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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Introduction In Chicago in the summer of 1995, unseasonably warm weather was coupled with increased deaths from hyperthermia. From July 11 to July 27, the maximum daily temperatures ranged from 93° to 104°F, resulting in 465 people dying from heat-related causes throughout the city (MMWR, 1995). The elderly and African Americans were disproportionately affected. Of all deaths, 51 percent occurred in individuals who were at least 75 years of age, while 49 percent were African Americans (Semenza et al., 1996). In the midst of this crisis, state and local public health agencies were able to use trends to identify important risk factors from the data and to develop interventions to protect vulnerable groups from heat-related health effects. NEED FOR ENVIRONMENTAL HEALTH MONITORING In its broadest sense, the environment is one of the major determinants of human health and well-being. This is in some sense understood by the U.S. population. In 2000, 86 percent of the U.S. population believed that environmental factors are important or very important in causing diseases, according to a poll by the Mellman Group, Inc., and Public Opinion Strategies, Inc., conducted for Pew Charitable Trusts. Unfortunately, they further believed that government agencies are tracking these diseases and other environmental incidences (such as the above example); for the most part, this is not the case. During times of crises—whether the crisis be natural, accidental, or an act of terrorism—health officials, policy makers, and emergency re-
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary sponse teams have a critical need for access to exposure and background data. This was reinforced during the tragic events of September 11, 2001, and the anthrax outbreak in 2001. The challenge is that the information is needed quickly and in a usable format in order to develop appropriate interventions and to inform the public. Environmental health professionals have called for further research into complex environmental exposures. According to many workshop participants, we know very little about the role of the environment in many disease incidences. This is a growing concern because, in the United States alone, chronic disease contributes to more than half of all deaths and illnesses at an annual cost of $325 billion. The role of the environment in disease is further questioned because of increases in the number of reported clusters for cancer, Parkinson’s disease, multiple sclerosis, and Alzheimer’s disease. Environmental health monitoring provides an important linkage between exposure to environmental toxicants and health outcomes. Its purpose, according to Richard J.Jackson, Centers for Disease Control and Prevention, is to find emerging threats over time, to put control tools in place, to evaluate whether they work, and to adjust them as needed. Environmental health monitoring is the use of epidemiological, toxicological, and other knowledge in an action-oriented way to accomplish the following: Monitor a move toward sustainable development Monitor trends in the state of the environment Monitor trends in the health effects of hazards Investigate links between the environment and health Monitor effects of policies and preventive actions Compare trends across geographic areas The concept of environmental health monitoring in the United States dates back to the 1970s, when the Council on Environmental Quality (CEQ) and Project Upgrade in the Carter administration used mapping to link health and the environment and to provide a “national report card” as a basis for moving forward. Environmental health monitoring was advanced further by the Institute of Medicine’s report The Future of Public Health (1988) and the Pew Environmental Health Commission Report America’s Environmental Health Gap: Why the Country Needs a National Health Tracking Network (2000b). This work provided the momentum at the national level for current legislative efforts to establish
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary a national tracking network, noted Thomas Burke of Johns Hopkins University. ENVIRONMENTAL HEALTH MONITORING IN THE CONTEXT OF THE INSTITUTE OF MEDICINE’S STUDIES IN PUBLIC HEALTH The future of environmental health and population health in general, in this country, is a very important issue, according to Susanne Stoiber, executive director of the Institute of Medicine. There is a growing recognition and appreciation of the multiple factors that influence the health of individuals and populations. These include the genetic endowment; the social and physical environments in which people live; the life-styles they adopt; and their access to education and adequate income, nutrition, good housing, safe neighborhoods, and of course, to services for the prevention, treatment, and management of disease. The Institute of Medicine (IOM) addresses issues that affect the health of the public. Its work is conducted primarily through study committees that issue reports. The issues addressed by the IOM cover a broad range from environmental health to basic biology and tackle controversial topics of vital importance, such as medical errors (Kohn et al., 2000), and stem cell research (IOM, 2002b). Other recent reports cover such diverse and timely topics as how to create a higher-quality health care system, how to ensure that the National Aeronautics and Space Administration (NASA) can provide proper clinical care for astronauts traveling to the Moon and to Mars, how to ensure the safety and efficacy of vaccines for anthrax and other diseases, and how to eliminate tuberculosis in the United States (Geiter, 2000; Ball and Evans, 2002; Corrigan et al., 2002; IOM, 2002a). In 1988, the IOM published The Future of Public Health, which revealed that the nation’s public health system was in disarray. Stoiber noted that the report spurred a national discussion in the public health community, and the interchange brought a better understanding of the important functions of public health and the investments necessary to promote them. The concept of public health broadened as people gained a deeper appreciation of the many factors that influence the health of individuals and populations. Ten years after that report, in 1998, the IOM established the Roundtable on Environmental Health Sciences, Research, and Medicine to build communication and collaboration and to educate
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary health care providers about the changing field of public health. Ever since, the Roundtable has built on its early work and has enhanced the unity of environment and health across many disciplines. Although much progress has been made in the public health community since publication of the 1988 report and creation of the Roundtable, the events of September 11 have highlighted the continuing need to invest in the public health infrastructure, concluded Stoiber. These events have also brought the recognition that without a strong public health system the nation is extremely vulnerable. The Committee on Assuring the Health of the Public in the 21st Century (IOM, 2003) recognizing the crucial needs for infrastructure, was convened to create a framework for assuring population health in the United States by recommending evidenced-based actions necessary to make the public health system effective. Further, collaboration is still lacking between governmental public health agencies and the private health care delivery system in the United States. Coordination also is missing between public sector programs that finance health care and those that organize public health functions, concluded Stoiber. Two other factors contribute to underinvestment and under appreciation of public health: the American fascination with science, technology, and medical interventions; and the relatively poor understanding of the determinants of health and the workings of the public health system. A national environmental health monitoring system, which has been present for several years, was the main topic of this Roundtable workshop. The national environmental health monitoring system can play an important role in increasing collaboration among organizations and can be a useful tool for engaging the public’s interest in public health. The Environmental Protection Agency, Centers for Disease Control and Prevention, National Institutes of Health, Agency for Toxic Substances and Disease Registry, National Institute for Occupational Safety and Health, and other agencies currently conduct activities and programs for monitoring human exposure to various environmental hazards. The Pew Environmental Health Commission Report (EHTPT, 2000), which called for a national environmental monitoring system, has been widely endorsed by many important health organizations. Recently, considerable activity has been focused on creating a coordinated national environmental health monitoring system, including congressional action to establish a nationwide health tracking network. Such a system can provide important scientific information, but like all monitoring systems, it
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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary will have limits, noted Stoiber. To be successful, it must be embedded in a larger system of public health and research. The challenge of this workshop was for participants to think how a national monitoring system fits into current exposure monitoring and a comprehensive science program. Further, people involved in designing the system need to discuss how to bring about not only a reunion of health and the environment, but a broader reunion of health care delivery and the science of environmental health.
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