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Concerning the workforce, historically, women have played a major role in the cultivation of tobacco, especially in the United States. In the 17 th century, European women were hired to work in tobacco plantations alongside men. In the 18 th century, female African slaves and their daughters predominated in these farms. In the end of the 19 th century and beginning of the 20 th century, a profound change in tobacco production took place, with cultivation shifting to small, family-owned properties, which promoted the participation of women in all stages of production, from cultivation to marketing.

In the 21 st century, this workforce was gradually replaced with mechanized agriculture and male seasonal workers, especially Latino migrants An anthropological study 1 shows that the tobacco workforce in the United States has been usually constituted by "others" - women, blacks, migrants - and is now characterized by a "globalized labor force. In Brazil, tobacco is usually grown in small family farms 10, It should be noted that child labor is observed in all countries with family-operated tobacco farms, with children working full time or during non-school hours, participating in the entire cultivation process 3,8.

The cultivation of tobacco in developing countries is physically demanding, with manual handling of heavy loads and application of a variety of pesticides in different stages, such as sprayed methyl bromide herbicide, insecticide, fungicide, and nematicide during seedling production, disulfoton organophosphate insecticide and acaricide following sowing and transplantation, and imidacloprid nitroguanidine insecticide and acephate organophosphate insecticide and acaricide for pest control until harvest.

It is well known that the use of these products causes various health problems and environmental damage damage 3, Among the health problems related to tobacco farming, the most noteworthy are GTS, respiratory and musculoskeletal problems, and mental disorders resulting from the exposure to pesticides. GTS, the best documented condition, is usually felt during the harvest, resulting from the dermal exposure to tobacco leaves that causes acute nicotine poisoning.

Symptoms include nausea, vomiting, headache, and abdominal cramps Respiratory effects are caused by tobacco dust, especially during processes such as curing, but they have not been extensively studied. The musculoskeletal problems described in the literature are mostly related to labor injuries 22, The occurrence of mental disorders such as chronic depression and suicide suggests a role of organophosphate pesticides 18, Concerning environmental damage, pesticides are a major source of soil and water contamination.

In addition, as a crop, tobacco quickly drains the soil, requiring a higher amount of nitrogen, phosphorus and potassium than other crops.

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The impact of depletion is higher in tropical countries, where the level of nutrients in the soil is lower. This explains why this crop requires intensive use of fertilizers Production characteristics and working conditions. Traditionally, tobacco was produced in the United States with government subsidy and sold at public auction. After being graded for quality standards by the United States Department of Agriculture USDA , tobacco leaves were sold in warehouses to buyers tobacco manufacturers or leaf dealers at prices that fluctuated during the selling season.

More recently, this system was replaced with a regimen of direct contracting between manufacturers and farmers 12 , which challenges the Jeffersonian notion of independence 1, In Argentina and Malawi, sharecroppers have been reported to work in tobacco fields Bolivians working as sharecroppers in the province of Jujuy, Argentina, and local families in Malawi 11, Sharecroppers represent a cheaper workforce and the transfer of production risks from landowners to the workers themselves The tobacco production network, Brazil included, is transnational and based on a direct link between producers and the industry, through an "integrated system.

The tobacco industry is responsible for the dynamics and innovation in agricultural production and has exclusive rights to sell inputs, as well as the right to purchase the final product 4,12, Three types of tobacco are grown in Brazil: Virginia, Burley, and common tobacco. In the South, In Malawi, Burley is the most common variety In the United States, the most common tobacco types are Virginia, used in the manufacture of cigarettes, and a variety of air-cured Burley used for chewing and also in the manufacture of cigarettes.

The regions where these products are cultivated depend on many factors, including topography, soil and climate conditions, and historical aspects In Brazil, the tobacco production cycle starts in May. A float system is used to produce transplants, using polystyrene trays covered in plastic, which workers call "swimming pools. At this stage, large amounts of pesticides are used.

