Environmental Health Indicators

BRIDGING THE CHASM OF PUBLIC HEALTH AND THE ENVIRONMENT

WORKSHOP SUMMARY

Lynn Goldman and Christine M.Coussens, Editors

Roundtable on Environmental Health Sciences, Research, and Medicine

Board on Health Sciences Policy

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
www.nap.edu



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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Environmental Health Indicators BRIDGING THE CHASM OF PUBLIC HEALTH AND THE ENVIRONMENT WORKSHOP SUMMARY Lynn Goldman and Christine M.Coussens, Editors Roundtable on Environmental Health Sciences, Research, and Medicine Board on Health Sciences Policy INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by contracts and grants between the National Academy of Sciences and the National Institute of Environmental Health Sciences, National Institute of Health (Contract No. 282–99–0045, TO#5), National Center for Environmental Health and Agency for Toxic Substances and Disease Registry, Centers for Disease Control and Prevention (Contract No. 200–2000–00629, TO#7); National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention (Contract No. 0000166930); National Health and Environment Effects Research Laboratory and National Center for Environmental Research, Environmental Protection Agency (Contract No. 282–99–0045 TO#5); American Chemistry Council; and Exxon-Mobil Corporation (unnumbered grants). Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. This summary is based on the proceedings of a workshop that was sponsored by the Roundtable on Environmental Health Sciences, Research, and Medicine. It is prepared in the form of a workshop summary by and in the names of the editors, with the assistance of staff and consultants, as an individually authored document. International Standard Book Number 0-309-09265-5 (Pbk) International Standard Book Number 0-309-54454-8 (PDF) Library of Congress Control Number: 2004110129 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624–6242 or (202) 334–3313 (in the Washington metropolitan area), Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Adviser to the Nation to Improve Health

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M.Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A.Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V.Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M.Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary ROUNDTABLE ON ENVIRONMENTAL HEALTH SCIENCES, RESEARCH, AND MEDICINE Paul Grant Rogers (Chair), Partner, Hogan & Hartson, Washington, DC Lynn Goldman (Vice Chair), Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD Jacqueline Agnew, Professor, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD Jack Azar, Vice President, Environment, Health and Safety, Xerox Corporation, Webster, NY Roger Bulger, President and Chief Executive Officer (CEO), Association of Academic Health Centers, Washington, DC Yank D.Coble, Immediate Past President, American Medical Association, Neptune Beach, FL Henry Falk, Assistant Administrator, Agency for Toxic Substance and Disease Registry, Atlanta, GA Baruch Fischhoff, Professor, Department of Engineering and Public Policy, Carnegie Mellon University, Pittsburgh, PA John Froines, Professor and Director, Center for Occupational and Environmental Health, Southern California Particle Center and Supersite, University of California, Los Angeles, CA Howard Frumkin, Professor and Chair of the Department of Environmental and Occupational Medicine, Rollins School of Public Health, Emory University, Atlanta, GA Michael Gallo, Professor of Environmental and Community Medicine, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, Piscataway, NJ Paul Glover, Director General, Safe Environments Programme, Health Canada, Ottawa, Ontario, Canada Bernard Goldstein, Dean, Graduate School of Public Health, University of Pittsburgh, Pittsburgh, PA Charles Groat, Director, U.S. Geological Survey, Reston, VA Myron Harrison, Senior Health Advisor, Exxon-Mobil, Inc., Irving, TX Carol Henry, Vice President for Science and Research, American Chemistry Council, Arlington, VA John Howard, Director, National Institute for Occupational Safety and Health, Centers for Disease Control and Prevention, Washington, DC Richard Jackson, Senior Advisor to the Director, Centers for Disease Control and Prevention, Atlanta, GA Lovell Jones, Director, Center for Research on Minority Health; Professor, Gynecologic Oncology, University of Texas, M.D. Anderson Cancer Center, Houston, TX Alexis Karolides, Senior Research Associate, Rocky Mountain Institute, Snowmass, CO

