3
Environmental Health Monitoring at the Federal Level*

In recent years, the field of environmental health has been evolving from a narrowly defined focus to a more holistic approach due to a greater understanding of the complexity of the environment, the development of newer tools to answer more sophisticated research questions, and the changing needs of environmental health. After the Institute of Medicine (IOM) report The Future of Public Health (1988) was published, noting that the infrastructure in the area of environmental health was deficient and often fragmented, many federal agencies became actively involved in mending the situation. Today, more than 50 federal agencies conduct environmental health monitoring. The five federal agencies that constitute the “traditional partners” in environmental health efforts—the Environmental Protection Agency (EPA), the National Institute for Occupational Safety and Health (NIOSH), the Agency for Toxic Substances and Disease Registry (ATSDR) and the National Center for Environmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC), and the National Institute of Environmental Health Sciences (NIEHS)—are the most recognized.

The public relies on these agencies to safeguard them from the dangers of environmental hazards. Individuals and communities look to the CDC for protection against environmental diseases, to the EPA for protection from environmental hazards, to NIOSH for elimination of workplace hazards, to ATSDR for its work on toxic exposures, and to NIEHS for research findings. At the workshop, speakers from these five federal

*  

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.



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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary 3 Environmental Health Monitoring at the Federal Level* In recent years, the field of environmental health has been evolving from a narrowly defined focus to a more holistic approach due to a greater understanding of the complexity of the environment, the development of newer tools to answer more sophisticated research questions, and the changing needs of environmental health. After the Institute of Medicine (IOM) report The Future of Public Health (1988) was published, noting that the infrastructure in the area of environmental health was deficient and often fragmented, many federal agencies became actively involved in mending the situation. Today, more than 50 federal agencies conduct environmental health monitoring. The five federal agencies that constitute the “traditional partners” in environmental health efforts—the Environmental Protection Agency (EPA), the National Institute for Occupational Safety and Health (NIOSH), the Agency for Toxic Substances and Disease Registry (ATSDR) and the National Center for Environmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC), and the National Institute of Environmental Health Sciences (NIEHS)—are the most recognized. The public relies on these agencies to safeguard them from the dangers of environmental hazards. Individuals and communities look to the CDC for protection against environmental diseases, to the EPA for protection from environmental hazards, to NIOSH for elimination of workplace hazards, to ATSDR for its work on toxic exposures, and to NIEHS for research findings. At the workshop, speakers from these five federal *   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.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary agencies outlined the contributions of their organizations to current environmental health monitoring efforts, and described the partnerships they have formed for collaborating on environmental health issues. GENERAL OVERVIEW OF EFFORTS OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION The CDC has a long history of using surveillance to determine the cause and magnitude of public health problems. The CDC conducts epidemiological studies that reveal risk factors and exposures and show linkages between them. These studies are the basis for designing interventions and evaluating their effectiveness. Effectively performing these tasks depends on having sound data, according to Michael McGeehin of the CDC. The CDC has 52 nationally notifiable infectious diseases—those for which regular, frequent, and timely information is considered necessary to control the disease. Uniform criteria are used for reporting each notifiable disease, and reports emanate from state and local health departments, health care providers, and laboratories. Uniform criteria are needed for reporting not just infectious diseases, but all diseases. Establishing a strong national health monitoring network, as a single source for uniformly collected data would make the data more reliable. In turn, the epidemiological findings would be more useful, and interventions would be more effective, stated McGeehin. Uniform criteria are needed for reporting not just infectious diseases, but all diseases. -Michael McGeehin The CDC oversees 15 surveillance systems, which are operated by eight agencies. Perhaps the largest problem with these systems is that they are fragmented, the information technology is outdated, and the data are often incomplete or untimely. They also place an unacceptable burden on respondents in the health care sector. Some of these problems are being addressed by the National Electronic Disease Surveillance System (NEDSS), which is a standards-based approach for developing efficient, integrated, and interoperative surveillance systems at the state and local levels. The system includes tools for transferring data electronically from health care systems to health departments, and it follows strict security standards to protect confidentiality. The CDC recently received $17.2 million from Congress to put into place the first step of the health monitoring effort for the nation. Recog-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary nizing that the involvement of health departments and environmental departments at the state level is essential for creating a national system, the CDC set up four environmental health tracking workgroups to obtain input from those interested in working together with the agency. The CDC also set up meetings to bring environmental and health groups together, not only at the federal level, but also at the state and local levels. The CDC has already begun pilot programs in several states to bring collaboration between state and local health and environmental agencies, to evaluate existing databases, to examine linkages among databases, and to help develop a health outcome surveillance system. The CDC also plans to establish university-based centers for excellence in health monitoring to provide research and technical assistance to the states. When the CDC has had good surveillance, it has succeeded in safeguarding the health of Americans, stated McGeehin. For example, the greatest environmental health success in the United States in the past 30 years has been the lowering of blood lead levels in children. The environmental intervention that brought these results—removing lead from gasoline and other sources—was a collaborative effort of the EPA and various health agencies that was based on good surveillance data. Further analysis and interpretation of blood lead level data showed health disparities in the population. For example, an African-American child living in older housing in the United States was found to be 22 times more likely to have an elevated blood lead level than was a white child living in newer housing (see Figure 3.1). Efforts have shifted toward vulnerable populations in recognition that eliminating childhood lead poisoning in the United States will require targeting the children who are most likely to be affected. The rapid response to the outbreak of toxic shock syndrome in the early 1980s is another example of the public health benefit of sound surveillance data. In this case, a disease emerged that had never been encountered before, and surveillance was put into place quickly. The greatest environmental health success in the United States in the past 30 years has been lowering of blood lead levels in children. -Michael McGeehin