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The harvesting of leaves starts between December and February, around 60 days later. Between transplantation and harvesting, farmers monitor growth, carry out pest and disease control, and remove flowers top the plants to ensure heavier and higher quality leaves 9,17,28, The lack of personal protective equipment, including masks, gloves, and boots, due to the high cost of this equipment or to the fact that it is not adapted to a tropical climate, makes agricultural workers vulnerable to acute and chronic poisoning caused by pesticides applied during different stages of the tobacco production process, mostly organophosphate agents agents 17, Virginia tobacco is harvested in stages.

The lower leaves, which are larger and older, are picked first, and the upper leaves, last. After harvesting, the leaves are strung onto sticks and dried in curing barns flue-cured tobacco Burley and common tobacco ripen more evenly and do not require two-stage harvesting. These two types of tobacco also differ from Virginia in terms of the curing process, which is done in well-ventilated areas air cured After curing, the leaves are baled or sheeted according to class and stored until transport to industry warehouses 9, Tobacco leaves from Brazil are internationally recognized for their high quality and low price.

Other agricultural activities, if any, are basically for subsistence; other products are sold only if there is surplus production. This makes farmers dependant on the tobacco industrial production chain, preventing agricultural diversification 11, The grading of tobacco by the industry for marketing purposes has resulted in a competitive environment that leads farmers to sell at an increasingly lower price.

Whereas a few large-scale growers have become rich, many small growers are having trouble with a crop that involves physically demanding work and investment in various resources, and that is associated with dangers to health and the environment resulting from exposure to pesticides and nicotine poisoning, placing at risk all those involved, especially women and children 4,13, The vertical relationship that these companies establish directly with farmers decreases the grower's productive and economic autonomy, resulting in working conditions that are inadequate and unhealthy, with negative impacts on health and environment.

A summary of the tobacco productive chain and the type of organization and workforce involved in tobacco growing is shown in Table 2.

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Main health problems associated with tobacco production. The production of tobacco causes short and long-term effects on human health. The recognition of such risks is not recent. In , Bernardino Ramazzini recorded various symptoms, including headache and abdominal cramps, among Italian workers and attributed these symptoms to exposure during tobacco cultivation In addition to the symptoms that characterize nicotine poisoning, there are respiratory and musculoskeletal impacts resulting from exposure to pesticides. Table 3 presents a summary of the main health and environmental issues associated with tobacco production and strategies for facing this problem available in Brazilian public policies, as reported in the literature.

Green tobacco sickness GTS. GTS was first described as a specific disease affecting rural tobacco workers in Florida in It is caused by stimulation or inhibition of cholinergic receptors in the central nervous system, leading to a clinical presentation that is often characterized by vomiting, nausea, dizziness and headache.

Additionally, abdominal cramps, diarrhea, changes in blood pressure and heart rate may also occur during or after exposure to Nicotiana tabacum found in tobacco leaves 20,34, In Poland, visual changes have also been described in association with other GTS symptoms The symptoms most commonly reported by affected workers were nausea, vomiting, headache and dizziness. Nonsmokers were affected most severely. Contradicting previous reports from other countries, exposure to wet leaves was not associated with increased risk of GTS 37, During the harvest, the body of tobacco workers is surrounded by tobacco plants and potentially exposed to nicotine.

Leaves are often held by workers underneath their arms. Dermal absorption of nicotine increases if the leaves are damp, and may be facilitated by preexisting lesions in the hands and armpits.

Gloves and water-resistant clothing may prevent this, but most of the time such protective gear is not worn because it makes harvesting more difficult 20, These workers are frequently inexperienced, do not communicate well in English, and do not have health insurance. They may also be illegal immigrants, and may thus be afraid to leave work and seek health care.

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This encourages self-medication in the presence of GTS symptoms 28,42,49, The consequences of acute and chronic exposure to nicotine for the health of men and women involved in the cultivation of tobacco have been reported by a study that identified a greater prevalence of hypertension and premature deliveries in this population as compared to a control group. However, according to the authors, these differences were not statistically significant, possibly because of the size of the sample, absence of comparative studies, and differences in the amount of nicotine absorbed during the various stages of tobacco cultivation 43, Some studies have assessed GTS symptoms and nicotine levels absorbed from shade tobacco leaves based on salivary levels of cotinine among agricultural workers from Connecticut, U.

