The following is a transcript of an episode of From the Front Row: Student Voices in Public Health, the University of Iowa College of Public Health’s student podcast. This week, Alexis and Steve welcome Dr. Susan Brumby to the program. Dr. Brumby is the founding director of the National Centre for Farmer Health, an innovative partnership between Western District Health Service and Deakin University in Australia. She discusses the issues surrounding the health, safety, and well-being of farmers and agricultural workers and how a practical understanding of rural communities helps create meaningful connections. Read more about Dr. Brumby.:

Alexis Clark:

Hello, everyone. Welcome back to From the Front Row, brought to you by the University of Iowa College of Public Health. My name is Alexis Clark, and I’m joined by Steve Sonnier. And if this is your first time with us, welcome. We’re a student run podcast that talks about major issues in public health and how they are relevant to anyone, both in and out of the field of public health. Today, we’re excited to have Dr. Susan Brumby on our program. Dr. Brumby is the founding director of the National Centre for Farmer Health, an innovative partnership between Western District Health Service and Deakin University in Australia.

Alexis Clark:

She leads the implementation of key strategies to improve the health, wellbeing, and safety of farm men and women, winning both a theoretical and practical understanding of agriculture, health, management in rural communities. She was awarded a Victorian traveling fellowship to the USA and EU looking at farmer health and decision-making and has presented both locally and internationally on farmer health. She is also a clinical professor in the faculty of health at Deakin University in Melbourne, Australia.

Susan Brumby:

Thanks and great to be here.

Alexis Clark:

Let’s start off with your path. What has your public health career path look like?

Susan Brumby:

My path has been quite unusual. I started originally doing a primary teaching course. Didn’t last very long there. I then went and did my nursing course at the Royal Melbourne Hospital, which is a very large hospital in Melbourne. I completed that. I had always actually wanted to farm growing up, but was told early on that that really wasn’t a career suitable for girls. My headmistress told me to get out of her office, that I needed to find a career much more suitable for girls. And I think that stays with you. I was in year nine when that’s what I was told, so I did a traditional, a primary teaching or nursing. I then did my midwifery in a smaller rural hospital, and I really, really liked mid.

Susan Brumby:

I guess what was important at that time is I did have parents on a farm, so I happened to meet my husband on a weekend home to the farm who was a vet. And we fell very quickly in love and married six months later. And we settled actually in a rural area. I was nursing in a small rural hospital and also doing kidney dialysis and went and purchased a small farm myself, with the help of my mum actually, and ran that really successfully. And during that time while we were in that small community, I undertook wool classing, and I completed my diploma of farm management by external studies. I also had three children during this time. And I mean, we were really busy. It was late twenties by this stage, early thirties.

Susan Brumby:

And I think at that time while I was working in the hospital, I was seeing a lot of issues that farming people were coming into our small rural hospital. And obviously, kidney dialysis, we were really fortunate to be doing that otherwise people needed to travel over a hundred kilometers to get dialysis. That was important for the rural community. A lot of people that were dying of heart attacks, suicides, that had undiagnosed cancers for too long. And these were rural people, farming people and, of course, horrific accidents. From the farming side, clearly, I was witnessing and being involved in practices where you could clearly see why there was this discrepancy with health here and agriculture over here with very different needs and wants around health, wellbeing, and safety.

Susan Brumby:

I completed my masters of health management. And during that time I had, at this stage, moved on and managed our family farm for 12 years. But, I got asked to go back into health and set up another program for more primary kids services, so taking away acute beds and replacing those funds with primary care services. And some of that was around farmer health. Some of it was around healthy aging, women’s health, men’s health, arthritis groups, more health promotion type of work for the community and community groups and advocacy. And I really, really enjoyed that work. And then, ultimately, I completed my master’s and came back to Hamilton, which was a larger health service in the position of director of community services.

Susan Brumby:

Now, what is important here is bringing my farming skills together and my health management, I now understood policy how things worked, had the agricultural skills, had the nursing skills. I applied for funding from an agricultural group called the Rural Industries Research Development Corporation, which was a federal funded body. And they provided us funding to set up a program called the Sustainable Farm Family. And this was a really big thing for a couple of reasons, one was here’s a health service actually receiving funds from an agricultural funded body. It was also a big turnaround for the health service to be purely focusing on farming people. And it also brought together a lot of key players in terms of the Farmers Federation, universities, health services, farmer benchmark group, industry bodies like Meat & Livestock Australia, Dairy Australia, Wool Australia at the time.

