5
The Challenges Ahead*

Presenters identified numerous reasons why increasing the availability of environmental public health indicators is critical. Not having access to reliable information in a usable, understandable format often creates confusion when trying to answer health questions during times of crisis. Some workshop participants pointed to the use of health monitoring as an essential tool to better understand environmental health risks, to guide responses to such risks, and to assist in preventing adverse health outcomes. Samuel Wilson of the National Institute of Environmental Health Sciences (NIEHS) suggested that monitoring would help set priorities for research.

Many participants suggested that while environmental health monitoring was a missing tool in the arsenal of environmental health scientists, the system for providing such data must be put together with care to ensure that the data are usable, timely, and accurate. During the course of the workshop, and particularly in the final panel discussion, participants discussed the needs and limitations of a monitoring system, and the barriers and challenges that may impede the implementation of such a system. Workshop participants discussed the challenges that the nation faces in promoting environmental health monitoring and in establishing a national environmental health monitoring system.

*  

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 5 The Challenges Ahead* Presenters identified numerous reasons why increasing the availability of environmental public health indicators is critical. Not having access to reliable information in a usable, understandable format often creates confusion when trying to answer health questions during times of crisis. Some workshop participants pointed to the use of health monitoring as an essential tool to better understand environmental health risks, to guide responses to such risks, and to assist in preventing adverse health outcomes. Samuel Wilson of the National Institute of Environmental Health Sciences (NIEHS) suggested that monitoring would help set priorities for research. Many participants suggested that while environmental health monitoring was a missing tool in the arsenal of environmental health scientists, the system for providing such data must be put together with care to ensure that the data are usable, timely, and accurate. During the course of the workshop, and particularly in the final panel discussion, participants discussed the needs and limitations of a monitoring system, and the barriers and challenges that may impede the implementation of such a system. Workshop participants discussed the challenges that the nation faces in promoting environmental health monitoring and in establishing a national environmental health monitoring system. *   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 ENVIRONMENTAL HEALTH SCIENCES The field of environmental health has been evolving in the depth of responsibilities for researchers and environmental public health officials. The Honorable Paul G.Rogers of Hogan and Hartsen noted that many are focusing on individual health issues or environmental hazards in isolation, when we need to have a more holistic understanding of the gamut of health and, in particular, environmental health. Henry Falk of the Agency for Toxic Substances and Disease Registry (ATSDR) agreed and noted that if we define environmental disease too narrowly, we miss a number of important conditions such as chronic diseases, where rates are currently rising. Carol Henry of the American Chemistry Council further noted that in addition to the importance of a strong definition of environmental health, we need a better understanding and agreement as to what constitutes “good” environmental health and greater knowledge of the relative importance of environmental factors in promoting health. Some participants suggested as we move forward in environmental health monitoring, we will have to answer some of these definitional questions to help shape a more usable monitoring system. ENVIRONMENTAL HEALTH MONITORING SYSTEM OVERVIEW What are the next steps to be taken in environmental health monitoring? Samuel Wilson of NIEHS echoed the thoughts of many participants in stating that the highest priority is to establish a national environmental public health monitoring system. For this purpose, public health should be described in the broadest sense possible to encompass chronic diseases, environmental diseases, and environmental circumstances that affect health, such as life-style, nutrition, and social stress. The monitoring system should be in the form of a relational database that could be used to make linkages and eventually to create hypotheses on cause-and-effect relationships. The usefulness of such a system would be immense and could lead to enormous gains in public health. The difficulty according to Baruch Fischhoff of Carnegie Mellon University is that the data collected will be used at a variety of different levels—the international, national, state, and local levels. One would like to have this information presented in a way that many people can make use of it.