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Fred Krupp, Executive Director, Environmental Defense, New York, NY Donald Mattison, Senior Advisor to the Directors of the National Institute of Child Health and Human Development and Center for Research for Mothers and Children, National Institutes of Health, HHS, Bethesda, MD Michael McGinnis, Senior Vice President and Director of the Health Group, Robert Wood Johnson Foundation, Princeton, NJ James Melius, Administrator, New York State Laborers’ Health and Safety Fund, Albany, NY James Merchant, Professor and Dean, College of Public Health, Iowa University, Iowa City, IA Sanford Miller, Senior Fellow, Center for Food and Nutrition Policy, Virginia Polytechnic Institute and State University, Alexandria, VA Alan R.Nelson, Special Advisor to the Chief Executive Officer, American College of Physicians-American Society of Internal Medicine, Fairfax, VA Kenneth Olden, Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC John Porretto, Chief Business Officer, Health Science Center, University of Texas Houston, Houston, TX Peter Preuss, Director, National Center for Environmental Research, U.S. Environmental Protection Agency, Washington, DC Lawrence Reiter, Director, National Health and Environmental Effects Research Laboratory, U.S. Environmental Protection Agency, Research Triangle Park, NC Carlos Santos-Burgoa, General Director, Equity and Health, Secretaria de Salud de México, Mexico D.F., México Michael Shannon, Chair of the Committee of Environmental Health, Associate Professor of Pediatrics, Children’s Hospital, Boston, MA Samuel Wilson, Deputy Director, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC IOM Health Sciences Policy Board Liaisons Lynn R.Goldman, Professor, Department of Environmental Health, Johns Hopkins University, Baltimore, MD Bernard D.Goldstein, Dean of the University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA Study Staff Christine M.Coussens, Study Director Dalia Gilbert, Research Associate Kyra Naumoss, Intern

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary IOM Health Sciences and Policy Staff Andrew Pope, Board Director Troy Prince, Administrative Assistant Carlos Gabriel, Financial Associate Laurie Yelle, Consultant

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Holly Brown-Williams, Associate Director; California Policy Research Center; Berkeley, CA Amanda Hawes, Attorney; Alexander, Hawes, and Audet; San Jose, CA Andrea Pfahles-Hutchens, Epidemiologist; U.S. Environmental Protection Agency; Washington, DC Bailus Walker, Professor; Department of Environmental and Occupational Medicine, Howard University; Washington, DC Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the final draft of the report. The review of this report was overseen by Melvin Worth, Scholar-in-Residence, Institute of Medicine, who was responsi-

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary ble for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Preface Public health is the heart and soul of any civilization’s defenses for ensuring and improving the protection of health. At the beginning of the last century, public health officers were facing different challenges than today. Their main concern and concentration was on infectious diseases, basic sanitation, and safe food and water. Today, while still struggling with some infectious diseases, such as HIV, West Nile virus, and SARS (severe acute respiratory syndrome), public health officers have larger and more complicated challenges that encompass changes in health care systems and the risks posed by life-styles and other environmental factors. Obesity, asthma, diabetes, and mental illness are among the many points of concentration for modern public health officers. What causes the new epidemics today? Is it environment, life-style, pollution, heredity, or a combination of factors? The answers to the challenges are complex, and we must develop new tools and technologies to help solve these issues. Historically, the responsibility for health and environment in the United States has been divided among various government agencies, which often have limited interactions. Although these structures have served us well in the past, there is a growing realization that a chasm has been created between environment and health. Cooperation between different public health agencies and a clear idea of where we are going and how we are going to get there are needed. The government has been engaged in monitoring activities for 100 years, and we now have to connect existing environment and health “pieces” of the system and expand the effort. Bridging the chasm between public health and the environment by connecting these pieces will give us the power of information and the ability to respond proactively to present and future public health needs.

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary The nationwide interest in monitoring as a means of linking environmental hazards, exposures, health outcomes, and interventions, as well as involving different public health agencies in the process of linking, is growing rapidly. This may be due to increased interest in cancer rates, environmental exposures, and potential biological threats by terrorists. What is clear is that when a health concern arises, people are looking for solid data and answers in a timely manner. Although only one piece of the data, environmental monitoring is an important piece of information. The Roundtable on Environmental Health Sciences, Research, and Medicine (EHSRT) was established in 1988 as a convening mechanism for stakeholders in environmental health from the academic, industrial, health, and federal research fields to meet and discuss environmenttal health issues of mutual interest. The EHSRT felt the need to expand the view of environmental health by using a wider perspective of the environment—one that encompasses the natural environment, the built environment, and the social environment. This broader definition of environment reflects the understanding that all three environments must be healthy for individuals and communities to be healthy. During the Roundtable’s first workshop in June 2000 (IOM, 2000b), several Roundtable members noted that professionals in environmental health tend to focus on narrow issues of environmental toxicology and environmental regulation rather than becoming engaged in the larger issues of environmental health. Many Roundtable members recognized that environmental health extends far beyond the realm of regulations and that progress on environmental health issues requires a broad view of the entire environmental health arena. The Roundtable’s fourth workshop (April 10–11, 2002), Environmental Health Indicators: Bridging the Chasm Between Public Health and the Environment, continued the overarching theme on rebuilding the unity of health and the environment. The purpose of the workshop was to bring people together from many fields, including federal, state, local, and private partners in environmental health, to examine potential leading indicators of environmental health, to discuss the proposed national health tracking effort, to look into monitoring systems of other nations, and to foster a dialogue on the steps for establishing a nationwide environmental health monitoring system. This workshop brought together a number of experts who presented, discussed, and debated the issues surrounding the implementation of a monitoring system. The energy and