Susan Brumby:

And that program was incredibly successful. That was our baseline foundation program. And that was really, I guess, the bit that boarded all together about farmer health, wellbeing, and safety, whether you’re from an agricultural lens or whether you’re looking at it from a health and a policy lens for that matter. And that’s how that started. The success of Sustainable Farm Families then led me to another overseas to study program in 2013 when I did come to the University of Iowa and stayed for six, eight weeks there. And I have very fond memories of that. That was my second visit. And that allowed me to further develop our National Centre for Farmer Health, which is based in Victoria, receives Victorian funds predominantly, but now has a team of over 13 staff.

Steve Sonnier:

That’s all an amazing accomplishment right there. And it’s fantastic to hear about that, especially hearing your wonderful time in Iowa. We always hope that folks enjoy their time while they get to visit us.

Susan Brumby:

Yeah. I loved it.

Steve Sonnier:

With that in mind, when you’re comparing the education side of things, you talked a lot about the holistic measures that are in play and then also the specifics of farming culture as a whole, when you’re looking at the public health education aspects of things, do you think that there are specific benefits from the way you were trained and when you went into practice how you were prepared in Australia?

Susan Brumby:

I think what I have really discovered and I find still quite concerning is if you’re looking at, I guess, farming in rural populations or agriculture populations, there is a lack of what I call cultural competence for people to work properly or successfully with farming populations and agricultural workers. Whilst my training brought the two together, there’s no set way or there hasn’t been any set way of bringing them together and recognizing them as a special skillset. I’m sure it’s almost the same in Iowa and the US, but your number of fatalities, your rate of fatalities and injuries on farm would still be the highest I would expect in the US. They are certainly the highest still in Australia.

Susan Brumby:

And they’re also hidden, too, because often farmers don’t necessarily get picked up by hospitals. They’re not necessarily recorded properly on a database or through workplace injury because they often don’t have any insurance. They’re very hard to get a real sense of unless they’ve died. And then, of course, we do know what the rate of death was. I don’t see a great effort being made to educate people in public health to address the specifics of agricultural populations. And despite all our best intentions, I think at best, we’re probably just a tiny little ripple on a massive lake that really needs to be getting a tsunami happening across the lake really, I think. We run an agricultural health and medicine course. Now, we have about 20 students a year that come through.

Susan Brumby:

I know the University of Iowa ran the seminal Ag health course, which I did come over and do as well and has really made inroads. I think that, for me, was a pivotal change in how I saw the world, so I have tried to replicate that. And certainly, the University of Iowa has always been really supportive and helpful when we’ve had issues around that area. I think we need to really push strongly to make sure anyone doing rural education, rural medicine, rural nursing needs to have that qualification.

Alexis Clark:

I definitely agree with your aspect on the regulation of having an education requirement. In your opinion, what are the greatest public health needs in your region specifically?

Susan Brumby:

Yeah, I stayed up and discuss this with my husband actually last night. In our region, specifically, we are an agricultural hub, but we have quite a few homeless people. We have domestic violence, family violence, a small number but growing multicultural populations coming in. I really decided I wasn’t really sure. In terms of public health I could say we need more bicycle trails. People need to be getting encouraged to go out. Public transport isn’t good, so if we want to go to Melbourne, you have to be on the bus at half past six. And it only goes twice a day, five hours down. You can’t get home till 11 o’clock at night. A lot of people can’t manage that. It’s just too big a day.

Susan Brumby:

We have a high rate of vaccination here, so we do a lot of things well. We’ve had really big programs at the moment to make the healthy choice the easy choice. For example, where I work at Western District Health Service. We’ve completely banned all sugary drinks. We’ve completely banned any food that has added salt or sugar and isn’t green on a traffic light. You can’t buy a chocolate bar. You can’t buy any lollies. You can’t even buy something that’s amber on a chart, an occasional food. It’s all healthy food. And that’s been amazing to see that come in. If you want salt, you need to bring your own salt to work. If you felt like a can of Coke, you have to hide it. It’s been really effective in changing us. Yeah. There’s lots of things happening in lots of means.

Steve Sonnier:

Yeah. I mean, it sounds like a lot of really exciting things. And, yeah, I think that it’s always hard to get those behavioral changes underway for everyone. It’s a constant struggle.

