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Needed Integration of Other Federal Agencies, State Agencies, and Nongovernmental Organizations to Build a Monitoring System*

A prevailing theme of the workshop has been that people who work in environmental health must come out of their individual “silos” and establish stronger linkages with each other. The workshop highlighted that at the federal level alone, more than 50 agencies are directly or indirectly involved in collecting data that are useful to environmental health scientists. By coupling this with the work of international organizations, state and local agencies, industry, and nongovernmental organizations, there are many potential partnerships and a need for increased cooperation at all levels to move forward as an integrated network. During part of the workshop, the Roundtable invited speakers from these other perspectives to hear what their organizations were doing and to explore how they might be involved in environmental health monitoring.

LESSONS FROM THE INTERNATIONAL COMMUNITY

The effort to develop information systems that give decision makers and the public interpretable indicators of the health benefits of environmental policies and practices is not confined to the United States, said Tord Kjellstrom, of the Australian National University. International sharing of experiences and collaborative research will lead to more cost-effective solutions and to harmonized sets of common indicators. As the concern about local environmental issues broadens to include global en-

*  

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 4 Needed Integration of Other Federal Agencies, State Agencies, and Nongovernmental Organizations to Build a Monitoring System* A prevailing theme of the workshop has been that people who work in environmental health must come out of their individual “silos” and establish stronger linkages with each other. The workshop highlighted that at the federal level alone, more than 50 agencies are directly or indirectly involved in collecting data that are useful to environmental health scientists. By coupling this with the work of international organizations, state and local agencies, industry, and nongovernmental organizations, there are many potential partnerships and a need for increased cooperation at all levels to move forward as an integrated network. During part of the workshop, the Roundtable invited speakers from these other perspectives to hear what their organizations were doing and to explore how they might be involved in environmental health monitoring. LESSONS FROM THE INTERNATIONAL COMMUNITY The effort to develop information systems that give decision makers and the public interpretable indicators of the health benefits of environmental policies and practices is not confined to the United States, said Tord Kjellstrom, of the Australian National University. International sharing of experiences and collaborative research will lead to more cost-effective solutions and to harmonized sets of common indicators. As the concern about local environmental issues broadens to include global en- *   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 vironmental threats, such as global warming and pollution from toxicants found in intercontinental drifts of dust, collaboration on the issues of environmental health monitoring is increasingly needed. Every country is facing problems similar to those in the United States in assessing the health effects of environmental hazards and monitoring progress toward reducing or preventing the effects, observed Kjellstrom. The environmental hazards faced by a nation depend on the country’s economic development and, to a lesser extent, on its geographic location. In most developed countries, the main focus in recent decades has been chemical pollutants—urban air pollution, exposures to chemicals and agriculture, and long-distance pollution from coal- and oil-powered electricity production. The threats of catastrophic radiation pollution from nuclear power plants and the problems posed by greenhouse gas emissions also are of concern. In developing countries the major environmental concerns are the biological hazards of unsafe drinking water and unsatisfactory sanitation, as well as the hazards of inadequate housing and poor worker health and safety. A look at Vietnam illustrates the typical environmental health concerns of a developing nation. Most of the country’s 80 million people live in rural areas, and the average gross domestic product is equivalent to USS400 annually. The country still relies heavily on traditional agriculture, which poses hazards of disease vectors, inadequate sanitation, injuries, and pesticide use by farmers. In the inner cities, water supplies, sanitation, housing, and transportation involve tremendous health hazards (see Figure 4.1). Occupational hazards, particularly exposures to toxic chemicals, also are a growing problem, as are traffic crash injuries. Recent progress has been made in some areas, such as access to safe drinking water. Another enormous health problem in developing countries is air pollution. For example, in Beijing, China, coal burning in industry and households raised PM10 (particulate matter of 10-μm diameter) levels to a staggering 600 μg/m3 on a typical day in November 1995. Air quality concerns are not limited to developing countries. In New Zealand, for example, a large contributor to air particulate matter is the use of wood fires for heating. Chimney density, obtainable from census data, has been found to be a reliable indicator of air pollution levels on calm, cold winter days. It also is an indicator of socioeconomic disparity, because in poor areas the houses are older and people cannot afford electricity for heating.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 4.1 In cities such as Hanoi, water supply and sanitation, housing, and transport systems are major “traditional” challenges. SOURCE: Kjellstrom, unpublished. Reprinted with permission. A ban on coal and open fires is being discussed in Christchurch, New Zealand, as are subsidies for efficient wood burners, investment in public transportation, and improved insulation and ventilation of housing. In addition, the New Zealand government recently invested the equivalent of US$15 million to upgrade the country’s single oil refinery. The country will soon have one of the cleanest diesel fuels in the world because the government took seriously the country’s high levels of air particulate matter. Some environmental health indicators in New Zealand that can be pinpointed clearly are mortality from asbestos-related cancer (about 70 deaths per year from mesotheliomas and about 140 per year from lung cancer) (Kjellstrom and Smartt, 2000) and the rate of dioxin-associated cancer (about 50 cases per year) (New Zealand Ministry for the Environment, 2001). More traditional indicators are rates of meningococcal disease and tuberculosis related to poor housing, crowding, and lack of access to

