Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary (2004)

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1 Bridging the Chasm Between Health and the Environment: Science and Policy Context* A CONGRESSIONAL PERSPECTIVE The Honorable Hillary Rodham Clinton The Gulf War syndrome was one of my first encounters with the in- tersection between environmental exposures and health. Many Gulf War veterans were increasingly concerned about the state of their health and that of their families, and I received many letters expressing these con- cerns. There were numerous explanations for their symptoms ranging from immunization—vaccinations that were given en masse to our men and women in uniform—to the oil burning fires, the abundant use of in- secticides, and so forth. At the end of the inquiry, I believe scientists concluded that the symptoms were caused by a combination of genetic susceptibilities to an environmental exposure among a subset of our mili- tary population. In parallel to the Gulf War experience, there have been a number of acute health observations in recent years that became the driving force behind the proposed environmental health tracking act, including the un- usually high numbers of childhood leukemia in Fallon, Nevada (Nevada State Health Division, 2002), the higher-than-national average of breast cancer in Long Island (Kulldorff et al., 1997), and the World Trade Cen- ter cough among rescue workers of September 11. In addition, we are seeing increases in a number of other diseases. Childhood asthma rates have increased 20 percent in the past 10 years, while endocrine and metabolic disorders such as diabetes and neurological disorders such as Parkinson’s also are on the rise. The disease clusters and increases in * This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics. 15 

16 ENVIRONMENTAL HEALTH INDICATORS their rates have led many people to look at the role of the environment in determining health status. What we know now is that too often there is little information on ex- posure with which to understand causal effects between the complexity of our environment and the What we know now is that too often reported increase of various dis- there is little information on exposure eases. In Fallon, Nevada, the with which to understand causal effects drinking water contains 100 parts between the complexity of our envi- per billion of arsenic—10 times ronment and the reported increase of the recommended level proposed various diseases. -Hon. Hillary Clinton by the previous administration. Further, because of agricultural activity, pesticides are on the ground as well as aerially applied. At the Congressional hearing, it be- came evident that in order to understand these linkages, we will require more information about environmental factors, their effects on the popu- lation, and resulting health outcomes. Similarly in Long Island, research- ers do not have the answer as to why breast cancer is higher than the national average. One can look at what is unique to the environment. Long Island was an agricultural center and still produces more agricul- tural dollars than any place in New York. It also was the center of war- time industry, resulting in heavy metal and chemical usage. Further, an aquifer that runs the length of the island has been contaminated for dec- ades by pesticide runoff and, more recently, by fuel additives, such as methyl tertiary-butyl ether (MTBE). These are a few of the questions that members of the public have in their minds about the possible causal ef- fects of breast cancer in this region. What we must do is establish a nationwide network to track chronic diseases, environmental exposures, and other risk factors. This will allow researchers and health officials to identify the causes of chronic diseases and, ultimately, develop strategies to prevent these diseases in the future. Through investigation of incidences in Fallon and Long Island, we dis- covered that most states are well equipped to track infectious diseases but are not able to track chronic diseases. We will have to provide states with environmental health tracking grants so that they are able to develop the infrastructure they need to participate in the nationwide network. As part of the Nationwide Health Tracking Network Act (U.S. Senate, 2002), we will have to create a national environmental health rapid- response service to develop and implement strategies for coordinated rapid responses to public health and environmental concerns. There will 

SCIENCE AND POLICY CONTEXT 17 be a need to expand our environmental health center structures through the establishment and operation of at least five regional biomonitoring laboratories, five environmental health centers of excellence, and the John H. Chafee environmental health scholarship program. Finally, the Act calls for a national environmental health report that will provide the public with the findings of the tracking network and the information it needs to ensure environmental health within its communities. Discussions of the nationwide tracking network are timely. Senators who serve on the Environmental Committee know that we face a broad range of pressing environmental problems, and there is no substitute for vigorous debate on how to address them. For this reason, we need the scientific research community to lead the charge in establishing the tracking system to ensure that the We need the scientific research data are nonpartisan and accurate. community to lead the charge in This will be necessary to help inform establishing the tracking system to the public’s decision-making process. ensure that the data are nonparti- At some level, people will have to san and accurate. recognize that we are all responsible -Hon. Hillary Clinton for our health. Each of us can help make ourselves healthier by staying away from bad habits and behavior and by making our environment as user-friendly as possible. However, we have to recognize that there are many issues related to health and the environment over which no indi- vidual has any control. If there is any area that needs society as a whole to act, it is the intersection of health and the environment. A VIEW FROM THE ENVIRONMENTAL PROTECTION AGENCY Paul Gilman At the Environmental Protection Agency (EPA) we work at the bot- tom of the chasm between health and environment. It is part of the mis- sion of the EPA to create links between environmental stressors and ecosystem or human health outcomes when a sturdy and formal bridge across the chasm has yet to be built. This is not to say that we haven’t made a number of strides in building these linkages. In fact, research re- lated to particulate matter and asthma is one of many examples of how we are trying to establish these links and use that information to direct 