Susan Brumby:

Yep. And of course, I haven’t mentioned mental health at the other big one as well for us.

Steve Sonnier:

On that point of mental health and the agricultural side of things, it’s a big point here, too, that we focus on a lot and how that interplays with the rest of our sectors of society, right, because we rely a lot on our farming communities here, but I think that we often overlook the mental health concerns of these communities, or other situations that crop up very commonly, but are not paid enough attention to. In your efforts right now, how does that evolve as a whole? Are you able to pay attention to those missed concerns at times or give them more of a spotlight, or how does that play out?

Susan Brumby:

We have researched and developed some services. We’ve done a work around the ripple effect, which looked at … it was focused mainly on male suicide but of people with lived experience sharing their stories. And that also worked looking at the level of literacy around suicide and stigma. And when we started, I guess, there’s a lot of work on mental health at the moment or contemporary work that suggested that if you lift the literacy of people around mental health, you’re going to have better outcomes for mental health. That was what we went into that research project thinking that if we were going to lift people’s literacy around stigma of suicide, that that would help.

Susan Brumby:

What we discovered was the baseline measures for that validated tool was much lower than when we worked with our cohort across Australia around suicide stigma. That was quite a surprise. In fact, they had such a high level of literacy around suicide and suicide stigma that we couldn’t have made any difference to it. It was incredibly high. What that did say to us is that it’s actually not the literacy, rural people have a high level of literacy around particularly suicide and stigma. Whatever intervention you’re going to put in there, it’s not about raising literacy around that. It may be around developing better behavioral practices and getting people to adopt them, but it’s not the literacy. That was really interesting. And we’ve done also some work with UK in Germany around some of that work with several population.

Susan Brumby:

We’re also doing quite a lot around co-design with farmers and agricultural industry. And that, too, has been interesting watching that unfold around the time that takes to co-design and really allow people to freely share their opinions about where they want things to go. This is a project looking at safety and mental health on farms and trying to help people stay safe, as well as look after their mental health. We have the traditional programs. We have the support programs. We have online access to a psychologist. We have an extensive book called Living with Stress on the Farm, all those kinds of things.

Susan Brumby:

I’m going tomorrow early out to visit 18 farmers. And when we put them through a health assessment, we do a psychological screening as well and can refer people on. Those things are quite well in place, but we still have these issues with mental health and positive wellbeing and emotional support.

Alexis Clark:

How do you guys engage positively with the community you work with, specifically maybe those with lower socioeconomic status that aren’t in those larger cities or at the University?

Susan Brumby:

Where I am, we’re 300 kilometers west of Melbourne in a town of around 10,000 people. Our lowest socioeconomic most likely to be for us in my work are people on farms, smaller farms, family farms that may have had someone ill or may have lost someone early, poor succession planning. We also find issues and problems with even successful farms. Even successful farms have all those challenges of family dynamics and distance to services, etc. The university that I’m associated with is actually 300 kilometers away, too. Our interaction is sporadic, I guess, and that does make it a little bit more difficult for us, but by the same token, we’re actually out here in the field actually doing real service delivery as well as research. I think we engage really, really positively with our communities. We have a broad structure to make sure we’re engaging well with the university and forever being in their ear about farmer health. And we certainly advocate very, very strongly for our community.

Steve Sonnier:

I think that’s a very good point, though, about the lived experiences component. And I think that really underscores a lot about what we talk about public health is, the need for someone who’s been through that situation or who has ties into that community to be part of implementing those solutions. When you’re reflecting on these lived experiences, which of them do you think is most critical? What do you think is the most powerful thing you have in your tool set for connecting with people?

Susan Brumby:

I think, for me, it has been having walked in their shoes. I’ve certainly farmed for, well, nearly 20 years of my life actively and actually ran the family farm. If people are talking about pregnancy testing, cows, weaners, vaccinations, shearing, wool, classing, mulesing, jetting, any of those things, I know what they’re feeling out. I know what they’re talking about if they’re talking about protein levels in grain, I understand all that. I think that’s been a really important advantage. We also try actively to seek people to work with us that have farming experience. That’s not always possible. That does create some difficulties for us because people need to be seen as being relevant. And certainly, if you can have a conversation around farming and understand it, that’s a big advantage. I think that’s been a really important measure of success.