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary health care (about 1,000 cases per year) (New Zealand Health Information Service, 2003). Because environmental health has many facets, no one global solution exists for identifying meaningful indicators and establishing monitoring systems. Nevertheless, the United States can learn much by examining the environmental health problems and monitoring efforts of other countries. Good monitoring systems—extremely good in some cases—exist in other countries, and monitoring research in the United States could benefit from international collaborative efforts that would save time and energy and allow answers to be obtained rapidly. For health effects that are rare, data from many countries may have to be pooled to yield valid epidemiologic results, especially if the results are needed quickly because potential problems are large and possible economic effects are great. For example, in New Zealand and other countries, there is the concern about cell phone technology and whether radiation emitted from these devices and “ground stations” is harmful to humans. International research and monitoring may help to resolve this issue, stated Kjellstrom. CONTRIBUTIONS OF A “NONTRADITIONAL” FEDERAL PARTNER: THE U.S. GEOLOGICAL SURVEY The earth science perspective has much to offer public health; yet, its contribution is often overlooked, stated Patrick Leahy, of the U.S. Geological Survey (USGS). What do the activities of the USGS have to do with human health? Human health is complementary to the mission of the USGS, a 120-year-old organization designed to examine the nature of the nation’s resources. The organization plays a supporting role in public health by collecting and analyzing environmental information that can elucidate the linkages between health and the environment. This is done through robust partnerships with other agencies. An example illustrates why these partnerships are so important. Approximately a decade ago at a meeting between the USGS and the National Center for Health Statistics (NCHS) on national water quality assessment, workers at the NCHS presented research on possible linkages between elements such as cadmium and certain cancers using USGS databases. The researchers had combined data on cadmium in many different locations—soil, streamflow, reservoirs, and even 2,500-foot-deep groundwater in saline water bodies—and had performed statistical analy-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary ses, but they had not accounted for the widely differing human exposure risks associated with various locations. At the time, it struck me as a good example of instances when geologists shouldn’t do human health work, and the human health community should not be doing geologic work—clearly the marriage of these two groups is where the breakthroughs in environmental health will come from, noted Leahy. In a 2001 report, the National Research Council (NRC) suggested that the USGS expand its goals to explore the intersection between natural sciences and the allied health sciences (NRC, 2001). The report acknowledged that the USGS is well positioned, in terms of its information resources, technological capabilities, and range of professional expertise, to provide well-coordinated, comprehensive responses to priorities of society and science. Leahy further noted that the USGS with its vast databases was able to investigate complex interdisciplinary problems that spanned multiple spatial and temporal scales, and to investigate spatial data and create risk factor mapping that can be used to analyze phenomena such as disease clusters. According to Leahy, since that report, the USGS has been actively seeking opportunities for collaborating with the public health community. He noted that earth science techniques that have special applications in environmental health monitoring: remote sensing, geospatial analysis, and advanced analytical capabilities, particularly in the chemical and biological arenas. An example of the relevance of remote sensing for health is the use of the Landsat-7 satellite to detect the movement of atmospheric dust from Africa across the Atlantic Ocean to the Americas (see Figure 4.2). The hundreds of tons of dust that move from Africa to the southeastern United States and the Caribbean region each year can transport heavy metals, pesticides, and pathogens such as soil fungus, which have been have been hypothesized as a cause for increased asthma in humans (die-offs of coral). By performing microbial characterization, including culturing and DNA analysis in conjunction with remote sensing, more than 400 bacterial and fungial isolates from African dust samples in the Caribbean have been identified, of these, approximately 25 percent are potential plant or animal pathogens. Other applications of remote sensing are multi- and hyperspectral mapping of mineralogical aspects of dust, the compositional variations in dust, and the source materials. Of particular interest are asbestos-form minerals and particulates. Techniques permit organic materials to be distinguished from inorganic, and they allow the thermal features of dust