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 3.1 CDC surveillance shows that blood lead level data indicate health disparities in the population. African-American and Hispanic children who live in older housing in the United States are found to be 21.9 and 13 times, respectively, more likely to have elevated blood lead level than white children living in newer housing. SOURCE: DHHS, 1998. Reprinted with permission. Good surveillance identified the affected population and showed that a specific type of tampon was the main source of the disease. Swift action was taken to withdraw the material from the market and to educate the public. Surveillance is considered essential to the work of the CDC and critical to all of public health. The CDC has taken on the task of improving its use and uniformity to make it yield more useful data and to reduce the burden on state and local health departments, health care providers, and laboratories. Environmental health monitoring is considered an important addition. Environmental health monitoring can be done, but it must be done collaboratively, it must be done innovatively, and it must be done right, noted McGeehin.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary CURRENT EFFORTS OF THE AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY (ATSDR) In 1980, Congress created ATSDR to implement health-related sections of laws that protect the public from hazardous wastes and environmental spills of hazardous substances. The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA), commonly known as the Superfund act, contains the congressional mandate to remove or clean up abandoned and inactive hazardous waste sites and to provide federal assistance in toxic emergencies. As the lead agency within the Public Health Service for implementing the health-related provisions of CERCLA, ATSDR is charged under the Superfund act to assess the presence and nature of health hazards at specific Superfund sites, to help prevent or reduce further exposures and the illnesses that result from such exposures, and to expand the knowledge base about health effects of exposure to hazardous substances (http://www.atsdr.cdc.gov/congress.html). The agency is a part of the Department of Health and Human Services (DHHS), but its funding comes through the Superfund stream associated with the EPA. Henry Falk of the ATSDR outlined the mission of the agency, which is to serve the public by using the best science, by taking responsive public health actions, and by providing trusted health information to prevent harmful exposures and diseases related to toxic substances. The ATSDR’s personnel work at about 500 Superfund sites throughout the United States each year. The question that the public most frequently asks ATSDR workers is, How does the environment affect the health of our community? To answer this question accurately, we need linked data from three sources—environmental hazards, environmental exposures, and health outcomes. We also need standardized ways of evaluating community concerns. ATSDR has set up exposure registries for people exposed to various chemicals at Superfund sites, including benzene, dioxin, trichloroethane, and trichloroethylene. Other registries have been proposed, including one for tremolite asbestos exposure in Libby, Montana; one for multiple exposures around the World Trade Center site in New York City; and a multisite registry for exposure to natural uranium in areas with high levels. The public is concerned about disease clusters, and communities are looking to ATSDR for answers. They are asking not only about clusters of diseases for which registries exist—cancer and birth defects—but also