18 ENVIRONMENTAL HEALTH INDICATORS future research. The Office of Environmental Information and the Office of Research and Development are leading an agency-wide “environ- mental indicators initiative” that will help the EPA understand where we are and where we must proceed in order to make sound, strategic decisions. Constructing these links requires solid building materials, rigorous tools, and a commitment to the task. At the EPA, our building materials are our vast physical and human infrastructure, our prior experiences in monitoring, and our partnerships with traditionally autonomous envi- ronmental and health organizations, including the Centers for Disease Control and Prevention (CDC) and the National Institute for Environ- mental Health Science (NIEHS). Our toolbox is filled with a variety of quantitative methodologies. By using these tools in conjunction with our building materials, I believe that we can make great progress in forging the links between environmental stressors and health outcomes. We have learned a great deal from previous attempts to monitor the health of ecosystems, and these lessons are useful not only to the EPA, but also to other groups that monitor ecosystem or human health. How- ever, like the proverbial man who misplaces his keys in his house but searches for them under a brightly lit lamppost because the area is easy to see, we at the EPA may become overwhelmed by the large amounts of information available to us and overlook connections and causal relation- ships between environment and health outcomes because they are not easily accessible. In the early 1990s, the National Research Council (NRC, 1995) high- lighted the disjunction between EPA’s data on environmental indicators and ecosystem health outcomes. To address this issue, the EPA, in con- junction with the NRC, developed the Environmental Monitoring and Assessment Program (EMAP). The goal of EMAP is to “develop the tools necessary to monitor and assess the status and trends of national ecological resources” (USEPA, 2002). As we developed EMAP, I be- lieve we overcame some hurdles in identifying appropriate indicators for truly understanding the health of coastal ecosystems. Strategic programs such as EMAP provide a template for integrating monitoring data from many spatial and temporal scales and are critical for connecting envi- ronmental characteristics with human health outcomes. Programs such as EMAP can help bridge the environment–health chasm only if they use appropriate tools and rigorous, quantitative, and accessible methodologies. Advances in technologies and tools, such as the use of biomarkers, risk assessment, and exposure assessment and 

SCIENCE AND POLICY CONTEXT 19 modeling, have increased our understanding of how environmental expo- sures, including exposures of susceptible populations, translate into health effects. Biomarkers measure a biological response to an environ- mental chemical. Biomarkers of exposure, effect, and susceptibility are important measures of toxicity that help quantify early responses to ex- posures and identify the most susceptible populations at risk. Risk assessment, including cumulative risk assessment, is a rela- tively accurate tool to characterize the chasm, effectively narrowing the divide between environmental characteristics and health outcomes. How- ever, I do not believe that risk assessment is as accessible to decision makers as it should be. Exposure research is another important tool for developing and un- derstanding the links between our environment and our health. A chal- lenge that we face in exposure research is to probe well beyond physical exposure routes to understand the pathways within our bodies as well. EPA scientists have begun to address the notion of compound mixtures instead of “simple” single compounds. Aggregating exposure data helps define the various pathways where a particular compound is acting within the complex tapestry of environment and health interactions. Understanding the intricate interplay between exposure measure- ments and health outcomes frequently requires a large degree of model- ing. It is often unrealistic to quantify exposure at maximum levels. Although quantifying exposure at low doses leads to reasonable extrapo- lation, the interplay between modeling and the actual measurement is ultimately what enables the extrapolation of data that are informative to policy makers. Because time constraints compel us to span the environ- mental health chasm before the bridge is built, the use of models to make accurate extrapolations is a primary tool of the EPA. Integrating tools, as well as data, from traditionally autonomous en- vironmental and health organizations through partnership building is an important part of our construction strategy. For example, the EPA re- cently partnered with the CDC in a National Health and Nutrition Ex- amination Survey (NHANES) study of blood lead levels. Although the CDC primarily collects human health data, scientists have become in- creasingly interested in environmental stressors. While the CDC contin- ues to monitor blood chemical levels, the EPA will work with it to address research questions regarding route of exposure. I believe this collaborative research project is a very productive interaction for foster- ing environment and health bridge building and for co-launching the Na- 

