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He. Environmental Public Health For several years, Denver, Colorado, has led the Environmental Protection Agengy's (EPA) list of cities with serious carbon monoxide air pollution problems. At the state level, Colorado has the fourth highest rate of death from chronic obstructive pul- monary disease." Bradley Beckham of the Colorado Department of Health says that researchers can speculate that these two phenomena are related, but no model based on reliable data exists to definitively relate one to the other. (#469) This situation is mirrored around the country with many environmental concerns. The most common observation of the 50 testifiers on environmental health goals for the year 2000 is that for a wide range of environmental problems, the data that might guide public health policy are sorely deficient. Most of the 1990 environmental health objectives are unquantifi- able. According to the majority of testifiers, research and monitoring are needed to gauge how much of a particular substance the population at large, or a certain group, is exposed to and what health risk this exposure induces. Testimony reported in this chapter illustrates the scientific and political problems involved in such issues as toxic agents, hazardous waste, water pollu- tion, air pollution, lead poisoning, food purity, electric and magnetic fields, and noise pollution. Several testifiers call for interdisciplinary research, whereas others go further and identifier the kinds of private and public action needed now. One speaker, however, is very circumspect in committing more public health resources to environ- mental issues. Environmental health priorities should be guided by better surveillance data and weighed against priorities for known risks found in the occupa- tional setting, argues Robert Spear of the University of California, Berkeley. Most toxic agent or radiation harm involves workers at specific sites. Thus, from a quantitative or population-based perspective, public health should devote more of its environmental efforts toward high-risk populations and to surveillance of the health outcomes of environmental conditions on populations such as these. Conversely, public health should not be expending as much of its limited funds, Spear urges, on "programs whose health benefits are difficult to Justin on the basis of procedures like quantitative risk assessment, let alone on epidemi 148 Healthy People 2000: Citizens Chart the Course ological grounds." (~275J Although most witnesses addressed either the immediate environment of the home and workplace or the proximate physical environment in terms of land, water, and air, Malcolm Watts of the University of California, San Francisco pointed out that to help ensure health for all people in the year 2000 and beyond, attention also must be paid to longer-term issues related to protecting our global environment. If these problems are neglected in the next 10 years, Watts says, they will be even more pressing-and possibly overwhelmingly the year 2000. #781) TOXIC AGENTS Much of the testimony on environmental health issues involved toxic agents, hazardous wastes, and human exposure to these substances through the water supply. "With the exponential growth of new technologies, and the associated new, potentially toxic substances used, what we do know continues to be far out- weighed by what we do not know concerning all of the effects produced by toxic agents," says George Gaines of the Detroit Department of Health. (~210) For example, Bernard Weinstein of Columbia Univer- sity reports that although it is known that en~ron- mental toxins and toxic chemicals contribute to several kinds of cancer, as well as to a variety of reproductive disorders, the mechanisms behind these effects are less well understood. (#456} Focusing on a particular health risk, Raymond Singer of Mount Sinai School of Medicine is con- cerned about how little is known of neurotoxicity. Exposure to neurotoxic chemicals, which are present in certain pesticides, solvents, herbicides, metals, polychlorinated biphenyls (PCBs), and other sub- stances found in consumer products, can cause per- manent nerve and brain damage, according to Singer. More than 850 chemicals are known to be neuro- toxic,2 and the National Institute for Occupational Safety and Health lists neurotoxicity as one of the 10 leading work-related diseases.3 However, "the effects of low-level exposure to neurotoxic chemicals to which most of us are exposed remains uncharted," says Singer. He encourages greater public awareness of the signs and symptoms of neurotoxicity, suIveil

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lance of workers who are continually exposed to neurotoxic chemicals, labeling of consumer products, and testing of these products under chronic exposure conditions. "Not only the public remains unaware of the widespread and insidious nature of neurotoxic chemicals, but also many health professionals," he states. (#638) Hazardous Wastes Robert Meeks of the University of Alabama at Birmingham writes that initial steps have been taken to protect the environment and the public from unsafe hazardous waste disposal through legislation. This includes the Toxic Substances Control Act and the Resource Conservation and Recovery Act. It is now up to the scientific community, he claims, "to develop an understanding of the potential and real effects on the health of individuals resulting from their exposure to toxic agents because they live near hazardous waste sites." Meeks proposes comprehen- sive risk assessment and health monitoring for individuals who are faced with having hazardous waste or toxic agent storage facilities in their communities. (#622) Even with public and private regulatory and control mechanisms, lack of public understanding of the means of disposal and public unwillingness to par- ticipate in reducing barriers to safe disposal are hurdles to action, according to Joan Sowinski of the Colorado Department of Health. "If we are to continue to manufacture products in this country, there have got to be ways to safely treat wastes," she says. If regulatory mechanisms are in place, the public must support new waste disposal technologies. Education in the schools is one method of resolving this problem. "I would wager,n Sowinski comments, "that elementary school kids know more about the space shuttle than incinerators." Education must out- line environmental problems and then provide an awareness of possible solutions. (#379) Water Contamination Sheldon Murphy of the University of Washington expresses concern about the quality of the nation's water: "Seepage of toxic chemicals into groundwater from toxic waste sites, agricultural applications, and domestic and industrial discharges appears to present a growing problem." (#357) Carl Johnson, representing the American Associa- tion of Public Health Physicians, speaks of the contamination of well water in rural areas. He notes that a significant percentage of rural wells in this country are contaminated with nitrate from stoclyards, septic tanks, and agricultural chemicals. To prevent infant illness and death from nitrate contamination of well water, management of environmental pollutants must be maintained. Johnson also calls for a reduc- tion in the number of pollutants in water. (#1114 Some of the most serious problems with the nation's water quality stem frown land and air use practices that have not yielded to regulation, report David Freeman and his colleagues at the Lower Colorado River Authority. Examples of these pro- blems include "an increase in suspended sediments from increased soil erosion; the increasing use of salt on highways in the winter; the increasing use of pesticides; and the increased use of fertilizers causing eutrophication of receiving bodies of water." A spe- cific result of these types of pollution is the nitri- fication occurring today in the Chesapeake Bay. Iden- ti~ing and implementing the necessary control mea- sures to mitigate "nonpoint-source~ pollution will require multiple strategies, some of which may be expensive, he predicts. `~o677 Lead Poisoning John Strauther of the Detroit Department of Health says that childhood lead poisoning is "the most common preventable pediatric disorder in the U.S. It affects more children than measles, mumps, rubella, and other communicable diseases combined. To prevent its effects he calls for increased professional awareness and screening. The medical community needs to be better informed about recent developments in the identification and medical management of lead poisoned children. Although lead poisoning is best handled by public health facilities, it should be part of every physician's responsibility to advise, urge, and refer every parent to have preschool children regularly screened until their sloth birthday. (#412) However, Despite almost 2000 years of experience with the health hazards of lead, we know relatively little about the different forms of lead and their toxicity or even their relative absorption by humans, reports Ellen Mangione of the Colorado Department of Health. The 1990 objective on lead poisoning is one of the four (out of twenty) trackable environmen Environmental Public Health 149

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tat health objectives, but several testifiers comment that changing knowledge of lead toxicity levels has made the 1990 goal obsolete. (~362) AIR POLLUTION According to Murphy, indoor air pollution is going to become a more apparent health issue over the next decade. Energy conservation measures have led to tighter buildings which, in turn, prevent the escape of volatile components contained in many new building materials; in addition, there are chemicals that may seep into homes from soil or vaporize from polluted water, fireplaces, stoves, and tobacco smoke. One goal, Murphy argues, should be to better characterize the exposure levels and health risks associated with air contaminants in private and public buildings where people spend most of their lives. (#357) Most of those who discussed air pollution, however, were concerned about outdoor pollution, especially that caused by automobiles. Allen Bell of the Texas Air Control Board suggests a mixture of public and private initiatives to reduce contamination of the environment and keep the public safe from environmental health threats. These include product bans, required or voluntary emission standards, voluntary changes in products to reduce emissions from product manufacture and use, informa- tion strategies to promote private behavior that reduces emissions, government subsidies to promote emission reductions, legal sanctions and financial penalties to compensate for past damages, and other economic incentives. (#017) According to Dave Anderson, the American Automobile Association (AAA) believes that auto manufacturers should play a role in reducing harmful car emissions by developing cleaner automobiles that operate efficiently under real-world driving conditions. Anderson, like Bell, underlines the role of public concern in controlling environmental risk. The public wants better air quality, the AAA argues, but has demonstrated concern about the cost of various air quality improvement programs. The AAA concludes, Officials at all levels of government have an obliga- tion to ensure that costs of such programs are not excessive in relation to proven benefits." (~008) More specifically, the AAA supports the lead phasedown program, already in process, that would permit one-tenth (0.10) of a gram of lead per gallon of leaded gasoline and a method to ensure the availability of additives that would protect engines designed to run on leaded gasoline. (#OOBJ 150 Healthy People 2000: Citizens Chart the Course Denver's solution to its air pollution problem, says Beckham, involves a number of major new steps that include year-round daylight saving time to move the afternoon rush out of the central Denver area before the temperature inversion establishes itself; a ban on wood burning during high-pollution days; voluntary driving reduction; expanding mass transit; an enhanced auto inspection program using computerized emission test equipment; and use of high-oxygen gasoline in the winter pollution season. (~469) Most of these com- nonents could be employed in programs elsewhere. FOOD-BORNE DISEASE The Association of Food and Drug Officials (AFDO) reports significant public health problems from food- borne transmission of infectious disease. The total incidence of diarrhea! food-borne illness in the United States may be as high as 24 to 81 million cases per year, and the estimated cost of food-borne illnesses is in the range of $1 to $10 billion annually.4 f#384) James Black of the Oregon Department of Agricul- ture, representing AFDO, contends that Concern for food-borne pathogens and subsequent illness desenes a higher priority than it has been receiving in the public health system. (#342) Pathogens introduced into a community through the food and dairy supply are now recognized to have a potential long-term effect on that community's health. Food-borne patho- gens "may lead to such diseases as chronic diarrhea, arthritis, certain types of heart disease, malabsorption of nutrients among the young, and Guillain-Barrd syn- drome,n writes Black. (#342) The AFDO recommendations for addressing the problem of food-borne illness include a reemphasis in schools of the basic sanitation principles that can prevent most of these disease occurrences and a consistent effort by federal, state, and local agencies to address the issues from a research, reporting, and regulatory approach. (~384) Roy Morse, representing the Institute of Food Technologists, offers similar solutions to food poison- ing outbreaks: (1) more reporting on the causes of the outbreaks, (2) more research on nutrition by the federal government, (3) increased funding for research and development in the food area, and (4) licensing public health inspectors for restaurant inspection. (~733J Positive identification of the causative agent in a water- or food-borne disease outbreak is the exception rather than the rule, according to Charles Treser, representing the Washington State Public Health