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary about clusters of diseases such as autism, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS), for which no data exist for comparison (see Figure 3.2). The agency has started disease-monitoring pilot studies for some of these diseases, such as multiple sclerosis. The NHIS showed arise ofabout 50 percent in the incidence of multiple sclerosis fromtheearly1980s to the mid-1990s, and cases in women accounted for most of the increase (see Figure 3.3). ATSDR has set up exposure registries for people exposed to various chemicals, including benzene, dioxm, trichloroethane, and trichloroethylene. ATSDR responds to concerns about disease clusters and other health issues by conducting site-specific investigations of diseases, performing epidemiological studies, establishing exposure registries, and launching pilot studies to track diseases. Falk cited a study that illustrates the high degree of precision needed in site-specific investigations. ATSDR investigated a cluster of childhood cancer cases that occurred in Toms River, FIGURE 3.2 ATSDR informs the public not only about well-known disease clusters such as cancer and birth defects, but also about clusters of diseases such as autism, MS, and ALS. SOURCE: ATSDR, 2002. Reprinted with permission.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 3.3 ATSDR is monitoring such diseases as multiple sclerosis. Their data show that from the early 1980s to the mid-1990s the incidence of MS rose by 50 percent. SOURCE: Noonan et al., 2002 (unpublished). Reprinted with permission. New Jersey, from 1979 to 1995. Of the seven townships in Ocean County, only one—Dover—had an unexpectedly high childhood cancer rate. Dover Township has many Superfund sites and many well fields. ATSDR investigators calculated the contribution of water from different wells and were able to link water from contaminated wells to affected children, said Falk. The analysis showed an association that reached statistical significance when water consumption factors were considered. The association would not have been found if investigators had examined the rate for the entire county, rather than for each township, and if they had considered only how far people lived from the wells and had not also factored in water consumption. The example illustrates that sound environmental data and good health data are needed for linkages to be explored in proper detail.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary As the incidence of diseases such as multiple sclerosis and asthma continues to rise, we can expect the public to press ATSDR harder for answers about the relationships of these diseases to environmental factors, stated Falk. To answer these questions, we need better surveillance and better monitoring, and we need more background data on exposure for comparison. We also have to examine combinations of risk factors, such as genetic susceptibilities, environmental factors from the distant and recent past, life-style, and other risk factors. CURRENT EFFORTS OF THE NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH The NIOSH has much to contribute to the national health monitoring effort because of its long history in occupational health surveillance and the wealth of data and experience it can offer, said Kathleen Rest of NIOSH. For the past 25 years, NIOSH has played a key role in the surveillance of work-related illnesses, injuries, fatalities, exposures, and hazards. It also supports an active program of state-based surveillance, which can provide a model for collaborative efforts needed in environmental health monitoring. According to Rest, the occupational health community received a wake-up call in 1984, when Congress issued a report on occupational illness data collection (Committee on Government Operations, 1984). At that time, occupational health surveillance was described as 70 years behind communicable disease surveillance. The report called for a national data collection system to advance understanding of the link between workplace exposures and hazards and their related health effects. The report noted many challenges, such as long latency periods, multiple exposures, illnesses with multifactorial etiologies, transience of the workforce, differential susceptibilities, lack of awareness among workers and employers, and lack of occupational health training among physicians and public health professionals. Environmental health tracking shares some of these challenges. The report also highlighted the fragmentation of existing surveillance systems and the resulting inadequacies. In 1987, the National Research Council expanded on this with its own report (Pollack and Keimig, 1987), again documenting inadequacies and offering a set of recommendations. These included the following:

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary improving classification of occupational illness in the Bureau of Labor Statistics survey; maximizing use of existing data systems, such as mortality records, national health surveys such as National Health Interview Survey (NHIS) and National Health and Nutrition Examination Survey (NHANES), cancer registries, and hospital discharge data; improving physician education and awareness; improving worker notification; integrating and expanding the role of state health departments; and improving hazard surveillance. There has been progress in the intervening years. NIOSH has collaborated with the National Center for Health Statistics and vital statistics departments to develop the National Occupational Mortality System (NOMS), which enables the use of national mortality statistics for periodic surveillance of cause-specific mortality in industries and occupations. It has collaborated with the Consumer Products Safety Commission (CPSC) to collect work-related injury data in the National Electronic Injury Surveillance System (NEISS). In the 1990s, NIOSH began period publication of its Work-Related Lung Disease Surveillance Report. To complement population-based occupational health surveillance, NIOSH developed and now supports state-based surveillance programs. The Sentinel Event Notification System for Occupational Risks (SENSOR) is a collaborative effort between NIOSH and states to improve recognition and prevention of selected occupational health conditions, some of which overlap environmentally related illness, such as asthma and pesticide poisoning. The Adult Blood Lead Epidemiology Surveillance (ABLES) Program is a state-based effort to identify and track cases of elevated blood lead levels in adults. The Fatality Assessment and Control Evaluation (FACE) Program has expanded from an internal program of fatality investigations to include cooperative agreements with states that investigate occupational injury fatalities to better understand their causes, formulate recommendations to prevent similar injuries, and disseminate the information to target audiences. In the past three years, NIOSH has worked with many stakeholders and partners from state organizations, other federal agencies, the private sector, and the academic community to develop a strategic surveillance plan. The goals are to advance the usefulness of surveillance information at the federal level, strengthen capacity at the state level, strengthen sur-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary veillance of high hazard industries and occupations, promote effective occupational surveillance in the private and nongovernmental sectors, and increase research to improve occupational surveillance. To illustrate the link between and potential synergies for occupational and environmental health surveillance, Rest offered three examples from NIOSH-supported state-based programs. The first is from the SENSOR program in the Department of Health Services, Occupational Health Branch in California. Over a six-day period in May 1999, a grower used metam-sodium to fumigate two fields in preparation for planning carrots. The process involved pumping metam-sodium from a tank, via a closed system, into an irrigation system where it was mixed with water and pumped through sprinklers into the air and onto the fields. When diluted with water during the soil fumigation process, metam-sodium breaks down and releases methyl isothiocyanate (MITC). MITC is highly toxic; exposure to MITC vapors can cause severe irritation of the eyes and respiratory tract, headache, dizziness, nausea, and diarrhea. Inhalation can result in long-lasting effects, such as reactive airways dysfunction syndrome (RADS). Workers at an automotive repair shop about a mile away from the treated fields were the first to complain; they called the Fire Department and the Sheriff about odors. Two days later, the fire department received reports of sick children at an elementary school located near the treated fields, and the school was evacuated. There were reports that other community members may have experienced symptoms. Pesticide poisoning was identified in three of the garage workers. The buffer zone around the metam-sodium-treated fields was deemed inadequate to protect the garage workers, as well as the school children and teachers. In this case, the garage workers were sentinels for the school children and the broader community. The second example is a case supported by the ABLES program in California. In the course of being treated for a work-related injury, a day laborer expressed concern about lead exposure. He was tested and found to have a very high blood lead level—74 μg/dL. He was working with a crew to dismantle an indoor firing range. The ABLES program reported the lab results to the California SENSOR program, which triggered a medical and industrial hygiene follow-up. These investigations found the firing range to be highly contaminated with lead, with few precautions taken to protect the workers. In collaboration with the local childhood lead program, the SENSOR program found four other workers with lead poisoning, nine children with elevated blood lead levels, and one spouse