20 ENVIRONMENTAL HEALTH INDICATORS tional Children’s Environmental Health Study, in which both health out- comes and environmental stressors will be tracked. As we begin to establish a national monitoring system, we have to keep in mind a number of issues. The protocol for linking environmental and health research programs and policy initiatives must be multifaceted. We must continue to fill our toolbox with additional research method- ologies that help us to understand better the complex interaction between environmental stressors, ecosystem health, and human health outcomes. Exposure and epidemiologic studies must be conducted to tease out the details of causality. Laboratory-based studies have to be conducted con- currently to illustrate the distinctions between very low dose events and extrapolated health outcomes. Modeling studies link exposure models to pharmacokinetic models and provide informative extrapolations for deci- sion makers. By drawing on previous experience and forming integrated partner- ships, we can proceed more efficiently in constructing this bridge. Throughout these processes, scientists and policy makers must remain cognizant of the many physiological pathways by which susceptible and nonsusceptible populations may be affected by the complex mix of chemicals in our environment. A VIEW FROM THE DEPARTMENT OF HEALTH AND HUMAN SERVICES Eve Slater During the last century, advances in the field of public health, par- ticularly in the treatment of infectious diseases, contributed greatly to improving the health of the people of the United States and other coun- tries. The effect of diseases such as smallpox and malaria has greatly di- minished as a result of combined scientific and public health efforts. These advances provide encouragement for the challenges that we face in improving public health, including those threats that are environmentally linked. Through the passage of the Clean Air Act, the Safe Drinking Water Act, and other legislation, we have begun to make good progress in sev- eral areas of environmental health in this country. Further, behavioral changes are beginning to have an influence on our environmental expo- sures. For example, the CDC reported a 75 percent reduction in exposure 

SCIENCE AND POLICY CONTEXT 21 to environmental tobacco smoke from 1980 to 1999, which is a true envi- ronmental health accomplishment (CDC, 2001). While this is promising, many environmentally related diseases, including cancer and asthma, still pose great challenges. Cancer and asthma illustrate the complexity of gene and environment interactions, where it is clear that not everyone exposed to an environ- mental toxicant will contract a disease. For example, environmental to- bacco smoke has been clearly linked with cancer, yet only about 20 percent of smokers develop cancer, suggesting that some individuals have a predisposition to developing cancer. Scientists are beginning to understand the genetic predisposition to environmental diseases by studying the altered expression of genes Scientists are beginning to understand and enzymatic activity as a result the genetic predisposition to environ- of environmental exposure. One mental diseases by studying the altered such study examined the link expression of genes and enzymatic activ- between the NAT2 gene for ity as a result of environmental exposure. acetyltransferase (an enzyme that -Eve Slater metabolizes nicotine) and blad- der cancer in nonsmokers and smokers. Results of the study revealed a twofold increase in the risk of developing bladder cancer in subjects who were slow acetylators—that is slow in breaking down nicotine. Studies of this type can potentially pro- vide an effective tool for proactively addressing environmentally related health outcomes. Similarly, a wealth of evidence suggests that asthma attacks are trig- gered by local environmental factors ranging from indoor irritants, such as mold and tobacco smoke, to outdoor air pollutants, such as ozone. Preventing and treating these complicated interactions requires a multi- factorial and community-based approach to asthma management. For example, at health centers in Detroit, Michigan, families are linked to local and state public health officials through a complex yet realistic “people chain.” The families are connected through their neighborhoods to school nurses trained in asthma detection. The nurses, in turn, are con- nected to state and local public health officials who help them understand asthma symptoms, treatment, and proper care. Another Detroit group has employed community residents to measure air particulate matter in two locales, thus allowing community members themselves to conduct the study to determine the source of environmental exposures. Presumably, their findings will be translated into a health benefit. Finally, in a study performed in conjunction with the Los Angeles School District, re- 

22 ENVIRONMENTAL HEALTH INDICATORS searchers found a 15 percent decrease in emergency room visits and a 30 percent decrease in hospitalizations for middle-school children with asthma one year after establishing a multidisciplinary team of health care professionals, service workers, and school nurses, who worked closely with parents and children to develop asthma management plans. These examples illustrate the benefit of developing community-based ap- proaches for tackling the prevention of environmentally triggered dis- eases. One problem in linking environmental and health information has been the lack of sophisticated measurement tools in the environmental sciences. However, I believe that Environmental science is coming of environmental science is coming age. Scientists now have the capacity of age. Scientists now have the to translate information about the hu- capacity to translate information man genome into environmental ob- about the human genome into servations and subsequently into environmental observations and scientific fact. subsequently into scientific fact. -Eve Slater The science of proteomics will greatly help us decipher the interaction between our genes and our environment as a result of very elegant informatic and biochemical tools that allow us to translate the effect of environmental factors on protein translation. These new tech- niques will permit a great leap forward in environmental health. An enormous amount of environmental data has been collected, and we must continue to develop tools to use this information appropriately. Many challenges still lie ahead as we work to bridge the chasm be- tween environment and health. We must track environmental hazards and diseases in ways that provide accurate information and both inform and empower health policy makers, state and local workers, community par- ticipants, and patients. We must strive to develop community-based deci- sions and eliminate health disparities. We need sound science and working partnerships to meet specific goals—such as quickly controlling the asthma epidemic and eliminating lead poisoning by 2010—and to influence chronic diseases in a more general way. In conclusion, the strong link between environmental factors and health effects indicates that public health leaders must be included whenever environmental is- sues are discussed.