Susan Brumby:

Our agricultural health and medicine course that we run is probably … if I had to hang my hat on one thing that I wouldn’t want to ever give up, it’s probably that. And I think we could do a lot more with it, but it is hard to get that political will. I think that it’s hard to get governments to go, “Well, this should be a compulsory unit,” or universities to go, “This should be compulsory unit.”

Alexis Clark:

Looking at 2020, it’s been a crazy year all over the world. Specifically, this question pertains just to rural health care though. What is currently being done to improve rural health care in Australia? And what would you like to see accomplished in the next five years?

Susan Brumby:

That’s probably a bit like the states, we have seven different states and they’re all very different. Well, we recently had appointed a rural health commissioner at a federal level who’s a very talented woman and really has the voice of government. Having said that, you’re so right, COVID has just changed everything. We haven’t had one normal board meeting since February whilst we’re just starting now to go back to more normal work and just, obviously, before the Christmas break. Our own center is very unique in terms for the state of Victoria. It’s not replicated in any other state. Various states do different things.

Susan Brumby:

In terms of what specifically for rural, we certainly have a lot of programs to try and address the inequity of access between metropolitan and rural people. Certainly, COVID has also reinforced the importance of people being able to access health care within their communities. And I think this will be an interesting time coming out of COVID because people couldn’t travel and were unable, everything was shut down, elective surgery, everything was stopped. If you couldn’t actually get emergency help, if you needed it in your own community or it was a long way to travel, it was very, very difficult.

Steve Sonnier:

I’m thinking about the changes that have undergone our culture in the United States as the results of the COVID-19 pandemic. And one that I think immediately stands out, at least in the rural side of things, is the reliance on tele-health or on other educative contexts. But, specifically in the broadband side of things, we worry a lot about are people able to access this? Are there issues of equitable deployment? Do you see that happening in Australia, too? Is that similar issue faced for rural communities as a whole?

Susan Brumby:

Yes. So thank you for raising the tele-health. I’ve actually had a couple of tele-health appointments myself, which I’d never had before COVID. So, exactly. We’ve had quite a movement towards tele-health. And the changing politics around that in Australia was significant because previously you weren’t able to claim Medicare. We have a nationalized health systems, so previously doctors wouldn’t have been able to claim for it. And with COVID, they now are. I don’t think they’re going to be able to wind that back. If you want to have a tele-health appointment and your doctor is happy to do that, that is now a new way of doing that. And that is really big. I think that will definitely stay changed.

Susan Brumby:

For ourselves, we obviously weren’t able to see farmers, so we actually developed some tele-health programs and some mentoring coaching program. And that actually surprised us. That was really well received, too. Having said that, we’re going out for the first time tomorrow, and again next week, and actually getting back into catching up, doing some health and lifestyle assessments in person. Very exciting.

Alexis Clark:

That is exciting. I think we’ve been a little bit more progressive in getting things back in person in America, but we are also unfortunately suffering the consequences of that. What are some of the biggest obstacles farmers are facing today, and how does the Sustainable Farm Families program help these families?

Susan Brumby:

Well, Farm Families, as I think I mentioned, started in around 2003, 2004 actually, as a pilot. And Farm Families itself has probably not had a program run now for 12 months, maybe even two years now. We have emerged into a health and lifestyle assessment program, with maybe a follow-up telephone coaching. Farm Families took a lot of time. It was four days over a two year period. The health and lifestyle assessments are half an hour, and then we can follow up by phone or tele-health. I think the world has changed, so there’s a lot more out there around in terms of health literacy. People are better at it and have higher levels.

Susan Brumby:

And I think you can now talk about farmer health, and legitimately, people understand what you’re talking about. 20 years ago, people had no idea what we’re talking about. I think that whole environment has changed. Our external environment has changed, and we have had an effect on people understanding the importance of farmer health. However, the biggest obstacles in terms of farmers still remain access. It still remains late diagnosis. There’s still a lack of evidence around, for example, high rates of bowel cancer and higher rates of neurological disorders. What is the cause of this? I’ve just had an honors student finish her thesis on chronic kidney disease of unknown origin. And her fantastic piece of work has definitely pulled up agriculture and length of time farming as an association with the chronic kidney disease. There’s more work to do in that.