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary with high blood levels associated with washing work clothes. This case illustrates that: toxins can be carried home; tracking both worker and community exposure can increase chance of finding more persons at risk of serious illness; state and local health departments can work together on such efforts; and collaboration between occupational and environmental health surveillance staff can create synergies and enhance the value of both surveillance systems. The third example is from the Massachusetts Department of Public Health SENSOR program. Through its surveillance of work-related asthma, the program found that cleaning agents were the second most common asthma-causing agent identified by affected workers completing interviews. The Health Department subsequently partnered with several state agencies to address exposure to cleaning agents that may contribute to asthma in workers and in the public alike. This led to the inclusion of non-asthma-causing cleaning agents on the state’s vendor list of environmentally preferable products. State agencies and municipalities are now encouraged to patronize these vendors and use these products. In this case, occupational surveillance helped identify a cause-effect relationship between asthma and a workplace product, which resulted in an intervention that will benefit both workers and the public. According to Rest, all three examples illustrate the integral connection between the work environment and environmental health. Indeed, the use of toxic substances in the workplace and their release into the air, water, and soil can be the source of environmental pollution, community contamination, and their appearance in human tissue. Moreover, there are a host of overlapping concerns in occupational and environmental health, related to both exposures and health effects. Yet despite the many direct and indirect links between occupational and environmental health, the work environment is generally overlooked in conversations and initiatives related to environmental health and environmental health tracking. Given the integral relationship between occupational and environmental health, it is ill-advised to discuss bridging the gap between environmental hazards, exposures, and health effects without considering and tracking exposures and health effects in the work environment. The time is right to enhance both federal and state capacity in environmental and

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary occupational health tracking and to exploit potential synergies for advancing public health. CURRENT EFFORTS OF THE ENVIRONMENTAL PROTECTION AGENCY The United States is still at an early stage in developing tools to understand environmental conditions and to make the linkages between health and the environment. According to Kimberly Nelson of the EPA, this is akin to the situation in the 1700s when Great Britain lost most of its naval fleet. One of its admirals simply miscalculated their location and took the flagship up onto the rocky coast of Great Britain. It was not that they didn’t understand the concept of latitude and longitude, but that they were using very crude, rudimentary tools and methods such as throwing a log off the side of the ship and counting how long it took the log to get from the bow to the stern. They would use this measurement to calculate the ship’s speed and to calculate their actual location. Nelson noted that we are in an analogous situation today as we try to understand environmental health data. To assess what environmental data are available and what they mean for characterizing the state of the environment in the country, in 2002 the EPA generated a State of the Environment Report (IDEM, 2003). The report had both short-term and long-term goals, stated Nelson. In the short term, the EPA’s intent was to gather and develop information that will enable the agency to make sound strategic decisions and to inform the public about the state of the environment. The EPA’s long-term goal was to use the report to bring together national, regional, state, and tribal efforts in the area of environmental indicators and to begin an in-depth dialogue about the relationships between environmental and health conditions. The report aimed to: describe current environmental conditions and trends using existing data and indicators; present what is known and unknown about environmental trends and conditions; identify data gaps and research needs; and discuss the challenges that government faces in filling these gaps.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary The content of the report is organized around five themes: ecological conditions, human health conditions, cleaner air, purer water, and better land protection. Many questions, issues, and available national indicators surrounding these themes have already been identified from surveys and EPA workshops to determine the public’s interest. The EPA obtained data and input from its state partners and from other health agencies. Before its release, the draft report was refined through external scientific peer review of the selection and description of indicators, the content and quality of supporting data, and the use of these data. The report is accompanied by supporting technical information that is consistent with input received from the EPA Science Advisory Board, the National Science Foundation, and the Heinz Center’s indicator effort. The report was circulated for public review and comment. Producing a comprehensive national State of the Environment Report required coordinated information exchange among federal, state, and local partners and provided an opportunity to strengthen partnerships, said Nelson. An important partnership was formed between the EPA’s National Environmental Exchange Network, which offers a grants program to states to support the collection of high-quality environmental information, and the Health Tracking Network grants program of the CDC/ATSDR. The EPA has encouraged state applicants to view the two programs as synergistic opportunities and has received many applications that have included partnerships with multiple states or multiple agencies within the state. Such partnerships result in end products that will support both agencies. RESEARCH ACTIVITIES OF THE NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES The NIEHS primarily researches linkages between exposure and disease, according to Samuel Wilson of the NIEHS. At the National Institutes of Health (NIH) and other health agencies, they address questions such as why environmental diseases occur, how researchers can prevent them, and how much exposure is too much. Environmental health scientists know that there are many data gaps in the biology of environmental disease, and there are probably more data gaps than there are well-understood pathways. However, he noted that the field of environmental health has recently come of age scientifically. The number of environmental health articles published in leading journals of biomedical science rivals