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 4.2 Recent USGS studies document that atmospheric dust transported from Africa to the southeastern United States and the Caribbean can transport heavy metals, pesticides, and a variety of pathogens such as soil fungus. SOURCE: Kellogg and Griffin, 2003. to be mapped. The intercontinental movement of the dust carrying these materials requires that these techniques to be applied internationally. Geospatial analysis is another technique that provides valuable environmental health data and has been used to map the concentration of arsenic in groundwater by county across the United States (see Figure 4.3). The map provides useful information for many questions about arsenic including the following: What percentage of the population is affected by high levels of arsenic in drinking water? What is the potential effect of tightening federal standards for arsenic in drinking water? Where in the country would the costs to lower arsenic levels to meet a stricter standard be greatest? The map by itself does not answer those questions. Geospatial analysis also can be used in landscape epidemiology. In this application, the geographic conditions needed to maintain specific pathogens in nature are determined, and the landscape is used to identify the spatial and temporal distribution of disease risk. Geospatial and statistical analyses are used to create interactive models that support decision making and to interpret data to produce specialized derivative

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 4.3 Arsenic in groundwater of the United States. SOURCE: Ryker, 2001. Reprinted with permission. map products. These maps have many uses in answering fundamental environmental health questions. For example, maps might help us investigate how West Nile virus is spread by revealing which bird species are primary carriers of the disease, where mosquito breeding sites are, and whether mosquitoes are spreading the virus at stopovers along fly ways. The third technique of interest, advanced analytical capabilities, refers to the USGS’s ability to handle and exchange vast amounts of data. For example, the microscopic analysis of dust using scanning electron microscopes, transmission electron microscopes, X-ray diffraction, and reflectance spectroscopy helps detect potentially deleterious minerals, such as asbestos silica, coal dust, sulfides, and other particulates. This analysis also reveals the bioavailability of heavy metals and inorganic contaminants such as arsenic, chromium, and dioxins. Applications to human health are far-reaching. For instance, advanced microscopic characterization of dust at the World Trade Center site allowed the USGS to make recommendations about the type of respirators that workers should use.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Advanced analytical capabilities have allowed the USGS to provide the first nationwide reconnaissance of the presence of pharmaceutical agents, hormones, and other organic wastewater contaminants in surface water resources (Kolpin et al., 2002). Many household chemicals, pharmaceutical agents, and biogenic hormones are not removed as part of the water treatment process. They pass into water supplies and end up in reservoirs, and sometimes even in groundwater, at very low levels. The USGS study analyzed 95 organic wastewater contaminants in water samples from a network of 139 stream sites in more than 30 states in 1999 and 2000. At least one organic wastewater contaminant was detected in 80 percent of the streams sampled, with 82 of the 95 contaminants detected in at least one sample. Most of these compounds do not have drinking water standards associated with them. Many were found at extremely low levels, in the part-per-billion or trillion range, and we were not even aware that they were in our water resources. Although USGS workers are identifying single compounds in our water supply, they have not begun to understand the potential effects of mixtures of these