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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Summary* Lynn Goldman The Institute of Medicine’s Roundtable on Environmental Health Sciences, Research, and Medicine was formed in 1998 to provide a neutral setting for individuals with different backgrounds and perspectives to discuss sensitive issues of mutual interest. By bringing together participants from the academic community, federal government, industry, and other sectors who are actively engaged in activities related to environmental health, the Roundtable helps to identify problems—current or potential—and considers approaches to solving them. The aim is to share knowledge and ideas, but not proffer formal advice or recommendations. This workshop brought together a diverse group of participants from a variety of fields to discuss the current state of environmental health monitoring in the United States, to look into monitoring systems of other nations, to consider the need for a national environmental health monitoring system, to foster a dialogue on the steps for establishing a nationwide monitoring system, and to explore how a national system will fit into current exposure and disease monitoring programs. The workshop was not intended as a forum for detailing which indicators should be included in a national monitoring system, because many organizations are already engaged in this work. Rather, the aim was to consider the overall tasks of identifying, developing, and using indicators to monitor environmental health. Representatives from federal and state government, local government, academic institutions, industry, private organizations, and global health organizations spoke about current environmental health monitoring efforts and plans for the future. Conference participants discussed the * This was an edited version of the summation by Dr. Lynn Goldman at the workshop.
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary use of indicators to monitor the status and trends of health, to develop the interventions to protect and promote health, and to build a core capacity to respond to environmental health problems. They explored frameworks for developing indicators and methods for ranking environmental health risks. They also discussed the criteria for establishing the national environmental health monitoring system, the potential benefits and limitations of the system, privacy issues raised by the system, the scientific underpinnings of the system, and the funding required. They discussed how to elicit the participation of health professions, industry, community groups, and the general public. Further, they considered how workers will collect and analyze information and the specialized education and training that they will need. Tord Kjellstrom of the Australian National University stated that a main aim of an environmental health indicator is to provide an easily interpretable measure of the state of the environment or the health of a defined population (e.g., an urban air quality variable, or the life expectancy of a population). He suggested that creating indicators that can be interpreted in terms of linkages between environmental quality and public health may be difficult. Thomas Burke of Johns Hopkins University noted that environmental health indicators fall into four categories: hazard indicators (for example, motor vehicle emissions), exposure indicators (blood lead levels), health outcome indicators (lead poisoning), and intervention indicators (programs that address motor vehicle emissions). Burke remarked that indicators must be measurable (comparable and quantifiable), understandable to policy makers and the public, and defensible (that is, they must support a relationship between environmental factors and health status). They also must allow trends to be examined over time. Further, they must be linked to public health goals. Several overarching themes emerged during the workshop. First, the concept of establishing a national system to monitor environmental health, and eventually all of public health, received consistent support. This support came from federal, state, and local government agencies; from leadership within the administration; from private organizations; and from the public. Senator Hillary Rodham Clinton cited a growing concern among the public about the effects of environmental exposures on health and noted strong congressional support for a national monitoring system. These views were echoed by Eve Slater of the Department of Health and Human Services and Paul Gilman of the Environmental Protection Agency, who represented the current administration. Carol Henry of the American Chemistry Council suggested that opportunities exist for
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary various private and public organizations to partner with one another to help promote understanding of the value of a national health monitoring system. William Pease of GetActive Software noted the potential for web-based services to provide access to health indicators. Morris “Bud” Ward of Morris A.Ward, Inc., mentioned the media’s role in informing the public about environmental health issues. Second, many participants agreed with Baruch Fischhoff of Carnegie Mellon University, that creating the infrastructure for such a system is a critical need. He stressed the importance of a design that incorporated social science principles of risk communication and evaluation. Samuel Wilson of the National Institute of Environmental Health Sciences noted that substantial research from the biomedical science community is available to inform the process and that newly developed analytic and informatics tools now permit a large body of complex information to be managed and analyzed. Third, several participants acknowledged current efforts to monitor environmental health as a platform for moving forward. Kimberly Nelson of the Environmental Protection Agency (EPA) stated that the EPA would soon publish a report that will accurately portray the state of the environment and environmental trends in the United States and the limitations of current data. Patrick Leahy of the U.S. Geological Survey (USGS) discussed the work of the USGS in addressing aspects of natural science that have links or potential links to public health issues. He emphasized that research conducted by the USGS is providing means of better understanding the processes and pathways between and among the abiotic and the biotic realms. Michael McGeehin of the Centers for Disease Control and Prevention (CDC) described a new initiative, the National Electronic Disease Surveillance System, that combines all current surveillance systems at the CDC into a uniform, efficient, standards-based system in an electronic format so that it is useful for public health, research, private industry, and other public health care industries. Kathleen Rest of the National Institute for Occupational Safety and Health (NIOSH) described collaborative surveillance efforts between NIOSH and state health departments to improve the recognition and prevention of occupational health problems. She noted the convergence of concern around a host of occupational and environmental exposures and health effects, and urged inclusion of the work environment in efforts related to environmental health tracking.