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary that of many other fields. In fact, some of the best success stories in environmental health sciences are the overall success stories in biomedical research. The underlying progress is occurring because scientists are developing a new set of tools for research on the biology of environmental disease that greatly increase our investigative capacity. For example, the application of genomics to the question of genetic susceptibility represents a powerful new tool for the field of environmental health, according to Wilson. Toxicogenomics and genetic toxicology, tools that emerged from genomic sciences, are advancing our understanding further. Toxicogenomics, which includes proteomics and messenger RNA profiling, links gene expression with exposures to environmental stressors. Genetic toxicology has produced a large amount of information that we can use for biomarkers and for understanding cellular response. The field of environmental health has recently come of age scientifically. -Samuel Wilson There has been a change in the toolbox, which makes our research capacity much more powerful. Animal models have been used in this field for decades; however with new genetic technologies, we can create animal models with specific types of experimental targets in mind and, thus, conduct more precise experiments. Instrumentations for analytical measurements have evolved and will continue to evolve in the coming decade. High-throughput assays in toxicogenomics and validation of assays and surrogates will allow precise measurement of exposures. The national tracking system will benefit research by helping researchers and agencies to establish priorities, stated Wilson. Understanding national trends, and trends over time, can be a very persuasive feature for allowing the NIH to set priorities. Further, tracking will create a new science—the science of understanding what the information means, how to correlate it with information from other countries, and how to correlate it with trends over time. The status of the toolbox is excellent, but we are going to need new science to answer the more complicated questions in environmental health sciences. Scientists are constantly looking for new approaches, outside the box, to understand problems. In many ways the problems are the same, but the technology and the approaches are changing and will undoubtedly get better over time, concluded Wilson.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary BUILDING PARTNERSHIPS FOR EFFECTIVE ENVIRONMENTAL HEALTH MONITORING Good dialogue with the public must be maintained while the national health monitoring system is created. Fortunately, the time has never been better for building relationships with the public and among agencies, noted Richard Jackson,1 of the Centers for Disease Control and Prevention. At the national level, the NCEH and ATSDR have recently completed a consolidation of the two agencies around environmental health. Another collaborative step has been the establishment of the National Electronic Disease Surveillance System to create a common architecture for all information systems that collect data. A third step is the E-Health Initiative, which will allow electronic access to the disease reporting of large information systems run by health insurance companies, pharmaceutical suppliers, and other reimbursement agencies. Three to four of the largest companies collect 85 percent of these data in the United States. Linking the CDC with that source makes more sense than having the CDC try to gather all of the information alone. The time is ripe for making this connection, and companies are open to working with the NCEH. The EPA has been a willing collaborator in many NCEH efforts, and communication has evolved over time. The NCEH is now in its third year of a collaborative program with more than 20 states, and its infrastructure allows workers to attend to a particular set of issues in environmental health. When the NCEH began its program, the state health officer typically did not know the state environmental director. Now, collaborative efforts within the states are common. A sound understanding of environmental public health issues at the state level is vital for developing intervention programs, because the results of research generated at the national level otherwise may not transfer well to the local level. A prime example of a potential disconnect between research findings and their application in the community is the Institute of Medicine (IOM) report Clearing the Air: Asthma and Indoor Air Exposures (2000a), which cited evidence from academic studies showing that asthma morbidity and incidence of attacks could be reduced through elaborate environmental methods, such as vacuuming the subjects’ houses three times a week and setting up various controls, that may not be workable in the “real world.” 