compounds. Linking the possible effects of these contaminants in our water supply to public health represents an important area of collaborative research for the earth sciences and health communities. In addition to its laboratory methods, the USGS has an extensive field infrastructure that is devoted to collecting real-time water monitoring data, including more than 7,000 stream gages and 700 real-time water quality monitoring stations. In today’s world, we are concerned about intentional, as well as accidental, release of contaminants, and we must be able to monitor these contaminants in real time. The USGS is working in partnership with industry to field-test instruments designed to detect volatile organic compounds, including biotoxins and chemical warfare agents. The USGS’s field work extends internationally. In China, arsenic poisoning caused by burning high-arsenic coal is a major health problem. In collaboration with the U.S. Armed Forces Institute of Pathology, the USGS is using its analytical capabilities to determine the concentration and distribution of arsenic in coal and its behavior upon combustion. The USGS has developed a simple field-test kit that allows Chinese villagers to determine arsenic levels in their coal prior to use so that they can avoid those coals or blend high-arsenic coal with other coal. The work of the USGS offers great possibilities for the agency to work together with the environmental health community—nationally and internationally—to mitigate the damaging effects of inorganic contami-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary nants and organic pathogens, stated Leahy. As analytical capabilities develop, they will open doors for collaborative efforts that we cannot even imagine today. ENVIRONMENTAL HEALTH MONITORING AT STATE AND LOCAL LEVELS It has been noted that identifying environmental health indicators and establishing a sound system for monitoring these indicators are critical steps in bridging the gap between health and the environment at a national level. Effort by Congress, the judicial system, and federal agencies to establish broad policy, to ensure that programs are instituted and funded, and to ensure accountability will not be enough to bridge the gap unless national activities have a direct and measurable effect on the way environmental health is dealt with at the local level. Successful environmental health monitoring requires strong partnerships with state and community organizations. Local officials must be involved in many environmental health initiatives, emphasized Mark Horton of Public Health Services, Orange County, California. Local environmental and public health workers inspect restaurants, respond to hazardous materials incidents, monitor water quality, and set up systems to ensure rational approaches for providing these services to the community. They organize responses to incidents involving nuclear power plants, earthquakes, and other disasters at the local level. They are responsible for community planning, urban development, and designating sites for landfills and wells. They plan, they respond, and they educate. They must be recognized as an essential part of the horizontal and vertical network of available services that ensure good health outcomes for the nation as a whole. Horton described a recent beach closure that illustrates the kinds of environmental health issues local public health officials face and the implications of these issues. About three years ago Orange County, California, closed Surf City USA, in Huntington Beach, California, for most of the summer because of increased bacterial counts; this had a major effect on the local economy. The sanitation district spent $500,000 investigating the integrity of the sewage system and convincing the public that sewage was not the cause. One year later, a $4 million research project was established to try to confirm or disprove a theory that sewage outfall in the ocean 2.5 miles from shore was causing a plume of contamination