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Limitation of the Environmental Monitoring System In constructing a national environmental health monitoring system, we must recognize that no single design will meet all needs, said Harold Zenick of the U.S. Environmental Protection Agency (EPA). A national design, such as the National Health and Nutrition Examination Survey (NHANES) study design, will not give information needed at the state and local levels. State designs will meet state purposes, but we may not be able to aggregate state data in a manner that will provide a national picture. Although organizations at every level desire self-sufficiency, this expectation may not be realistic. Our situation today, in trying to bring together environmental data sets and health data sets in a national health monitoring system, is like the start of a marriage. Once the marriage is created, both partners must change over time to meet each other’s needs. Our current monitoring systems were designed for totally different purposes from those we are trying to achieve now. As committed partners, we must look for ways in which we can modify them to fit our common goal. Learning Lessons from Past and Current Monitoring Systems Richard J.Jackson of the Centers for Disease Control and Prevention (CDC) noted that the CDC has considerable experience in establishing successful monitoring programs. When establishing programs of this magnitude it often isn’t until you get started, that you find the best way to make things work—clearly one size does not fit all. Planning and use of prototypes represent time well spent as one modifies the program based on outcome data. Workshop participants discussed some of the current monitoring efforts to monitor aspects of health in the United States. For example, cancer registries represent one of the best health monitoring efforts in this country. Steps have been taken to establish national standards for these registries. A separate standards-setting body, the North American Association of Central Cancer Registries (NAACCR), has a relationship with state registries and other organizations that pool cancer data, such as the National Cancer Institute (NCI), the CDC, and the American Cancer Society. However, not all states and programs meet the gold standard set forth by the NAACCR.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Further, today’s data on birth defects cannot be compared from state to state because a national gold standard has not been set and collection methods and analysis differ widely. Also, not all states have registries for birth defects or even cancer. The nationwide monitoring effort will strengthen the cancer registry system across the country and help make data on other health outcomes, such as birth defects, more comparable. Looking at these and other efforts in more detail will aid in the development of the environmental health monitoring program, according to some participants. EXPANDING RESEARCH EFFORTS For this monitoring program to be successful, we will have to improve the research effort to work in concert with the monitoring effort, asserted many speakers. According to Falk, bridging the chasm between the environment and public health will require better detection of the links between environmental exposures and health outcomes. For example, in the State of California, environmental health data have been collected that have not been used fully because they have not been analyzed or interpreted, noted Lynn Goldman of Johns Hopkins University’s Bloomberg School of Public Health. As the national monitoring effort progresses, policy makers must make sure that resources are allotted not just for collecting information but also for making use of it and for connecting it to the research conducted by the nation’s research communities. Wilson further noted that we must ensure that the data collected are accessible and suitable for analysis by scientists and others in the field. The quality assurances and quality control applied in generating the data must be done transparently so that the data can be trusted. We must provide more repositories for and access to disease and exposure samples than we have today. We must focus on developing animal models because animal model research is the key to understanding the dose—response relationship and developing biomarkers for use in human populations. He further asserted that we should carefully consider the social and legal implications of the monitoring system.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Gaps in Data Collection Gaps in information gathered by a monitoring system hinder its usefulness, stated Thomas Burke of Johns Hopkins University. For example, the National Research Council (NRC) report, Toxicological Effects of Methylmercury (2000), on the exposure of women of childbearing age to mercury revealed very little about the source of that exposure. For the potential outcomes to be understood, we must understand and validate the sources of these exposures. We have an obligation to develop an effective monitoring network that extends from source to end point, although it should not be totally constrained by the cause-and-effects model or by Koch’s principles of causality. The gaps in surveillance data are not in one particular area of environmental health, but rather exist in many facets, including the occupational sector, stated Kathleen Rest of the National Institute for Occupational Safety and Health (NIOSH). Many states have little or no capacity to monitor occupational health indicators or occupational health problems in the state. Current opportunities to build the federal and state capacity for environmental and occupational health monitoring must be exploited, she asserted. Shelly Hearne of Trust for America’s Health added that most states do not have the ability to respond effectively to a disease cluster, yet clusters may be a key to understanding the cause of chronic disease and its prevention. The National Institutes of Health (NIH) has to work in partnership with the states, the ATSDR, and the CDC to improve the mechanisms for investigating chronic disease clusters, suggested Hearne. Although the nation’s investment in its medical research capacity has doubled in recent years, most of the funds have been dedicated to the methodology of treating disease. Very few resources have been applied to research on disease prevention. Asthma funding provides an example. Seventeen percent of the asthma research budget of NIH is used for investigating the cause of the disease and less than one percent is devoted to monitoring (Pew Environmental Health Commission, 2000a). Ensuring a Continuum of Data from Source to Health Outcome At the EPA, much research on environmental health has focused within narrow areas, such as identifying the source of an environmental hazard, determining the exposure of a population to a toxic substance, or