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Association. Thus, "it is probably not feasible, or necessarily desirable, to establish objectives for spe- cific causative agents." Instead, he recommends that the Year 2000 Health Objectives include "an explicit objective calling for a 50 percent reduction in the incidence of gastrointestinal illnesses by the year 2000. (#348) IMPLEMENTATION Public awareness of a range of environmental influences, and the consequent concern, Justin the inclusion of environmental health in the Year 2000 Health Objectives, says Bell. The concern of the public "appears to be intensified by the complexity of issues relating to environmental exposure to hazar- dous substances and the involuntary nature of the health risks.n Assessment of the total and relative risks to human health, he argues, could aid tremen- dously in directing resources and In helping the public evaluate the health impact of environmental condi- tions. (#01 7) The rapidity with which new substances are intro- duced into the market has stymied many attempts to isolate and assess environmental risks to humans. One major restraint in Catching up" with industry output is finance. According to the American Public Health Association's Laboratory Section: With the exception of the Food and Drug Administration, there is very little monitoring of commercial products on behalf of consumers. The catalogue of drugs and chemicals used for the control of infectious diseases is extensive. If the trend continues of less federal dollars for activities in protection of the consumer, then it is anticipated that the state public health labora- tories will have to become more involved in testing consumer products for safety and effec- tiveness. (#548) REFERENCES Many states and local agencies are given the lion's share of responsibility for managing and maintaining the community's healthful environment, says Larry Kamberg of the Washington State Environmental Health Association. They do not, however, get the lion's share of funds. (#318) For many testifiers, the EPA and the FDA are essential to ensuring environmental public health. For example, William Scheckler of the University of Wisconsin feels that the EPA and FDA strategies should be more public health oriented. Broader use of epidemiological expertise' by the EPA, the FDA, and other federal health agencies should be mandated." Epidemiological evaluation is important in goal setting as well. Scheckler suggests that All major environmental health protection initiatives undertaken by the federal government be analyzed by appropriate experts in epidemiology and cost benefit and then reviewed in the context of other health promotion and disease prevention priorities before being funded and implemented." (#194) A representative of the Detroit Department of Health feels that the EPA should "have established firm guidelines for acceptable levels of risk for exposure to asbestos and most toxic agents," based on the assumptions that "the focus of safety and health practice will continue to shift toward preven- t~on as opposed to control" and that "technology advances will continue to outgrow data requirements." This testifier also feels that an expeditious method of controlling potentially harmful chemicals would be to change current EPA regulatory procedures. (#210) For example, even though the Toxic Substances Con- trol Act requires the EPA to screen all new chemicals before they enter the marketplace, the agency has been slow in accomplishing its task, according to Paul Rogers of Hogan & Hartson in Washington, D.C. (#782) The Detroit official continues, "chemicals are currently regulated one by one. By the year 2000, the EPA must develop a more systematic approach, i.e., regulating chemicals as recognized characteristic groups." (#210) 1. Colorado Department of Health: Health Status in Colorado, 1985. Summary. Denver: June 1986 2. Anger K, Johnson B: Chemicals affecting behavior. Neurotoxicity of Industrial and Commercial Chemicals. Edited by JL O'Donoghue. Boca Raton, Fla.: CRC Press, 1985 Environmental Public Health 151

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3. Centers for Disease Control: Leading work-related diseases and injuries-United States. Morbid Mortal Wkly Rep 32~2~:24-26,32, 1983 4. Kvenberg JE, Archer DL: Economic impact of colonization control on foodborne disease. Food Technol, July 1987 TESTIFIERS CITED IN CHAPTER 18 008 Anderson, Dave; American Automobile Association 017 Bell, Allen; Texas Air Control Board 067 Freeman, S. David, et al.; Lower Colorado River Authority 111 Johnson, Carl; South Dakota Department of Health 194 Scheckler, William; University of Wisconsin 210 Gaines, George; Detroit Department of Health 275 Spear, Robert; University of California, Berkeley 318 Kamberg, Larry; Washington State Environmental Health Association 342 Black, James; Oregon Department of Agriculture 348 Treser, Charles; University of Washington 357 Murphy, Sheldon; University of Washington 362 Mangione, Ellen; Colorado Department of Health 379 Sowinski, Joan; Colorado Department of Health 384 Messenger, Tom; Association of Food and Drug Officials 412- Strauther, John; Detroit Department of Health 456 Weinstein, I. Bernard; Columbia University 469 Beckham, Bradley; Colorado Department of Health 548 Blaine, James; American Public Health Association, Laboratory Section 622 Meeks, Robert; University of Alabama at Birmingham 638 Singer, Raymond; Mount Sinai School of Medicine 733 Morse, Roy; Institute of Food Technologists 781 Watts, Malcolm S. M.; University of California, San Francisco 782 Rogers, Paul; Hogan & Hartson (Washington, D.C.) 152 Healthy People 2000: Citizens Chart the Course