Injuries and Illnesses that generates estimates of nonfatal workplace injury and illness rates. U.S. law requires agricultural businesses with more than 10 employees to participate in the surveys. This type of OII data collection process does not exist in Thailand and even in the U.S., information on OIIs in the informal sector is difficult to obtain. Therefore, in 1990, the U.S National Institute for Occupational Safety and Health developed the National Agricultural Workers Survey, a periodic surveillance program of nonfatal injuries to hired workers on U.S. crop farms, regardless of worker immigration status [37].

Thailand needs data collection tools and a database that can measure OII, lost income and workdays, and lost productivity for informal sector workers. It should be developed by the National Statistical Office of Thailand in collaboration with Ministry of Public Health and the Ministry of Labor. If collected through UCHS it will require sufficient training for healthcare personnel to classify an injury or illness as work related. It is important that family members who are injured on a family-owned farm, especially children, should be classified as having an OII. In addition, a method is needed to indicate that a family member was living on a family-owned farm, but not working at the time of exposure to a farm hazard that caused an injury or illness (pesticides, farm animals, farm tools) [38].

Alternatively, the Ministry of Agriculture or Ministry of Labor might develop a nationwide surveillance system to collect demographic, employment, and health and safety data in face-to-face interviews. Ideally, this would involve direct collection of data on working conditions, injuries and illnesses, and especially lost time, lost income and productivity, and related costs for the workers and their dependents. The timing of data collection should reflect the seasonality of agricultural production and employment. Better data on OIIs and the true costs, beyond medical treatment, including lost worktime and productivity, will provide incentives for changes in government policies to reduce UCHS expenditures and improve national agricultural productivity. Detailed information about the sources and nature of OIIs (crops, seasons, tools, activities) will aid efforts to target occupational health and safety training and interventions.

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