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Participants discussed the many challenges in developing and administering a national environmental health monitoring system. Several speakers noted that such a system must be structured so that officials working at the state and local levels can use it effectively. The effort is complicated by the fact that no strategic plan is in place to move the program forward within the federal government. Further, no process exists for stakeholders to guide the process over time. Several participants suggested that a commission or advisory committee could be an avenue for providing continual input to the program. Participants also considered the challenge of improving coordination among the agencies involved in environmental health monitoring. Shelley Hearne of the Trust for America’s Health noted that monitoring must be a fully integrated operation, not only within the CDC as the epicenter of activity, but also among the 50 or more agencies that have some involvement in environmental health activities. Harold Zenick of the EPA cited the need to link separate areas of research to produce an environmental health continuum from source to exposure to health outcome. Mark Horton of Public Health Services, Orange County, California, described the need for a coordinated approach to environmental problems by institutions and agencies acting at the local level. Richard Jackson of the CDC noted that the federal Children’s Environmental Health Initiative provides a successful model of interagency cooperation on cross-agency issues. Speakers representing the current administration suggested that leaders in the administration might be able to establish the required coordination. A further challenge discussed by participants was finding ways to bridge the gap between environmental health and chronic disease. In health agencies, chronic disease research and public health interventions are often isolated from environmental research and environmental health interventions. Yet successful monitoring of environmental health requires the participation of the chronic disease community. For example, tobacco smoke may be considered a social issue, an environmental issue, or a chronic disease issue; addressing this issue requires a coordinated effort from all three standpoints. Participants noted that the gap between the science community and the public health community also must be bridged. Wilson mentioned that complementing the environmental health monitoring program with a strong research program will better enable public health officials to set priorities. Jackson added that good research requires adequate and sustained funding. Leahy called for a strengthening of partnerships and col-
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary laborative efforts between the natural science community and the public health community. Finally, many participants said that the next generation of experts must be trained in epidemiology, environmental health, laboratory sciences, and related fields, because their expertise will be required to enable a national monitoring system to function properly. Funding is necessary to provide these experts with jobs in the areas that need them. Henry Falk of the Agency for Toxic Substances and Disease Registry noted that medical educators have to emphasize the role of the public health system and the links between medical care and public health. The nation has reached a pivotal time for establishing a national monitoring system. The Pew Commission report of 2000 was instrumental in planting the idea (Pew Environmental Health Commission, 2001). About a year was needed for the concept to become known and accepted by health agencies, the government, and the public. Currently, efforts to develop the national monitoring system have begun, and support for the concept is growing slowly in many quarters. A surge in acceptance could bring a new set of concerns. Once legislation has been passed and the initiative has been funded, the monitoring process will be largely out of the control of environmental health experts. Thus, the time to act is now. What can be done today to ensure that the growth of the national environmental health monitoring system is systematically achieved and well coordinated? One means is to achieve a central focus for the program, through either a federal task force or a single leader. A second means is to create a guiding body to help steer the effort so that progress is structured both from the “top down” (e.g., the federal level) and from the “bottom up” (e.g., the state, local, and community levels). A third means is to begin to fill the brain trust that must be in place to achieve a well-functioning monitoring system. Attaining any one of these goals may appear to be a daunting task, yet achieving all of them simultaneously is vital to creating an effective monitoring system that will safeguard the environment and human health.
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Representative terms from entire chapter: