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CHAPTER 6
CONCLUSIONS AND RECOMMENDATIONS
PURPOSES AND PROCEDURES OF THE ONGOING STUDY
Amidst growing concern with environmental hazards and the
resulting health effects and costs, Congress passed Public
Law 95-623. Section 7 of the law calls for an ongoing study to
provide information on sources of environmental hazards, on the
health effects attributable to these hazards, and on the costs
associated with these health effects. In particular, Congress
requested a study that would provide estimates of the reduction in
health costs which would result from each incremental reduction in
environmental hazards resulting from human activity. The law also
calls for reports every two years on these issues, and for advice on
improving the data available to obtain the required estimates.
Because of the law's broad scope, the Department of Health and
Human Services (DHHS) asked the Institute of Medicine to engage in a
planning study to consider how the ongoing study should be conducted
and to assess the feasibility of meeting the requirements in
Section 7.
This committee recognizes the desirability of developing the
kind of information requested in P.L. 95-623, but finds that the
scope of the congressional charge far exceeds what is feasible in our
present state of knowledge. Major deficiencies in data bases,
methodologies, administrative procedures, and, most important,
theoretical knowledge for relating environmental hazards to health
problems and their associated health costs have precluded earlier
straightforward assembly of the information needed. Therefore, the
committee proposes a series of phased activities for the ongoing
study, including case studies, methodological and operational
research, and evaluative efforts, to develop the required data bases
and strategies for analyzing them. Only by starting now to collect
needed data will the base become available for deriving the estimates
requested by Congress. As the initial phases of the ongoing study
proceed, it will become clearer to what extent the estimates Congress
has requested can be provided.
The ongoing study can serve many functions. It can enhance data
collection and coordination. It can draw attention to the need to
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relate environmental data to health data to develop hypotheses or
evidence about environmental hazards. It can define areas needing
basic research and encourage development of new methodologies and
models, including predicting human risks from animal data and
estimating costs in ways that policymakers can use.
Many efforts are under way to determine health effects
attributable to or associated with environmental hazards. Far fewer
attempts are under way systematically to estimate attendant health
costs, such as costs of medical care and loss of output due to
morbidity or premature mortality. A decrease in health costs
attributable to some action can be considered an increase in
benefits. Policymakers have a pressing need for estimating benefits
of proposed actions in order to make more informed choices among
alternative actions. In attempting to estimate the health costs
mentioned in the law, the ongoing study can provide a focus for
developing methodologies and data for assessing benefits of steps
that could reduce environmental hazards.
P.L. 95-623 requests only some of the information that agencies
require in doing cost benefit analyses. The ongoing study is to
address only health benefits and omit other possible benefits, such
as improved recreational facilities. It also will omit costs
associated with pollution abatement, such as the costs industry
incurs to decrease worker exposure or to decrease harmful emissions.
Although the ongoing study need not specifically consider pollution
abatement costs or non-health benefits, these factors, in addition to
others, need to be included in decisions related to environmental
hazard control.
The ongoing study is to address those health problems of current
concern. Many health problems in the United States, including major
diseases and illnesses, such as heart disease, respiratory illness,
and cancers, develop over long periods and result from the
interaction of environmental factors with factors related to
individual susceptibilities. These health problems are costly in
terms of mortality, medical care costs, lost productivity, and
associated pain and suffering and psychosocial problems. Long-term
epidemiologic studies, and other kinds of studies and analyses, are
needed to obtain information that will be useful in ameliorating or
preventing these health problems. The ongoing study can encourage
appropriate studies.
Much relevant information is now collected both by the federal
government and other groups. However, coordination of these efforts
needs to be improved and committments of appropriate resources to
long-tenm studies assured. Existing data collection systems need to
be assessed for quality and relevance. While future analyses of
existing information may yield useful results, substantial new data
collection systems are also required to provide answers to current
questions about environmental health hazards.
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The ongoing study as envisioned by this committee, will consist
of two major parts. One encompasses all the data collection and
analyses and related activities mentioned in the law. The other is
made up of the biennial reports and any other written materials
deemed appropriate. As indicated later in this chapter, the
committee suggests that DENS be responsible for obtaining the data
for the biennial reports from the various agencies that would be
responsible for collecting such data.
This committee has identified several goals and characteristics
the ongoing study should have in order to work towards providing the
estimates that Congress has requested. The first four items below
are broad goals for the ongoing study; the last three are
characteristics the ongoing study needs to achieve these goals.
1. Integrating available data
The ongoing study should help to generate, coordinate, and integrate
environmental and health data for use in identifying relationships
among health problems and their environmental causes, and to enable
evaluation of the consequences in terms of health costs. At present,
health data and data related to the environment generally are
collected independently, and it is difficult to integrate them.
However, further exploration of extant data sets may show
associations between illness in populations and environmental factors
that suggest further study. In addition, there may be ways of
linking various records about individuals in order to more
effectively associate exposure to environmental factors and resulting
health effects. Although the planning study focuses primarily on
improving epidemiologic data, it is necessary also to consider data
from animal and other experiments in order to prevent unnecessary
human exposure and to extend the information obtained from human
s tudies .
2. Coordinating statistical policy
The ongoing study should encourage various groups, especially in the
federal government, to explore the administrative and policy
questions that hinder coordination of statistical policy.
Questions of confidentiality and date compatibility might be
addressed. The effort would help prevent unnecessary duplication of
effort and would maximize the usefulness of data that are collected.
Data linkage in this report refers to the process of combining a
variety of sources of data about an individual in order to analyze
them for suspected relationships. Thus, one might link data from
occupational records with data from Social Security files and from
death certificates to see if workers in certain occupations developed
particular diseases or illnesses.
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3. Developing cost estimates
Many of the costs associated with illness cannot reliably be measured
with existing data. The ongoing st dy should improve the methodology
and data used to evaluate and expres_ these costs in dollar terms, as
well as in dimensions other than dollars, from which the dollar
f igures are derived. These other dimensions include, for example,
morbidity measures, loss of workdays, and measures^of utilization of
med ical servi ces .
4. Encouraging research
Efforts to associate environmental factors with resulting health
problems quantitatively, and to estimate all the associated health
costs, are in early stages of development. Further research is
needed to understand basic biological mechanisms, including
individual variability, as well as to develop methods of analyzing
data. Thus, the ongoing study should highlight areas needing further
research and methodological development. These efforts should lead
to better analyses of data and should improve the effectiveness of
data collecting efforts.
5. Assuring continuity
A mechanism to assure continuity and coordination is required for the
ongoing study. The National Academy of Sciences (NAS) and DUBS can
serve as the center of the coordinating effort, which will require
cooperation of many groups inside and outside the federal government.
6. Providing funding
A short-tenm effort would be of limited value in achieving the goals
of the ongoing study, although useful insights could result. A
continuing and adequate source of funding will be required to allow
the ongoing study to begin to provide the estimates Congress has
requested, and the ongoing study will need periodically to assess its
costs. New funding sources may be necessary to implement the
required long-tenm effort.
7. Providing flexibility
Finally, the ongoing study must be flexible. It must respond to new
developments. It must focus attention appropriately as new
analytical methods become available, new information develops about
disease etiology, and new problems assume major importance.
Approach for the Ongoing Study
P.L. 95-623 specifies an extremely broad charge. Although the
committee wishes to plan an ongoing study that responds to that
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charge as closely as possible, it will not be possible to cover all
areas mentioned in the law every two years. Therefore, the committee
recommends a more modest approach initially.
The committee considered which environmental factors should be
considered at first, given that the law specifies "pollution and
other environmental conditions resulting from human activity...."
These environmental conditions include almost all extrinsic
influences on humans. They include activities often classified as
"life-stylet' or "voluntary," such as habits of exercise, nutrition,
alcohol consumption, and smoking, as well as exposures to noise,
chemicals, air pollutants, radiation, and related factors.
The committee recognizes that "voluntary" and "involuntary"
exposures span a continuum with no sharp distinction between the
two.* Nevertheless, the committee recommends that the ongoing
study initially focus primarily on the health effects and costs
resulting from relatively involuntary exposures to physical and
chemical agents deriving from human activity. Any studies to assess
the health effects of the involuntary exposures to physical and
chemical agents, however, must take life-style and related factors
into consideration when they affect a person's response to harmful
agents. For example, studies on respiratory illness among miners or
asbestos workers should include smoking history. Thus, data related
to life-style and other factors such as socioeconomic status should
be collected when possible.
