Abstract
Pressures on North Carolina's agricultural community are at an unprecedented level. Known stressors are compounded by lawsuits, tariffs, and beliefs that others have a negative perception of agriculture. Individuals find themselves with an array of negative emotions precipitating stress, anxiety, depression, and increased risk of suicide without needed prevention.
Times like these will make you think of doing things you wouldn't ordinarily do. The words of the young farmer reverberated in my ears and in my thoughts. In that moment I felt as helpless as I ever have. “I'm the Director of the North Carolina Agromedicine Institute,” I thought, “I should know what to do.” But did I? The problem was that the young farmer was my son and I knew that the Institute was hearing the same thing from other farmers across the state. This was both a personal and professional call to action, but where to begin? The one thing I was sure of was that this farmer couldn't fix his problems with duct tape or baling twine.
Behavioral health issues among farmers have been well documented [1, 2, 3]. Relationship problems such as marital problems, domestic abuse, quarreling with elders, blame, and anger are most common (40%). Adjustment problems such as anxiety and depression that resolve when stress subsides are second (24%), followed by anxiety disorders, including excessive worry, panic, and post-traumatic stress disorder (PTSD) (11%). Depression occurs 18-33% of the time with major depression being most common. Substance misuse, either drug or alcohol, occurs in 7% of cases but co-occurs 40% of the time with other diagnoses. Personality disorders and psychotic disorders are much less common, with each occurring 1.5% of the time or less [4]. Farmers have been found to have higher rates of suicide when compared to all US workers [5].
Identified stressors contributing to farmer behavioral health concerns and suicide include weather, market prices, taxes, health care costs, concern over the future of the farm, outsiders not understanding the nature of farming, problems with machinery, and not having enough time to spend with family in recreation. The more hours worked on the farm and the more responsibility, the greater number of stressors experienced by farmers [6].
What had not been well documented were the emotional precursors that led to stress and more serious behavioral health concerns. Specifically, what emotions were farmers experiencing? What precipitated emotions and how did farmers cope with them? And finally, did farmers feel that anything could be done to help them, and did that help exist?
Farmer Emotions
To gain insight into farmer emotions, the lead author conducted a pilot study consisting of semi-structured interviews with 15 male farmers from across the state [7]. Compared to all North Carolina farmers, participants were younger and more racially diverse. Average age of participants was 43.3 years vs. 56.9 years for all farmers. Fewer participants were Caucasian: 87% vs. 94% for all farmers [8]. Farms ranged from 20 to 6,000 acres, with all being multi-commodity except one. Generation of farm ownership varied from first to fourth with length of time on current farm ranging from two to 50 years, with most farmers having been on the farm for more than 15 years. Six farmers had off-farm employment. All but one lived on the farm they owned or managed with their families. Families varied in configuration from the farmer and his immediate family to the farmer and multiple generations [7].
Farmers expressed fewer positive than negative emotions. Positive emotions included pleasure, gladness, gratification, happiness, reward, and satisfaction along with serenity, independence, and freedom. Each was associated with the farmers' interpersonal relationships with their farms. Of concern was that pride and satisfaction have been known to adversely influence the incidence of stress, depression, and suicide among farmers [7]. They love their families, the farm, and farming but pride can prevent farmers from sharing feelings of burdensomeness, hopelessness, inadequacy, and isolation with others until it is too late [9, 10].
Negative emotions included feelings of being overwhelmed, misunderstood, guilty, sad, aggravated, helpless, consumed, challenged, depressed, frustrated, tired, isolated, driven, worried, hurt, and pressured. Emotions were attributed to farm economics, family relationships, and the perception that non-farm people did not understand farming practices and the efforts put into producing food and caring for the environment. Almost in the same breath farmers described life on the farm as both positive and negative with stress being as routine as taking a breath. Life on the farm is “consuming but enjoyable, peaceful but stressful, stressful but rewarding,” said one farmer. “Stress is like an everyday thing. It ain't a habit. It's just something you have to deal with [7].”
Farmer Coping
Farmers shared four strategies for dealing with emotions: figure and reassure, repression, distraction, and relying on positive reserves. Participants described figuring out how to make farm operations successful so that they could reassure themselves and their families that everything was okay. For instance, if they could sell cattle while prices were high then there would be enough money to afford the family's health insurance. Some over-ate or drank to repress stress. One farmer had gained over 100 pounds in the two years since he'd taken over responsibility for farm operations from his grandfather. Others distracted themselves by walking away from stressful situations to clear their heads and get their thoughts together. Just riding to check on newborn calves could provide a much-needed distraction from dealing with a costly and complicated repair to a combine in the middle of wheat harvest. Farmers who relied on positive reserves said that experiences like spending time with grandchildren and having a profitable year with a specific commodity helped them get through stressful times [7].
Reliance on family, friends, and other social support was virtually absent. Farmers described their spouses as having traditional caregiving roles on the farm—cooking, cleaning, and caring for the children. Attempts to share information with their spouse about farm-related issues were kept to a minimum so as not to cause them to worry or to “get upset [7].”
Demands of caring for the farm prevented farmers from spending time with friends. Farmers described feeling alone even when being near others. When they were working in the field they were alone and did not have anyone come to check on them. When they were working on the farm books they might have been in close proximity to their family, but they were still mentally and emotionally alone. Farmers were inseparably connected to their farm, not being able to see themselves apart from it. They were the farm and farm was them. Even when physically off the farm, farmers were thinking about the farm or attending a farm-related meeting [7, 11].
Although farmers did not rely on social support, they relied on God. Farmers described the responsibility to care for their farm as God-given and stated that no matter what happened, God would take care of them. When they did not talk to anyone else they talked to God. Faith was seen as an essential farm implement as it was the one thing that sustained them and kept them from succumbing to stress [7].
Requests for Assistance
Requests for assistance focused on three key areas—helping to educate the public about farming, assistance with farm economics, and health and wellness. Farmers wanted the non-farming public to realize the value of farming to society, the intensive labor and risks associated with farming, farming practices, and the farmers' stewardship of the land. They wanted children to understand that food does not come from a grocery store but from a farm. They wanted individuals to understand that farming is a 24/7 occupation and that the place of work is also the place of residence and leisure. Paid vacation, sick leave, and retirement do not exist. Asking a farmer to take a vacation or to take medication that will impair their ability to work in an already dangerous environment is out of the question [7].
Farming practices are driven by the need to feed a growing US and world population with a decreasing number of farms. Farmers now make up less than 1% of the US population [12, 13]. Use of chemicals to treat diseases in soil and plants has been an important tool to maintain high yield levels; however, farmers' reluctance to use chemicals is growing due to government regulation, cost, and pressure to use organic production methods. Farmers shared that being a good steward of the land is something that they take very seriously as it is a God-given responsibility, they are dependent on the land for their livelihood, and they want it to be intact for future generations.
The lack of ability to control farm market prices is one of the most stressful areas for farmers. Pressures to keep up with markets have caused farmers to increase the size of their farms to meet the “commodity of scale.” Farmers want help to re-evaluate agribusiness models relative to return on investment ratio and to achieve a sustainable balance between work effort and return. Mentally, physically, and emotionally they feel that they are investing all they have at the expense of themselves and their families.
Farmers recognized the barriers that farming poses to spending time with family, improving health and wellness, and dealing with stress [7]. To overcome those barriers, farmers suggested the development of programs to help farm families deal with stress. They recommended that in addition to commodity production meetings, NC Cooperative Extension and commodity associations offer events for the entire family. They also suggested that efforts be put into developing paid vacation and respite services so that farmers can take time off to decompress. Affordable health care at days/times convenient to farmers and farmworkers in both English and Spanish was requested. Farmers also felt that more on-farm health and wellness programs, like those offered by the North Carolina Agromedicine Institute, were needed [7].
Current Climate
The sentiments expressed by the farmers in the study are consistently being repeated by farm men and women, Cooperative Extension agents, and other farm-related organizations. Requests for assistance with behavioral health issues are being received by the North Carolina Agromedicine Institute daily. The increase is attributed to issues related to farm economics, deteriorating public relations, and weather. Multi-million-dollar judgements in nuisance hog farm lawsuits are crippling multi-generational farms. Dairy farms have operated at or below costs for years and now are being told that their contracts are being withdrawn.
The US Department of Agriculture Producer Price Index reports that 2018 cattle prices are down 13.1% from 2017 with prices expected to decrease another 3-4% during the coming year. Wholesale pork prices are 6.9% lower than in 2017 and are expected to decrease 5-6% in 2018. Farm-level vegetable prices are 10.4% lower than in 2017 and are expected to decrease by an additional 10% over the next year [14].
Weather conditions have been variable throughout 2018. Cold and wet conditions early affected wheat growth and corn planting. Dry conditions that followed affected wheat, corn, and tobacco growth. The return of rain initially promised an improvement in the tobacco growth but too much rain negatively affected crop condition and further delayed crop harvest. For farmers relying on a second or third crop to cover for a less-productive crop all hopes were decimated by Hurricane Florence. Agricultural losses are estimated to be over $1.1 billion [15].
Agricultural Behavioral Health Services
Unlike New York and Canada, North Carolina does not have targeted agricultural behavioral health programs. The New York Center for Agricultural Medicine and Health's Farm Partners provides free and confidential counseling and case management assistance to farmers and their families. Manitoba Farm, Rural and Northern Support Services uses farmers trained as counselors to provide phone and online crisis support. The North Carolina Agromedicine Institute relies on training and written resources from these programs and agricultural psychologists in Iowa and Missouri to provide technical assistance to North Carolina's farm community.
Efforts are underway to identify funding and expertise to expand the Institute's ability to provide agricultural behavioral health services. Both farmers and existing programs have stressed the importance of services being delivered by individuals with integral knowledge of farm operations and culture.
Conclusions
Emotions experienced by farmers are those associated with stress, depression, and suicide. Substantial efforts are needed to develop tools to assist farm families in coping with emotions and preventing the development of serious behavioral health issues. Efforts must take into consideration the day-to-day demands of farming, farmers' faith, strong tendency towards isolation, and external pressures. Preferred coping strategies of figure and reassure, repression, and distraction may be contributing to farmer isolation and failure to rely on social supports. As farmers turn inward to cope with negative emotions, stress, depression, and risk for suicide may increase.
Efforts are needed to educate the public about farmers, farms, and the process of farming. Agribusiness leaders and government officials have a role to play in addressing farmers' negative emotions and stress by re-evaluating the impact of current business practices on farmers' health, wellness, and interpersonal relationships.
Acknowledgments
The authors wish to acknowledge Dr. Annette Greer of the Department of Bioethics and Interdisciplinary Studies in the Brody School of Medicine at East Carolina University and Dr. Karl Jicha of the Department of English and the North Carolina Agricultural Institute at North Carolina State University, who served as peer reviewers for the farmer emotion pilot study.
Potential conflicts of interest. All authors have no relevant conflicts of interest.
- ©2018 by the North Carolina Institute of Medicine and The Duke Endowment. All rights reserved.
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INVITED COMMENTARIES AND SIDEBARS