The authors found a low risk of nicotine dermal absorption and a low incidence of GTS in the sample assessed, suggesting that shade tobacco may exhibit lower levels of nicotine when compared with either Burley or Virginia tobacco 52, The main differential diagnoses of GTS are pesticide poisoning or heat exhaustion. Pesticide poisoning usually occurs at the start of the harvest season, since the last spraying is usually done a few weeks earlier 48, In contrast to GTS, workers with heat exhaustion have fever and do not present increased levels of cotinine, a nicotine metabolite.

In addition, GTS symptoms may also appear in rainy days, when heat exhaustion is less likely Urinary cotinine levels, which correlate significantly with the total amount of nicotine absorbed, are used to monitor environmental exposure to tobacco and evaluate the degree of poisoning 56, Despite its nonspecific symptoms, GTS can be diagnosed if correlated with tobacco farming. In addition, the measurement of cotinine levels may help establish a differential diagnosis 48, A study with tobacco workers in Malaysia 59 reported significantly increased levels of urinary cotinine among nonsmokers, suggesting greater absorption of nicotine from tobacco leaves.

Smoking cigarettes is a strategy known to increase tolerance to the signs and symptoms associated with tobacco poisoning 49, Among smoking workers, the incidence of GTS was lower incidence density of 2. The occupational health risks associated with nicotine absorption in tobacco workers are a reason for concern. In addition to the handling of leaves, the strategy of smoking makes these workers more susceptible to other problems associated with tobacco, as well as to the consequences of smoking.

Monitoring and reporting of suspected cases to surveillance systems is necessary so that the magnitude of the problem can be determined and its economic impact on the healthcare system and on the productivity of tobacco workers, taking into account work days lost, can be measured As previously mentioned, little information is available in the literature concerning the respiratory problems associated with tobacco cultivation. The exposure of workers to dust from dry tobacco leaves, resulting from the curing process, which concentrates nicotine and other chemical substances likely to cause damage to the respiratory system, especially when personal protective equipment is not worn 15, Respiratory exposure also occurs during stacking, when the leaves are tied; when leaves are loaded for transportation; and during the mixing and spraying of chemicals Pulmonary function tests in workers exposed to tobacco dust and other types of workers revealed a increased risk of emphysema in the former, even among nonsmokers 62, The ability of the highly vascularized respiratory system to absorb minute particles makes it especially vulnerable to irreversible respiratory problems in both smoking and non-smoking tobacco workers.

Musculoskeletal lesions. A study carried out in a university hospital in Kentucky, U. The authors propose that extreme heat and poor design or maintenance of barns contributed to the high incidence of falls Still in the state of Kentucky, a population-based study investigated the occurrence of nonfatal agricultural injuries in farmers older than 55 years of age, having reported a yearly overall crude injury rate of 9. Farms with beef cattle and tobacco came second after farms with beef cattle alone in terms of the number of injuries By restricting their sample to this age range, the authors focused on the ability of older farmers to carry out the routine activities of agriculture and the possibility of increased vulnerability due to the sensorimotor losses associated with aging Tobacco production also predisposes to other injuries associated with tractor overturns, use of knives to cut stems, and falls from the high drying and storage barns 1.

Chemical products used in tobacco fields are usually applied by hand or using acrylic backpack sprayers. In the absence of protective gear, this may cause exposure to concentrated doses of pesticides that can be absorbed through the mouth and skin or inhaled 15,16, Because of that, pesticides are often applied by children younger than 15 years of age, who are more tolerant to these effects 16, Although this tolerance is mentioned in the cited literature, the reasons behind it are still unclear, which is indicative of the research gap regarding this topic, particularly in this population.