The remainder of this chapter presents several types of
recommendations. First are recommendations for implementing the
initial phases of the ongoing study, including preparation of the
first biennial report (after the planning study). Following this are
more general recommendations designed to improve our ability to
provide the estimates Congress requested. These recommendations
concern ways of improving data and analyses related to health, the
environment, and costing; improving coordination among various
concerned groups and maximizing usefulness of the reports; and
providing the required backup activities needed to carry out the
earlier recommendations. Most of these general recommendations are
long-term continuing efforts. They could begin in the near future
with appropriate support, but would be unlikely to become fully
implemented or to yield results in the near future.
In making these recommendations, the committee is building on
previous efforts and expects that the ongoing study will remain
Differences of definition and usage can blur the distinction even
further. For example, some people question whether smoking is a
"voluntary" activity, and others argue that asbestos workers have
"voluntarily" assumed their exposures.
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cognizant of related activities, especially those that the National
Center for Health Statistics (NCHS) is carrying out in complying with
other portions of P.L. 95-623.
The Early Years of the Ongoing Study
Conceptual Framework
The committee recommends the use of a conceptual framework for
identifying and organizing the data requirements for the ongoing
study. The framework consists of a series of tables which, if they
could be completed, would provide the data required to meet the
congressional charge in Section 7(e)~1)E of Pit. 95-623.* (See
Appendix A for the full text of Section 7.) For simplicity, the
framework is expressed in teems of substances, but could apply to
noise and radiation.
To trace the chain of impacts, four types of tables are
required. The first relates sources of hazards to ambient
concentrations or total amounts of these substances in the
environment,** a second relates amounts of hazardous materials in
the environment to human exposure, a third relates human exposure to
health effects,*** and a fourth puts a value on these health
effects. To determine the reduction in health costs from incremental
reductions in a particular environmental hazard, relevant entries
from the four types of tables would be appropriately multiplied
together and additional necessary computations performed.
This scheme is idealized; much of the needed information is not
available now. Even attempts to provide the required information for
such well studied cases as asbestos or lead leave many questions
unanswered, and require monographs rather than simple tables. In
addition, the information that exists has been collected in a variety
of forms for many different purposes. It is, therefore, difficult to
mesh the various sources, including literature sources, to yield in a
consistent manner information required to fill in the framework.
However, this framework may be helpful in organizing available
This Section asks the ongoing study to Quantify (i) the present
and projected future health costs of the diseases and effects
identified under subparagraph (B), and (ii) the reduction in health
costs which would result from each incremental reduction and change
referred to in subparagraph (~(ii)."
**These tables would correspond to Sections 7(e)~1)A and C of
P.L. 95-623.
*The second and third tables correspond to Sections
7(e)~1)B and D of P.L. 95-623.
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information and seeing where information is available and needed.
Any numerical estimates would have much uncertainty.
Initial Activities
The early phase of the ongoing study wit 1 have four re lated and
intertwined activities, which may continue in modified form
throughout the ongoing study. These are:
o reviewing what is known
o assessing the importance and promise of available information
o deve loping i 1 lus trative case studies
o encouraging development of required methodologies.
In recommending these activities, the committee recognizes that
the state of the art may be such that some of these activities may
not be possible to complete at this time, but the committee regards
the activities themselves as valuable and informative for developing
the congressionally mandated program. These beginning activities of
the ongoing study would not require new data collection.
A. Reviewing What Is Known
The conceptual framework described earlier will be used to
identify and assess information on the sources and amounts of
pollutants, levels of human exposure to these environmental hazards,
the health effects resulting from such exposures, and costs of the
health effects of such pollutants. Topics would be chosen by
applying the general criteria for setting priorities identified in
Chapter 1 of this report. The ultimate objective of this approach
to classify the various agents and their adverse health effects in
teems of:
their known, suspected, or potential health impacts, taking
into consideration the amount of hazardous material in the
environment
o the reliability of existing knowledge about them and the
potential usefulness of additional information in minimizing
harmful impacts
the public perception of their importance
o the need to study them further for policy purposes.
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Use of these criteria in setting priorities will require continuing
refinement as more experience is gained with efforts to examine
specific cases.
B. Assessing the Importance and Promise of Available Information
From the exercise of seeking needed information and evaluating
the data available, data needs will be identified, promising areas
for research outlined, and additional recommendations made to
assemble the needed data. This assessment will provide a perspective
for priority setting and a way of mandating feedback to improve
future studies.