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary monitoring the incidence of a disease, according to Zenick. A main challenge, as we move toward a national health monitoring system, is to create the synergy needed to link these areas to produce a continuum from source to health outcome. We have to expand our emphasis on hazard and exposure indicators, where fair amounts of data are available, to include health outcome indicators, where data are more modest. The EPA is currently embarking on an innovative air quality program—the Air Toxics Program—which is oriented toward reducing cancer risk and many other health risks. The program targets 33 air toxics that present the greatest threat in the country’s urban areas. Part of the program’s strategy will be a nationwide ambient air monitoring system. Because the latency period between exposure and an asthma attack is a matter of minutes (rather than years, as in cancer), the location of a cluster of asthma cases could indicate the exposure location. Thus, if air toxics data and asthma attack data are sound, an association can be made with some confidence, noted Hearne. According to the Pew Environmental Health Commission, human exposure could be measured directly for most priority air toxics (Pew Environmental Health Commission, 2001). Hearne further noted that the primary focus of the work of the EPA is extrapolating environmental data to human outcomes, not monitoring human exposures and assessing health outcomes. Yet models of extrapolation do not always give an accurate picture of the influence of environmental factors on the human population, stated Hearne. An example is the effect on human health of removing lead from gasoline. Extrapolation models in that case were misleading. It was the biomonitoring data gathered by the CDC that showed the one-on-one correlation between the reduction of lead in gasoline and the drop in blood lead levels in humans. As we advance in our environmental regulatory decision making and standards, this example teaches us that human biomonitoring and health outcomes data must be integrated. Integrating Biomonitoring and Human Outcomes Data Across Agencies and Organizations Many speakers discussed the need to integrate data across agencies and organizations. Monitoring must be strengthened to improve detection capabilities, noted Falk. Attesting to this need is a figure that appeared in the Seattle Post Intelligencer showing cumulative deaths attributable to

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary asbestosis, lung cancer, and mesothelioma due to tremolite asbestos exposure from the vermiculite mine in Libby, Montana (Schneider, 1999). What is the problem with this figure? There is nothing wrong with the figure itself, stated Falk; the data have been corroborated by ATSDR. The problem is that a newspaper journalist was the first to put the data together and report the problem. A series of actions—from medical testing to a national evaluation of vermiculite sites—was precipitated by this newspaper article about a problem that should have been picked up routinely by public health departments and the EPA. Jackson noted that virtually all diseases are being reported and stored in large information systems run by insurance companies, pharmaceutical suppliers, and other reimbursement agencies. Approximately 85 percent of these data are being collected by three or four companies. He suggested that it would be difficult for environmental health scientists using the equivalent of a “drinking straw” to understand the linkages with isolated disease, when a better data flow exists by linking into these databases. IMPROVING CAPACITY During the course of the presentations, many speakers and participants alluded to the need for continual funding to organize and maintain such a program. However, they further alluded to the challenges of building a system from a critical infrastructure need. The Multitude of Agencies Involved in Environmental Health Monitoring—Eliminating the Stovepipes As we plan for a nationwide health monitoring system, an essential question is whether we have the capacity to implement it, stated Hearne. Several core agencies are at the heart of health monitoring and establishing the defense network needed to address environmental health threats: the CDC and ATSDR, NIH, EPA, NIOSH, and the Office of Surgeon General. The fact that more than 50 federal agencies are in some way involved in environmental health activities raises the question, Who is in charge? Many speakers and participants allude to the “stovepiping” that occurs at both the federal and the state levels. Wilson noted that for those