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary to reach the beach. To date, no answer has been obtained about the source of pollution. This local challenge to environmental health raised important questions: What was the connection between bacterial contamination on the beach and human disease? What ability did public health institutions have to monitor the effect of the contamination on human health? Unfortunately, their ability was nearly zero. During the beach closure, the only mechanism for monitoring the health effect of contamination was the number of telephone complaints received from people who had gastrointestinal symptoms after swimming in the ocean. According to Horton, using fecal coliform and enterococcus counts as signal indicators for protecting the public’s health was woefully inadequate for supporting the protective activities and actions required under state and federal legislation. A main reason was the 24-hour delay between collecting beach water samples and obtaining laboratory results. Better technology is needed to increase protection, determine the source of the bacteria, and generate rational decisions about how to approach the problem, noted Horton. The Huntington Beach closure also raised questions about which jurisdiction was responsible for investigating the source of pollution. The sanitation district ensured that the pollution was not caused by sewage, but who had responsibility for other potential causes, such as urban runoff, was less defined. Officials were uncertain whether the problem rested with Huntington Beach or the county as a whole. Several other examples also illustrate the need for increased surveillance and a greater ability to link environmental exposures to health outcomes. A local power plant was given permission to double its energy output in response to an energy crisis in California. Local environmental health officials had little capacity to answer questions posed by community residents about the possible relationship between the doubled output of pollution from the power plant and anecdotal increases in chronic diseases and acute episodes of asthma. In this instance, community members also raised concerns when a large tire fire broke out, causing a huge plume of smoke to settle over the community for more than a week, and later when a large construction project caused enormous dust clouds to descend over nearby residential communities. The Air Quality Manage-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary ment District maintained that the air was being monitored, but there was a disconnection between data from the Air Quality Management District and anecdotal reports of increased levels of disease by community members. Local Community Needs Better organization and coordination at the state and local levels are greatly needed, said Horton. Fragmentation among the vertically oriented institutions and agencies engaged in environmental health activities is as much a problem at the state and local levels as it is at the federal level. The fact that priorities are dictated elsewhere hinders planning and prioritization at the community level. More and more local environmental health agencies are being placed in regulatory agencies, and officials are separated from epidemiology, surveillance, and other components of public health. Obtaining adequate resources is another problem at the community level, noted Horton. Most local environmental health activities are fee-based, and fees are calculated to cover only those activities that directly relate to the inspection activities required under ordinance or statute. Thus, local officials have little flexibility to gather reserve funds or garner the resources needed to respond to emergent issues, such as anthrax threats, or to explore other challenges that do not fit into established categories. Lack of funds hinders the local community’s ability to take the initiative, to plan and prioritize, and to reorient resources and energies to address these plans. Strengthening Local Efforts from the National Level What can be done at the national level to promote efforts at the local level? The proposed national health monitoring network should help address local environmental health issues by improving surveillance, increasing data generation, and linking data sources. Horton noted that it also will provide a more rigorous scientific basis for local environmental health work. Such a system will require a major national investment in surveillance, epidemiology, and the scientific underpinnings of environmental health. This capacity must permeate all levels of government, including the local level.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Strengthening existing registries and developing new registries could serve as a cornerstone for the proposed national health monitoring system, suggested Horton. Registries have proved their worth at local, state, and federal levels—particularly cancer and birth defect registries. Data collected can potentially be used to examine possible links between human disease and environmental exposures. Reporting of toxic exposures has to be expanded and the data must be used as a basis for decision making on the local level. The ability to link databases—on birth defects and pesticide exposure, for example—is very important. Strengthening existing registries and developing new registries could serve as a cornerstone for the proposed national health monitoring system…. The ability to link databases—on birth defects and pesticide exposure, for example—is very important. -Mark Horton Help can be given to local officials in locating or developing models for surveillance. For example, surveillance methods for addressing exposures to pollution from such sources as a tire fire, a power plant, or a construction site may already have been developed elsewhere in the nation and need not be reinvented locally. The techniques used in the geographical information systems of the USGS will be of great value at the local level in identifying health challenges and environmental exposures and in determining health linkages. CONTRIBUTIONS OF INDUSTRY TO ENVIRONMENTAL HEALTH MONITORING Business and industry also are stakeholders in the environmental health monitoring effort. The business and industrial enterprise in the United States has vast human, technological, and material resources that could be useful in developing and maintaining a national environmental health monitoring system. Why does industry care about the environmental health monitoring issue? The answer is that it is part of the issue and has a vital role to play, stated Carol Henry of the American Chemistry Council (ACC). The work of the ACC serves as an example of the ways in which industry can contribute to environmental health monitoring efforts. The ACC represents more than 160 chemistry companies, employing over 1 million people and representing a $450 billion enterprise. The business