C. Developing Illustrative Case Studies
These case studies would not attempt to duplicate the efforts of
other groups, such as the International Agency for Research on Cancer
or the National Academy of Sciences, but would go further in
attempting to integrate the many kinds of information needed to meet
the congressional request. Until concrete cases have been developed,
the appraisal of health costs will continue to be a theoretical
exercise of little or no value for action. When many case studies
are available, the resulting data on comparative health costs will
help policymakers decide where the national effort can best be
distributed. By choosing and appraising cases likely to be of
economic importance, the ongoing study can add substantially to the
growing body of knowledge so that, in addition to being a valuable
illustration, it also contributes to the long-term goals stated by
Congress. However, even for instances that do not have major
economic implications, a case study may be valuable if reduction of
ill effects is likely to be readily attainable at modest cost. A
full case study shows the users of the report the complexity and the
uncertainties raised by these cost and health questions.
At each step in the process, the uncertainties and gaps in the
data would be identified and the reasons for them described. From
this activity, recommendations for changes could be derived that
would make more satisfactory execution of the task possible in the
future.
The conclusions drawn from case studies would be presented with
appropriate qualifications and their usefulness for the purposes of
setting policy analyzed. It would be particularly important to
attempt to extract from this exercise any generalizations that might
apply to methodology, economic, political, or ethical issues.
Two case studies should be undertaken at first. One would focus
on a health problem and consider exposures as environmental
determinants. The other would focus on a pollutant or source of
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pollution and consider all health consequences. This dichotomous
approach would requi re re searchers to cons ider an array of
environmental determinants and health consequences. Cost estimates
would be attempted in both case studies. The goal would be to choose
cases where the etiologies are relatively well understood so that
data gaps could be identified, methodologies tried, and cost
estimates attempted. Examples that might serve these purposes are:
Health problems: chronic respiratory disease; lung cancer;
angiosarcoma; chronic disorders of the nervous system
Pollutants: asbestos; vinyl chloride; lead; nitrosoureas.
During the first two years of the ongoing study, it should be
feasible to report back to the Congress for a disease, or group of
diseases, of known etiology. Relevant questions include:
o What is the national estimate of exposure to the agents of
concern?
o How is this distributed among demographic subgroups of the
popu let ion ?
o What proportion of it is due to direct or indirect
occupational exposure, such as by family contacts ?
0 How does community exposure, stratified, for example, by
contact with production sources, compare with general
exposures ?
o Are there particularly sensitive populations at risk?
Similarly, if antecedent epidemiology and animal studies have
been done, it should be feasible to estimate the proportion of the
disease attributable to environmental exposures of various types.
Attempts to carry cut these case studies should indicate
methodological and data gaps that require attention.
D. Methodological Proarams
In addition to the studies indicated above, the ongoing study
needs a program of methodological development. Once systematic
attempts are made to assess current information, it will become clear
which areas require new methods to get quantitative results. The
ongoing study, therefore, will need to explore the comparative merits
of various data sources and methods for estimating health effects of
the environment and their costs. Original appraisals of various
methods will be required, because, as usually executed, these methods
would not contribute much to the data of the ongoing study.
Consequently, the appraisals would need~to consider not only the
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of the problem every two years, areas of attention should vary,
perhaps on a rotating basis. The reports would include the parts of
the framework described earlier, that is, data on sources of hazards,
human exposure, health effects, and health costs, as well as in-depth
analyses of some aspect or aspects of environmental health cost
problems. The reports also would discuss methodologies and make
recommendations.
The committee believes that these reports would be responsive to
the congressional charge to "identify deficiencies and limitations in
the data on the matters under consideration," "recommend actions
which may be taken to eliminate these deficiencies and limitations,"
and "include recommendations for facilitating studies of the effects
of hazardous substances on humans...."
The law also requires that the reports list various regulatory
and related activities that federal agencies-are taking to reduce the
identified health costs. A section of each biennial report can
include these.
Because the committee views methodological development as a
particularly crucial part of the ongoing study, it suggests that
periodically, as part of the ongoing study, a systematic review of
the methodologies available to do the work of the ongoing study be
collated, summarized, and published. Monographs prepared by the
National Center for Health Statistics, which puts out its
methodological papers periodically, may be appropriate models. The
proposed review would involve statistical, epidemiologic ,
toxicological, decision-making, econometric, and other methodologies,
insofar as they are relevant to the work and reports of the ongoing
study. The ongoing study could further encourage and publicize
methodological developments by additional means, such as holding
conferences and publishing papers.
The First Biennial Report
The first biennial report will reflect the work of the ongoing
study during the first two years. Thus, it will consist of tables of
data related to the conceptual framework, indicating in which areas
data are available and how dependable the estimates are; two case
studies; and a discussion of some specific methodological problems
and data needs, particularly those discovered while attempting to do
the case studies and fill in the framework. Recommendations arising
from these activities will be noted.
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substantial improvement. Promising sources for additional cost and
utilization data include Medicare Part B records, the National
Medical Care Utilization and Expenditure Survey (NMCUES), the
National Medical Care Expenditure Survey (NMCES), the National
Ambulatory Medical Care Survey (NAMES ), and third party payers,
especially the data of the Federal Employees' Health Benefits
Program. These data sets have, however, important limitations .
Medicare applies only to individuals over 65 or disabled; the NMCUES
and NMCES may include too few people to follow the costs of specific
diseases, though they provide good estimates of aggregate costs; the
NAMES includes only office visits by ambulatory patients to
physicians engaged primarily in office practice.
An investigation should be made of the
difficulties of analysis introduced by the
presence of multiple diagnoses.
Although many patients have multiple health problems, the usual
method in studies of costs of illness by diagnosis has been to
attribute all costs to the primary diagnosis. For more accurate
allocation of direct costs by disease category, in certain cases a
portion of costs should be attributed to conditions that aggravate,
bring about, or simply occur simultaneously with the condition that
is the principal diagnosis.
A comparison should be made between prevalence-
based and incidence-based direct cost estimates
for chronic diseases.
Prevalence-based costs are more easily estimated than are
incidence-based costs.* In many respects, however, incidence-based
costs are more logical and would give more appropriate information,
as, for example, in estimating future health costs of environmental
hazards and stepwise reductions in costs that could be achieved by
stepwise reductions in hazards. Few incidence-based health cost
studies exist, but a comparative analysis of prevalence- and
incidence-based studies would provide evidence as to how closely
prevalence costs approximate incidence costs in those instances that
logically call for incidence costs.
Net direct costs of illnesses should be calculated
In addition to the total direct costs now reported.
Prevalence-based costs for a disease during a given year are the
costs incurred during that year by all existing cases of the disease,
both new and old. Incidence-based costs for one year are the total
present and future costs (from discovery until cure or death) of all
cases of the disease that began during that year.
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Total direct costs are direct costs as conventionally
estimated. Net direct costs take into account future direct costs,
appropriately discounted, * that would have been incurred if the
person had not died. Net direct costs are the total direct costs
minus the discounted value of the health costs that would have been
incurred if the person had survived. Net direct costs are the
appropriate measure of direct cost reductions that could be expected
if the incidence of an illness or disease decreased; use of total
direct costs instead of net direct costs would exaggerate the savings
in medical expenditures that could be realized by eliminating some
d isease s .
To obtain profiles of medical care costs over time
incurred by individuals with specified diseases, a
longitudinal survey of patients in a prospective
study of costs by diagnosis should be begun.
Where possible, existing data sources likely to
provide useful information should be used.
Profiles of medical care costs over time could indicate the
distribution of costs between signal events, such as between first
diagnosis of a disease and death, and the distribution of costs among
a cohort at various points in the course of the disease. These two
kinds of information would provide important parameters relating to
some costs of disease about which little is known at present. The
Medicare and Federal Employees' Health Benefits programs are two
promising sources of data for developing profiles of medical care
costs by disease category.
The value of a longitudinal sample in providing more accurate
estimates would be realized only over-a period of years. Direct
costs in this sample would be calculated by directly measuring
expenditures on behalf of patients with specific diagnoses. Hospital
charges, physician charges, and other health care expenditures should
be determined for each patient, and average expenditures for new
cases of each d isease shou Id be derived from the individual data.
The prospective study should permit more accurate allocations of
direct costs among disease entities and also should yield new kinds
of information, especially the distribution of costs over time within
an episode. Non-health sector direct costs should be included with
other direct costs if they are found to be significant for
pollution-related diseases. The value of the sample would be further
enhanced if socioeconomic variables and life-style characteristics
were entered for each patient.
l
win estimating future costs, economists use a discounted value of
these costs, because resources that will be available or lost in the
future have a decreased value compared with those available or lost
now.
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In addition to longitudinal surveys,
cross-sectional surveys of patients to determine
utilization and costs of medical care should be
considered as a source of information about direct
costs and health effects.
A cross-sectional survey does not provide information on medical
care utilization and costs over extended time periods for
individuals, but it can include a larger number of respondents at
lower cost than can a longitudinal survey. As examples, NMCUES and
NMCES are two surveys that will provide data, starting in 1981, on
costs of disease and illness incurred by participants during one-year
periods.
Indirect Costs
The development of indirect cost estimates poses problems that
differ from those presented by direct costs. Direct costs measure
expenditures that occur, whereas indirect costs seek to measure
output or earnings that would have occurred, but didn't. The
recommendations below are designed to improve estimation of indirect
costs.
New data sets containing personal and job
characteristics for workers should be developed.
They should include personal characteristics
relevant to earnings and health, health histories,
and work histories, including occupation,
industry, and firm. Health problems should be
categorized, at a minimum, into fatalities,
permanently disabling injuries and illnesses, and
temporary disabilities. There should also be
measures of worker's compensation coverage.
Non-market activities should be entered, if
possible.
If feasible, these histories should be combined with the
longitudinal study of direct costs. These data will be valuable for
measurement of both indirect costs and willingness-to-pay (the latter
by improving the estimates of risk premiums in wages; in particular,
failure to correct for worker's compensation causes a downward bias
in the imputed wage premium for risk or injury).
Improved methods should be developed for
estimating earnings lost because of death.
The estimates might be improved by using occupation and
educational characteristics as well as age, sex, and race as
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predictors of earnings. Biases in the estimates of lost earnings may
occur because health status and earnings are correlated ; this
possible source of bias should be investigated.
Improved estimates of the value of non-market time
should be developed.
The value of time for homemakers, retirees, and the unemployed
needs further consideration.
Estimates of productivity losses due to illness
should be developed.
These include direct loss of time due to absenteeism, the
effects of chronic illness on productivity, and the effect of lost
on-the-job training due to prolonged illness.
The basis for choosing a particular discount rate
for calculating present discounted values needs
study and justification.
There is strong theoretical justification for discounting, but
there is little basis for choosing a particular value of the discount
rate. However, the calculation of indirect costs (and net direct
costs) depends critically on the discount rate chosen.
Willingness-to-pay Estimates
The ongoing study should assess the suitability of
willingness-to-pay values drawn from existing
studies for valuing losses due to morbidity and
mortality resulting from environmental hazards.
Further research on methods and data needs for
estimating willingness-to-pay to avoid specific
health outcomes should be undertaken. Continued
use and development of relations between wages and
risks as one way of estimating willingness-to-pay
for avoiding death is recommended.
The theoretical justification for willingness-to-pay is already
well developed, and few methodological breakthroughs can be
expected. However, there may well be considerable payoff from
improvements of data.
Wage data used in willingness-to-pay estimates
should be improved.
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According to economic theory, the appropriate measure for risk
premiums should be after-tax wages rather than before-tax wages.
However , gross wages should also be available for other types of
ca lculations .
Surveys should supplement market-based studies in
estimating risk premiums paid to workers.
Surveys, with all their difficulties, may be able to elicit
information that alternative approaches cannot. For instance, wage
premiums may inadequately reflect the cost of long-ter~ exposure to
toxic agents, because workers inadequately perceive the risk. The
committee proposes that, after identifying to the extent possible the
diseases and symptoms caused or exacerbated by pollution, the ongoing
study include surveys to assess willingness-to-pay to avoid
consequent health problems, including death from; particular
diseases. Symptoms of concern might include acute and chronic
respiratory problems, angina, and so on. Any such survey should
include important socioeconomic variables, such as age, sex,
occupation, wages, education, wealth, and health status variables,
especially a listing of the respondents' chronic diseases. These
data should enable researchers to derive a function relating
willingness-to-pay values for each of the health effects to personal
characteristics of the individuals at risk.
Costs of Pain and Suffering
Surveys of willingne~s-to-pay seem at the moment
the most promising method for measuring costs of
pain and suffering. It is recommended that
questions be added to surveys to determine if they
yield consistent and reasonable answers for
valuing pain and suffering. Any approach to the
measurement of costs of pain and suffering must be
regarded as a research problem at this time.