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary discussion clearly signaled that we are headed in the right direction for establishing a national monitoring system. This workshop summary captures the presentations and discussions by the speakers and participants that occurred during the two-day meeting. The views expressed here do not necessarily reflect the views of the Institute of Medicine, the Roundtable, or its sponsors. Paul G.Rogers, J.D. Chair

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary Contents     SUMMARY   1     WORKSHOP OBJECTIVES AND CHARGE TO COMMITTEE   7     INTRODUCTION   9      Need for Environmental Health Monitoring,   9      Environmental Health Monitoring in the Context of the Institute of Medicine’s Studies in Public Health,   11 1   BRIDGING THE CHASM BETWEEN HEALTH AND THE ENVIRONMENT: SCIENCE AND POLICY CONTEXT   15      A Congressional Perspective,   15      A View from the Environmental Protection Agency,   17      A View from the Department of Health and Human Services,   20 2   OVERVIEW OF ENVIRONMENTAL HEALTH MONITORING AND THE USE OF INDICATORS   23      Criteria for Establishing an Effective Nationwide Environmental Health Monitoring System,   24      Environmental Health Indicators,   27      International Frameworks for Developing Environmental Health Indicators,   30      Using Indicators to Rank Environmental Health Risks,   32

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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   35      General Overview of Efforts of the Centers for Disease Control and Prevention,   36      Current Efforts of the Agency for Toxic Substances and Disease Registry (ATSDR),   39      Current Efforts of the National Institute for Occupational Safety and Health,   42      Current Efforts of the Environmental Protection Agency,   46      Research Activities of the National Institute of Environmental Health Sciences,   47      Building Partnerships for Effective Environmental Health Monitoring,   49 4   NEEDED INTEGRATION OF OTHER FEDERAL AGENCIES, STATE AGENCIES, AND NONGOVERNMENTAL ORGANIZATIONS TO BUILD A MONITORING SYSTEM   53      Lessons from the International Community,   53      Contributions of a “Nontraditional” Federal Partner: The U.S. Geological Survey,   56      Environmental Health Monitoring at State and Local Levels,   61      Contributions of Industry to Environmental Health Monitoring,   64      Contributions of Web-Based Information Services to Environmental Health Monitoring,   66      Role of the Media in Informing the Public About Environmental Health Monitoring,   68 5   THE CHALLENGES AHEAD   71      Environmental Health Sciences,   72      Environmental Health Monitoring System Overview,   72      Expanding Research Efforts,   74      Improving Capacity,   77      Community Involvement,   79      Future Steps for Environmental Health Monitoring,   79

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Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment, Workshop Summary     ABSTRACTS   81      The Common Ground: The Critical Role of Indicators and Tracking in Shaping the Future of Environmental Health,   81      Ensuring Usability in Environmental Health Monitoring,   82      Environmental Health Monitoring: A View from Industry,   84      The Local Community: Environmental Challenges and Recommendations,   85      The Interaction with the Global Community,   86      What Earth Science Technology Can Do to Assist Public Health,   89      Centers for Disease Control and Prevention’s Approach to Disease Surveillance,   90      Understanding the State of the Environment: Moving Beyond the Process to True Outcome Indicators,   91      Environmental Health Indicators and Web-Based Information Services,   93      Environmental Health Monitoring in the Workplace: Safeguarding Workers and Advancing Public Health,   93      Yes, But Will the Public Care? (and Do the Media Care?),   95     REFERENCES   97     APPENDIXES     A   WORKSHOP AGENDA   101 B   SPEAKERS AND PANELISTS   107 C   WORKSHOP PARTICIPANTS   109

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