A study assessing the size and effect of exposure to organophosphates and carbamates in children working in or accompanying their parents to tobacco fields in Nayarit, Mexico, did not find a difference in terms of acetylcholinesterase levels in working and nonworking children living close to the fields Those authors have stated that the problem may be larger than initially thought, since the population surrounding tobacco fields also seems to be affected through generalized environmental contamination, including contamination of drinking water sources, due to pesticide runoff The effects on the central and peripheral nervous system resulting from exposure to pesticides commonly used in tobacco plantations, such as organophosphates, carbamates, and dithiocarbamates, were examined in 76 tobacco growers and 38 sex- and age-matched controls in Kelantan, Malaysia Speed of nerve conductance and postural oscillations appeared to be sensitive indicators of the effects of these products on the peripheral and central nervous system All the workers analyzed had a significant decrease in serum cholinesterase activity as compared to controls.

A study was carried out to evaluate clinical, psychiatric, and extrapyramidal symptoms in addition to plasma acetylcholinesterase activity in a sample of 37 workers involved in family agriculture of tobacco in the South of Brazil. These farmers had been chronically exposed to organophosphates. Tests were carried out on two occasions: during a three-month period of pesticide exposure and after three months without exposure.

The results showed that acetylcholinesterase activity was normal in all subjects, with no differences between the periods during or following exposure. Clinically significant extrapyramidal symptoms were present in 12 out of 25 individuals. Tremor was the predominant sign, followed by masked facies and reduced arm swing characteristic signs of parkinsonism. According to the authors, the findings support the need for parameters other than acetylcholinesterase activity to monitor the chronic consequences of low-dose exposure to organophosphate pesticides, and suggest that exposed workers may develop permanent extrapyramidal symptoms in addition to transient motor and psychiatric impacts, such as symptoms and signs of clinical depression and parkinsonism Environmental problems resulting from tobacco production.

Flue-cured tobacco requires a considerable amount of wood, with potential for significant deforestation. Even though the agreement between the tobacco industry and farmers contemplates reforestation efforts with seedlings provided by the industry mostly leucaena and eucalyptus , the results are limited by the great requirement for fuelwood in the region. The region's climate can best be described as a humid continental climate , according to the Koppen Climate Maps.

The city lies roughly halfway between Toledo and Dayton , Ohio and weather is at a similar medium. Summers are hot and humid and winters are generally cool to cold, with moderate precipitation year-round. Due to the city's inland location the moderating effects of Lake Erie are diminished, causing the city to experience higher averages in the summer and colder plunges in the winter than Toledo.

On average the city sees around 4 more inches of snow annually than Dayton. The percentage of college graduates is 9. As of the census [20] of , there were 38, people, 14, households, and 8, families residing in the city. The population density was 2, There were 16, housing units at an average density of 1, The racial makeup of the city was Hispanic or Latino of any race were 3.

There were 14, households of which The average household size was 2. The median age in the city was The gender makeup of the city was As of the census [3] of , there were 40, people, 15, households, and 9, families residing in the city. The population density was 3, There were 17, housing units at an average density of 1, Hispanic or Latino of any race were 1.

There were 15, households out of which In the city the population was spread out with The median age was 33 years. For every females, there were For every females age 18 and over, there were About Published authors from Lima have produced poetry collections, scholarly works, novels and memoirs. Famed stand-up comic Lenny Bruce did a comedy routine entitled "Lima, Ohio", in which he talked about the several weeks he once spent during the s booked at a club in Lima. The routine appeared on his record album American.

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Lead actor Pierce Brosnan made a mistake during filming and pronounced Lima incorrectly. Christian, the male lead of Moulin Rouge! Locally, Lima has had the same mayor, David J. Berger D , since December Berger has been reelected 7 times. Lima is served by one daily newspaper, The Lima News. As of the — television season, Lima is ranked by Nielsen Media Research as the second smallest television market in Ohio, ahead of only Zanesville , and the th nationwide.

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Lima has been a regional medical center since its earliest days. Currently, the city's two hospitals serve a county area of northwest and west central Ohio. Rita's Medical Center , a level 2 trauma center, with nearly 4, employees as of June , is Allen County's largest employer while Lima Memorial Health System ranks third. In , St. Rita's in December , in the midst of a national and global influenza epidemic. Since then, the hospital has grown dramatically, with major expansions launched in and The hospital has also created satellite facilities in the surrounding towns of Ottawa , Delphos and Wapakoneta.

SRMC also houses a separate hospital with the walls of the main facility.