IS SUES RELATED TO COORDINATION AND PLANNING
Efforts should be made to coordinate data
resources among the many groups that have an
interest in environment-related health effects and
ensuing health costs, because such efforts will be
mutua 1 ly bene f i c ia 1 .
As an early activity of the ongoing study, mechanisms of
communication should be established with the many groups that can
either provide information re levant to the ongoing study, or use the
data and reports provided by the study. Such groups include federal
officials, non-federal government officials, labor groups, industry,
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health professionals, private foundations, insurance companies,
voluntary health organizations, public interest groups, research
institutions, universities, and international health groups.
Information from the various groups should be sought about data
collection and establishing principles, procedures, and standards for
collecting, analyzing, and disseminating raw data. For example,
public interest groups find that they need access~to raw data in
order to support their views on policy issues. The ongoing study
should maintain close liaison with non-federal government officials.
Such contact should lead to more effective data collection at the
state and local level. Such continuing contact also may guide the
ongoing study towards providing data and analyses that more readily
meet the needs of state and local government officials, many of whom
require environment and health data in order to set regulatory
standards.
The various groups, especially those in the
federal government, should explore the
administrative and policy questions that hinder
the coordination of statistical policies and the
sharing of data. Feasible solutions should be
sought.
This is a long-term effort that includes questions of data
compatibility, confidentiality, the purposes of the various agencies,
and funding arrangements for collecting data that could be used by
more than one agency. State and federal officials concerned with
environmental health problems should increase efforts to communicate
their needs to each other. Many issues need to be resolved about
what kinds of data can be exchanged among agencies, and under what
conditions and safeguards. Among its general recommendations, the
committee would give high priority towards continuing efforts to
coordinate statistical efforts at all government levels.
Planning
P.L. 95-623 calls for a broad study to determine the reductions
in health costs that would result from incremental reductions in
environmental hazards. However, environment-related health costs can
be calculated reliably for few, if any, illnesses at present. The
first biennial report will present some of the available information
needed to make such estimations and will attempt to develop estimates
for specific cases. A major purpose of the ongoing study is to set
in motion the activities needed to develop improved estimates.
This chapter has provided a conceptual framework for the ongoing
study, including recommendations for its administration and
suggestions for improving the available data. In order for the
ongoing study to proceed, it requires additional funding, trained
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personnel, and research efforts. The ongoing study must also
incorporate sufficient flexibility and feedback to respond to change
and maximize the usefulness of the biennial reports produced.
Funding
Adequate resources must be available for Carrying
out a task as complex and important as the ongoing
study.
Additional funding will be required to encourage various
agencies to collect and analyze data in ways that meet the goals of
the ongoing study. Costs of carrying out the ongoing study will
depend greatly on the extent to which the recommendations in this
report are followed. As the ongoing study proceeds, it will
periodically need to assess its associated expenses.
Although some recommendations for improving analysis of existing
data or for adding questions to existing surveys are not overly
expensive, collecting new data and setting up new data systems
require a long-term commitment of funds. In particular, longitudinal
studies must be undertaken to study long-te`~ effects of
environmental exposures, and such studies are expensive. They can
involve thousands of persons who must be studied over decades.
Stable funding is required to make such efforts feasible.
The costs of obtaining additional data or
different kinds of data and of doing additional
analyses should be considered in relation to the
potential usefulness of the new information.
Setting up and maintaining a data collection system is
expensive. Therefore, the possibility that an existing system could
be modified to serve a particular function adequately should be
investigated before establishing a new system.
Trained Personnel
Efforts should be made to increase the number of
persons trained in the fields needed to carry out
the goals of the ongoing study.
The language of P.L. 95-623 specifies a sufficiently broad and
concerted effort to deal with environmental health cost areas that
additional trained people will be needed in various fields. These
fields include epidemiology, toxicology, biostatistics, environmental
health, occupational medicine, and economics, the latter particularly
combined with extensive knowledge of environmental health issues.
Training in dealing with uncertain information would also be useful.
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Interdisciplinary efforts should be- encouraged so that data
collection and analyses reflect the best information available in the
various fields.
Opportunities for training people in the environmental health
fields should be increased. Training grants, such as those in
toxicology given out by the National Institute of Environmental
Health Sciences, may be useful. In addition, continuing education
programs can develop competence in the various fields among people
whose primary training was in related fields, such as medicine or
scientific research. Medical school and other health training
curricula should emphasize potential relationships between factors in
the environment and health consequences.