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary of chemistry is a science-based industry whose future product innovations, and hence the health of the public, will be influenced by the outcome of the environmental health monitoring debate. What does the ACC have to offer in this arena? Fourteen years ago, the council began a voluntary program called Responsible Care™, which has substantially improved environment, safety, and health performance within the industry. Since 1988, industry emissions have been reduced by 65 percent, the incidence of illness and injury has decreased by 37 percent and industry output volume has increased by 33 percent, according to Henry. Responsible Care™ has provided a framework and an ethic that has improved performance and provided opportunities for partnerships with communities, government agencies, and environmental groups. Community Advisory Panels have been formed in nearly 300 communities throughout the country and represent a network whose function can potentially be expanded. Also, the ACC has established partnership programs with more than 82 customer companies and 30 associations. The Long Range Research Initiative (LRRI) of the ACC, founded in 1999, represents a commitment from Responsible Care™ to invest $25 million per year, with a rolling three-year commitment, to generic research that is intended to help answer the question, How do chemicals potentially affect our children, our environment, and ourselves? The LRRI sponsors independent, third-party research investigations. It is currently supporting research to increase understanding in three areas that can aid efforts to establish a national environmental health monitoring network: (1) biomarkers; (2) tools used by epidemiologists, especially in the workplace; and (3) mechanisms of developmental and reproductive biology. Where do the chemical industry and the ACC stand on issues of environmental health monitoring and public health surveillance? They support the following: the concept of a comprehensive public health surveillance system that will help reveal disease trends in the United States and will help generate hypotheses for research on disease causation; improvement in the ability of state and federal public health agencies to monitor priority chronic diseases and risk factors for these diseases; and a system to aid in understanding chronic disease trends in the United States, in prioritizing public health issues, and in guiding resource allocation among states and federal agencies. Also, they believe that prioritizing public health issues and allocating resources accordingly, will help shift the environmental health “debate” from speculation

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary about disease trends to intervention and prevention based on scientific evidence. A shift to disease prevention could greatly benefit the country economically. CONTRIBUTIONS OF WEB-BASED INFORMATION SERVICES TO ENVIRONMENTAL HEALTH MONITORING The focus of today’s workshop has been on the “superset” of federal agencies that will produce national reports on the state of the environment. Some of this information will have an audience in Congress, and some will flow through media outlets. However, environmental health information also has to be made available along the chain of stakeholders who are engaged in making daily decisions that have environmental consequences—whether a consumption decision by an individual, a production decision in industry, or a regulatory decision in a government agency. Currently, one of the web’s most popular resources for environmental information is Scorecard (www.scorecard.org), a web-based information service sponsored by the nonprofit organization Environmental Defense. Its goal is to help people easily find acceptable, usable information about environmental quality in their area, stated William Pease, of GetActive Software. The site receives about 100,000 visitors and one million page views in a typical month. Users enter their zip codes to gain access to extensive, interpreted information about environmental conditions in their immediate surroundings. The site generates hundreds of requests for further information from people across the country. Many of these people are not environmental health professionals but are simply concerned about an environmental aspect of their daily lives. The amount of questions from Scorecard users reveals much about how the environmental health community must prepare itself. A common theme during this workshop has been recognition of the many gaps in our understanding of the link between specific environmental factors and specific health outcomes. Environmental Defense has found that it is essential to keep these gaps in understanding in the forefront of people’s minds. If people are made aware of these problems, such as the absence of a surveillance system or the lack of reliable toxicity data on high-production-volume chemicals, they will respond as well as if they were provided with a science-based indicator, noted Pease.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Increasingly, web-based services are providing access to health indicators. The GATHER system, operated by the Agency for Toxic Substances and Disease Registry (ATSDR) and the National Cancer Institute (NCI), accesses information collected from cancer registries, and gives a geospatially refined view with a small number of important health end points—essentially cardiovascular disease and cancer. Yet these information services lack true environmental health indicators, as defined earlier in this workshop. They cannot provide any potential environmental cause. Other efforts can provide information about health risks. An example, from Scorecard, of the kind of information available is a listing of the top 10 counties in the United States, ranked by population size, in which cancer risk from hazardous air pollutants exceeds 1 in 10,000 people. The information emanates from Scorecard’s ability to aggregate all major Environmental Protection Agency (EPA) databases that deal with emissions or exposures to toxic chemicals. In this case, Scorecard took data from the National Air Toxic Assessment, which provides estimates of the concentrations of hazardous air pollutants down to the census tract level across the United States, and intersected it with health effects information and risk assessment information from other data sources. Using basic screening-level risk assessment techniques, Scorecard generates an estimate of the added cancer risk associated with exposure to these air toxins for every census tract in the country, relative to similar census tracts. Although the scientific validity of such aggregated data could be challenged, according to Pease the information reflects what people want to know about environmental conditions in their communities. The choice is to say nothing at all or to start with these types of approximations of relative levels of risk. Another example is from Health-Track (www.healthtrack.org), which connected National Cancer Institute cancer mortality data to the Toxics Release Inventory (TRI) and hazardous air pollutants emissions rates. On a geospatial map, counties in the United States were color-coded according to their all-cancer rate and rates of individual cancers. Overlaid is information from regulatory agencies about point releases of recognized or suspected carcinogenic agents, from a small number of source categories, for a given year. However, there are methodological problems because emissions are considered and not exposures; future efforts could incorporate exposure modeling. Another methodological improvement would be to map several years worth of releases and perhaps include time lags as well. Nevertheless, the map exemplifies the