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary who work in the federal government in these stovepipes, it is clear that one of the challenges is to share information, to reach out to establish linkages among agencies. This includes reaching out to nontraditional health agencies as well as to local community groups. For nationwide environmental health monitoring to be effectual, each of the agencies must be fully engaged with one another in a collaborative, integrative way. The top leadership must be focused and dedicated and must sometimes “break glass” to pull all of these operations together, Hearne asserted. Jackson further noted that the timing is right on the ability to build the relationships needed to move this program forward. Personnel Infrastructure A common theme of many speakers and panelists was the need for more personnel to effectively implement the monitoring effort. This would range from scientists involved in the research effort, to statisticians and epidemiologists, to health officers at the local level. Hearne noted that environmental health investigators for chronic diseases are in short supply in this country, and 24 states did not have a single CDC Epidemic Intelligence Service officer affiliated with them in 2000. Federal agencies must work cooperatively to build the capacity to educate the next generation of scientists and practitioners needed to implement environmental health monitoring, many participants agreed. Restoring the EPA’s fellowship program for environmental science would be a good start. A goal of the CDC’s pilot studies is to build the necessary capacity at the state level to respond to environmental concerns. Medical education appears to be reemphasizing the role of the public health system and the linkages between medical care and public health. However, the concept of the link between the environment and health has to be reinforced in medical school curricula, suggested some panelists. Although training physicians is important, the bulk of the training has to take place in state and local health departments. Federal agencies may have a role in coordinating and leading this training effort. Adequate training requires a funding commitment that is stable and long-lasting. Otherwise, the most critical part of the infrastructure—human resources—will be undermined.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary COMMUNITY INVOLVEMENT During the workshop, many speakers and panelists noted that the community would have to be involved. Wilson noted that environmental health is not just the purview of the scientific community and those who attend workshops such as this one. It is really the job of the American people. Environmental health must render its services at the neighborhood and community level—where environmental health can be influenced. Jackson echoed these remarks and further stated that the environmental health monitoring program has to be built from the bottom up. It has to make sense to local public health departments and be keyed to local public health actions. There has to be translation from the research arena to the community, particularly impoverished and disenfranchised communities. FUTURE STEPS FOR ENVIRONMENTAL HEALTH MONITORING A variety of suggestions were put forward to start the monitoring program. Zenick suggested that a succinct, highly focused strategy is needed to move forward on national environmental health monitoring. The strategy may involve choosing a particular exposure or a certain disease as an initial focus so that we can demonstrate over the next few years that the system can work. Government agencies might agree on two or three national goals for environmental public health that would take priority. They could then make a concerted effort to fulfill these goals within the next 5 to 10 years. These goals could be used to influence how the monitoring system is constructed and what biomarkers are included in the National Human Exposure Report. Agreeing on a set of goals would be less ambitious than setting a national agenda, but it would help give direction to the monitoring effort. Expanding the National Report on Human Exposure to Environmental Chemicals (CDC, 2003) is critical, he noted, because within a few years we will be able to identify stable trends in exposures. Having precise knowledge about the health outcomes related to these trends may not be necessary. If we require evidence of a strong cause-and-effect relationship before monitoring some exposures, we will hinder our progress. There may be some complementary, independent monitoring activities

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary that we should not ignore simply because we lack evidence of strong linkages. Wilson also posited that one activity might be to convene working groups to hammer out communications issues, the definition of terms, and goals. Henry suggested that the Department of Health and Human Services convene a commission to address the needs of a broadly conceived public health surveillance system. The commission’s purpose would be to promote broad support for the concept and increase public understanding of its purpose. The nation has reached a pivotal time for establishing a national monitoring system. The Pew Commission report of 2000 (Pew Environmental Health Commission, 2000b) was instrumental in planting the idea. About a year was needed for the concept to become known and accepted by health agencies, the government, and the public. Currently, efforts to develop the national monitoring system have begun, and support for the concept is growing slowly in many quarters. A surge in acceptance could bring a new set of concerns. Once legislation has been passed and the initiative has been funded, the monitoring process will be largely out of the control of environmental health experts. The workshop presentations made it clear that now is the time for environmental health experts to contribute to the understanding of appropriate indicators.