1   State Health Officer of California.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary How can these kinds of measures be translated into action at the local level, particularly in impoverished and disenfranchised communities, to bring progress in reducing asthma? The answer at NCEH was to invite each state to devise its own model for putting asthma controls into place. The states, in turn, have developed partnerships with local universities and with advocacy programs and have tried to develop the best model for an asthma intervention program. Creating 25 or so prototypes and examining how each worked was time well spent. The NCEH was able to identify programs that worked in schools, in day care centers, in inner cities, and in a variety of other settings. Linked to these programs were surveillance programs that allowed the NCEH to monitor the number of asthma cases and identify sentinel events. The environmental public health community is beginning to recognize the value of working together. Agencies are beginning to understand that if common standards and common definitions can be agreed upon across agencies, information can be shared more easily. This cooperative effort will require compromise and a willingness to give up some systems that are unique to a particular organization, but the potential benefit is an improved quality of information and greater access to that information by agencies, health professionals, and the public, noted Nelson. In the past, we’ve learned that if research is ahead of the public health enterprise, things don’t work. Similarly, if the public health enterprise doesn’t communicate and work with local communities, then things don’t work, stated Nelson. Can a time be envisioned when the government issues a State of the Environment Report that involves not only the EPA but also the CDC, NIOSH, NIEHS, and other federal agencies engaged in environmental health work? Such collaboration would imply a new arrangement, a supra-departmental or supra-agency way of examining environmental health issues and deciding what the federal government’s priorities would be in this area, suggested Nelson. The EPA has begun the dialogue with other federal agencies and will be communicating with people from the states about its State of the Environment Report (USEPA, 2002). The agency hopes someday to have the report involve more than just the EPA and its state and tribal partners, noted Nelson. EPA representatives are meeting with the Council on Environ- Agencies are beginning to understand that if common standards and common definitions can be agreed upon across agencies information can be snared more easily. -Kimberly Nelson

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary mental Quality (CEQ) and other federal agencies to discuss how they wish to be involved in this year’s report. The EPA wants to work with its partners to do whatever can be done within the short timeframe available for producing the report. Such collaboration is only the first step. The ideal is to have merely a report that is issued not by one agency with help and support from others, but a single report that is produced by many partners working together. Conversations in that direction are under way with pertinent agencies. Although the 2002 EPA report was not produced in complete partnership with other agencies, bringing the agencies together to cooperate on aspects of the report would not have happened 10 years ago, stated McGeehin. Today, agencies do come together, and public health officials are present when environmental regulations are considered. The federal government’s strategic plan to eliminate lead poisoning in children is a good example of collaboration among federal agencies in addressing an environmental health problem that also is a housing problem and a disparity problem. The approach has involved the Department of Housing and Urban Development (HUD), EPA, DHHS, CDC, and several other agencies. Another example of a collaborative effort that would not have taken place 10 years ago is the study of the childhood leukemia cluster in Fallon, Nevada. Two of the primary agencies involved in that study are the state environmental agency and the state health agency. However, the EPA also is involved, as are the ATSDR and NCEH at the CDC. All of these agencies have become involved in bringing their expertise to bear on this environmental health issue, to everyone’s benefit.

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