Research
Further research, including research related to
the basic biological mechanisms associated with
disease processes, is needed for deriving the
estimates required by P.L. 95-623. The committee
suggests particular attention to methods of
estimating exposure, populations with special
susceptibilities, extrapolation of dose/response
relationships to human beings from animal and
other laboratory studies, and, in the long teed,
the social environment.
People are exposed to many substances for varying lengths of
time and at different stages of their lives. Research is needed to
learn what the important measures are. For example, are illnesses
that are correlated with high peak exposures di fferent from illnesses
associated with many years of chronic low-level exposure? In
addition, ways of expressing and measuring effects of exposure to a
variety of substances must be developed; usually only one substance
or kind of substance is considered at a time.
The effects of genetic factors and other conditions that
predispose individuals and groups to disease susceptibility need
further exploration. Results of these studies could play a major
role in strategies to prevent illness from exposure to environmental
hazards.
There should be a strengthening of methods for assessing impacts
of the environment on human health by extrapolation from comparative
toxicological data in laboratory animals and other experimental
systems. Such studies serve a predictive function, warning of
potent ial harmful e f fee ts to human beings and al lowing prevent ive
measures to be instituted before illness or disease occurs.
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Some environmental factors resulting from human activity need
considerable further definition and study, and, therefore, the
committee does not suggest studying them in the short term. Research
on effects of some parts of the social environment, such as housing
and employment, that affect mental health should be conducted so as
to generate the type of quantitative information needed for
estimating the health costs required by the ongoing study. The
social environment could be a subject for one of the biennial reports.
Evaluation and Feedback
The committee recommends that there be provision
for evaluating the ongoing study and its reports
to determine how they can better meet the needs of
the various groups using them. The ongoing study
must incorporate sufficient flexibility to respond
to changing needs and conditions.
The ongoing study and biennial reports should serve a variety of
purposes. Regulators and policymakers may use the reports to obtain
data for setting standards; public interest groups need data to help
decide where to focus their efforts with limited resources; educators
can use the reports as teaching tools. If widely distributed--and
the committee hopes they will be--these reports could help keep the
general public informed on such issues as pollution chemistry, health
effects, economic analyses, and public policy issues related to
environmental affairs.
These reports also should alert readers to new methods relevant
to studying costs of environment-related health effects and newly
available data and data sources. For example, the reports could
identify clearinghouses for certain kinds of information. The
reports should present data and information in forms that are easy to
use, with limitations, uncertainties, and sources of information
clearly indicated. The various groups that may use the reports
should have ample opportunity to indicate their needs. The ongoing
study is seen as a continuing and changing effort, and it should be
responsive to the various groups using it.
CONCLUSION
The cost estimates that Congress has requested cannot be
obtained with precision in the near future. However, this committee
concludes that if the assumptions, limitations, and uncertainties of
any estimates are clearly indicated, attempts to obtain such
estimates can help decisionmakers to make informed judgments.
Much of the information Congress asks for is not now being
provided, but much could be provided with a little more effort and
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some organizational changes. Some requires new attitudes or new
methods of data collection. For example, change in data collection
systems is required to remedy the current lack of information on the
relationship between exposure to various materials or processes and
health outcomes.
During the past decade, increased public awareness has drawn
attention to the role of environmental factors in health and
disease. Many efforts are under way to understand, measure, and
control these effects. The ongoing study provides a unique
opportunity to evolve new efforts and methods and to focus and
coordinate existing efforts.
The ongoing study will encourage improved methods of estimating
costs of health effects and of expressing them in a variety of ways.
These estimates will permit a better evaluation of benefits of
potential programs to reduce environmental hazards. Used with other
necessary information, such benefit estimates can be used to better
allocate resources for improving health and the environment.
If the spirit of the foregoing recommendations is followed, the
nation's ability to prevent illness and disease will be enhanced.
Not only will information about relationships between environmental
hazards and illness increase, but also analysts will be better able
to assess the efficacy of actions designed to decrease harmful
environmental health effects. By showing where efforts to modify the
environment will yield the greatest health benefits, the ongoing
study could provide a major impetus for preventing health problems.
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Representative terms from entire chapter:
direct costs