Susan Brumby:

If you look at a map of Australia and you see where our hotspots are for kidney disease, they’re in rural areas and agricultural areas. Not to the same level as, say, Sri Lanka or Guatemala or anything, but even so you are seeing that difference. I think there’s a lot in terms of access, equity, and research that is still a big gap. And this challenge of not having people properly prepared to work in rural areas, whether they’re nurses or doctors or allied health. People need to understand their community but also making sure that we’re getting the research done as well by people that understand how rural communities and how agriculture works. And I think there’s the biggest challenge because it’s quite possible to do pretty interesting research that is nonsensical when you apply it into an agricultural context and people don’t realize that.

Steve Sonnier:

You talking about that issue, one of the most pressing things I think about with this is recruiting folks from these communities or getting the folks interested who are representative of these communities, or even bring people to these communities in the first place. We have a lot of issue I think here in the United States, and I wonder about this, too, in Australia, of brain drain, of people leaving the rural communities and going into other areas rather than focusing on the needs of those areas that need a lot of help. Where do you see that field tracking specifically in this area because I think this is a very difficult issue to solve of how do we retain folks who are highly skilled in these areas that need help?

Susan Brumby:

Yeah. Oh, that is the perennial question. Having said that, our university is now starting from next year, so recruiting now, they have reserved 30 medical school places for people in our direct footprint. That is a huge change. And so they say they take 120 per year, first priority are the 30 from reserved spots are around our area. And then to the broader Victorian footprint and then to other rural areas across Australia. That is a big change. And I think we could definitely see more of those. Obviously, for me, seeing more people doing agricultural health and medicine and growing that network of people that have done that. We’re actively trying to really support those people so when they go back to their health service, one of the challenges is obviously getting your health service to believe doing services for farmers specifically is important. And we actively advocate for that. I think there is some things happening and, again, COVID-19 has definitely shown how vulnerable people are in large cities. Melbourne had a much stricter lockdown than we’ve had in the agricultural community.

Alexis Clark:

I have one final question for you. What is one thing you thought you knew but were later wrong about?

Susan Brumby:

I’ve been thinking this question. There’s probably so many. It’s great saying there’s no point in having your mind if you’re not prepared to change it. There have been numerous things that I’ve been wrong about and been prepared to change. One of the key things for me was that even if you have the most logical, best evidenced, well-organized program or research or whatever that is right, that doesn’t mean it’s going to be picked up. And it doesn’t mean it’s going to make a difference beyond your piece of work. And the ability to persuade and to get political will is a skill that is just so important. And that is a very frustrating thing to learn and, I guess, to be taught that at the end of the day, it doesn’t matter if you’ve got everything correct and beautifully done, it doesn’t mean that it will get picked up. A far less program with someone that can persuade better can win.

Steve Sonnier:

I think it’s a big topic that we see a lot here, too, is this idea of we can have the best research. We can have a really great plan and everything along those lines, especially when it comes to COVID-19 and our responses towards it, and then things happen and get in the way sometimes, or they take a different direction. That can be frustrating. But, I do love that phrase. The mind phrase is just such a wow light bulb in the head kind of thing. That’s such a fantastic insight.

Susan Brumby:

Yeah, it is good, isn’t it? Because it does make you … because people are often, and particularly over the years, have been quite gendered about women changing their minds. And I’ve always quite enjoyed being able to say, “Well, there’s not much point in having your mind if you’re not prepared to change it, is there?” I’m pleased you like that.

Alexis Clark:

I write quotes in my planner, and honestly, I think that’s one worthy of writing, so thank you so much for enlightening us with that one.

Susan Brumby:

My pleasure.

Steve Sonnier:

Perfect. Perfect. Well, Dr. Brumby, thanks so much for coming on our program today. It was a delight to chat with you. It was wonderful to hear about your experiences. We’re so glad to be connected with you and to hear your praises of Iowa, too. That’s always fantastic.

Susan Brumby:

Very, very fond of Iowa. Always, always sing the praises of Iowa.

Steve Sonnier:

That’s it for this week’s episode of From the Front Row. Major thanks to our guest, Dr. Susan Brumby, for coming on today. This episode was hosted and written by Alexis Clark and Steve Sonnier. This episode was edited and produced by Steve Sonnier. You can find more about the University of Iowa College of Public Health on Facebook. Our podcast is available on Spotify, Apple Podcasts, and SoundCloud as the University of Iowa College of Public Health. If you enjoy this episode, please share it with your colleagues. Our team can be reached at cph-gradambassador@uiowa.edu. This episode was brought to you by the University of Iowa College of Public Health. Keep on keeping on out there.