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary types of associative analyses that can be done in the future and may help construct the health indicators that policy makers and the public are demanding. What types of information do people want from indicators? According to Pease, they want indicators to be relevant to either a health decision that they are about to make or a health effect that they are experiencing. Alternatively, they may want the indicators to be relevant to their local communities. The ability to provide comparative community profiles is very effective in satisfying the demand for relevance. In some domains of interest, indicators are needed for a specific audience—for instance, policy analysts concerned about environmental justice issues or legislators concerned about whether the actions of an agency are improving public health (see Figure 4.4). Citizens want indicators to be actable. A potential role for indicators is to support personal preventive action. An example is e-mail-based air pollution alert services, which work well to help persons with asthma and other respiratory conditions avoid high air pollution. A further use of indicators is to support policy change. For example, intersecting information on environmental quality with census data can reveal, for any county in the United States, the relative burden experienced by different census subgroups. Discovering such inequities may lead to corrective measures. Successfully implementing web-based indicator services will require integrating domain expertise across many different fields and ideally bringing the information together so that it updates itself automatically as surveillance systems move forward. It also will require openness in supporting web-based intermediaries, outside of government agencies, that are less subject to scientific and regulatory constraints. Developing privacy protection will pose considerable challenges. ROLE OF THE MEDIA IN INFORMING THE PUBLIC ABOUT ENVIRONMENTAL HEALTH MONITORING To gain public support for a national environmental health monitoring system, the concept must be widely understood and its potential benefits recognized, stated Morris “Bud” Ward of Morris A.Ward, Inc. Most Americans receive the bulk of their information (or misinformation) on environmental health from the news media. Unfortunately, the opportunity for environmental health coverage has shrunk appreciably in

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary FIGURE 4.4 Distributions of environmental burdens. SOURCE: Environmental Defense and GetActive Software © 2004. Reprinted with permission. Scorecard is available at www.scorecard.com. recent years. The trend toward consolidation, mergers, and joint ownership in news organizations has greatly influenced the way in which news content is selected for airing or publication. Today, the overriding factor that guides content selection is profitability, noted Ward. Some major new organizations shun environmental news as a strategy because it is not a seller for their editors. Where environmental health news is accepted, environmental journalists may have difficulty convincing their editors that they can produce unbiased reports and are not simply “environmentalists with press passes.” The trend away from environmental coverage is apparent not only in print media but also in television broadcasting. “Sweeps Week” is the quarterly event in which local television stations are judged on their audience share. Even a small percentage increase in market share of the audience is important, because each increment of market share brings an enormous increase in advertising rates for air time. Until five years ago, key players who advised stations on what to air during “Sweeps Week”

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary encouraged airing environmental news as a means of increasing audience market share. Since that time, the advice has been not to air news about the environment because it is not considered compelling to audiences, noted Ward. Part of the problem in environmental health reporting lies with scientists themselves, who sometimes contradict each other and give mixed messages in interpreting research results. Some recent developments in environmental health reporting are encouraging. The Society of Environmental Journalists (www.sej.org) in Philadelphia is a professional fraternity of about 1,200 members. It counts among its members most of the print journalists who cover environmental news regularly, and it offers serious continuing education in environmental journalism. A counterpart in the broadcast community is the Radio and Television News Directors Foundation in Washington, DC, which has as its members about 750 local television and radio station editors who cover environment in particular. Also, some schools of science journalism have recently incorporated environmental journalism into their curricula. These developments may signal a new understanding of the importance of the media in educating the public about environmental health issues.