Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary (2004)

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Summary* Lynn Goldman The Institute of Medicine’s Roundtable on Environmental Health Sciences, Research, and Medicine was formed in 1998 to provide a neu- tral setting for individuals with different backgrounds and perspectives to discuss sensitive issues of mutual interest. By bringing together partici- pants from the academic community, federal government, industry, and other sectors who are actively engaged in activities related to environ- mental health, the Roundtable helps to identify problems—current or potential—and considers approaches to solving them. The aim is to share knowledge and ideas, but not proffer formal advice or recommendations. This workshop brought together a diverse group of participants from a variety of fields to discuss the current state of environmental health monitoring in the United States, to look into monitoring systems of other nations, to consider the need for a national environmental health moni- toring system, to foster a dialogue on the steps for establishing a nation- wide monitoring system, and to explore how a national system will fit into current exposure and disease monitoring programs. The workshop was not intended as a forum for detailing which indicators should be in- cluded in a national monitoring system, because many organizations are already engaged in this work. Rather, the aim was to consider the overall tasks of identifying, developing, and using indicators to monitor envi- ronmental health. Representatives from federal and state government, local govern- ment, academic institutions, industry, private organizations, and global health organizations spoke about current environmental health monitor- ing efforts and plans for the future. Conference participants discussed the * This was an edited version of the summation by Dr. Lynn Goldman at the workshop. 1 

2 ENVIRONMENTAL HEALTH INDICATORS use of indicators to monitor the status and trends of health, to develop the interventions to protect and promote health, and to build a core capacity to respond to environmental health problems. They explored frameworks for developing indicators and methods for ranking environmental health risks. They also discussed the criteria for establishing the national envi- ronmental health monitoring system, the potential benefits and limita- tions of the system, privacy issues raised by the system, the scientific underpinnings of the system, and the funding required. They discussed how to elicit the participation of health professions, industry, community groups, and the general public. Further, they considered how workers will collect and analyze information and the specialized education and training that they will need. Tord Kjellstrom of the Australian National University stated that a main aim of an environmental health indicator is to provide an easily interpretable measure of the state of the environment or the health of a defined population (e.g., an urban air quality variable, or the life expec- tancy of a population). He suggested that creating indicators that can be interpreted in terms of linkages between environmental quality and pub- lic health may be difficult. Thomas Burke of Johns Hopkins University noted that environmental health indicators fall into four categories: haz- ard indicators (for example, motor vehicle emissions), exposure indica- tors (blood lead levels), health outcome indicators (lead poisoning), and intervention indicators (programs that address motor vehicle emissions). Burke remarked that indicators must be measurable (comparable and quantifiable), understandable to policy makers and the public, and defen- sible (that is, they must support a relationship between environmental factors and health status). They also must allow trends to be examined over time. Further, they must be linked to public health goals. Several overarching themes emerged during the workshop. First, the concept of establishing a national system to monitor environmental health, and eventually all of public health, received consistent support. This support came from federal, state, and local government agencies; from leadership within the administration; from private organizations; and from the public. Senator Hillary Rodham Clinton cited a growing concern among the public about the effects of environmental exposures on health and noted strong congressional support for a national monitor- ing system. These views were echoed by Eve Slater of the Department of Health and Human Services and Paul Gilman of the Environmental Pro- tection Agency, who represented the current administration. Carol Henry of the American Chemistry Council suggested that opportunities exist for 

SUMMARY 3 various private and public organizations to partner with one another to help promote understanding of the value of a national health monitoring system. William Pease of GetActive Software noted the potential for web-based services to provide access to health indicators. Morris “Bud” Ward of Morris A. Ward, Inc., mentioned the media’s role in informing the public about environmental health issues. Second, many participants agreed with Baruch Fischhoff of Carnegie Mellon University, that creating the infrastructure for such a system is a critical need. He stressed the importance of a design that incorporated social science principles of risk communication and evaluation. Samuel Wilson of the National Institute of Environmental Health Sciences noted that substantial research from the biomedical science community is available to inform the process and that newly developed analytic and informatics tools now permit a large body of complex information to be managed and analyzed. Third, several participants acknowledged current efforts to monitor environmental health as a platform for moving forward. Kimberly Nel- son of the Environmental Protection Agency (EPA) stated that the EPA would soon publish a report that will accurately portray the state of the environment and environmental trends in the United States and the limi- tations of current data. Patrick Leahy of the U.S. Geological Survey (USGS) discussed the work of the USGS in addressing aspects of natural science that have links or potential links to public health issues. He em- phasized that research conducted by the USGS is providing means of better understanding the processes and pathways between and among the abiotic and the biotic realms. Michael McGeehin of the Centers for Disease Control and Preven- tion (CDC) described a new initiative, the National Electronic Disease Surveillance System, that combines all current surveillance systems at the CDC into a uniform, efficient, standards-based system in an elec- tronic format so that it is useful for public health, research, private indus- try, and other public health care industries. Kathleen Rest of the National Institute for Occupational Safety and Health (NIOSH) described collabo- rative surveillance efforts between NIOSH and state health departments to improve the recognition and prevention of occupational health prob- lems. She noted the convergence of concern around a host of occupa- tional and environmental exposures and health effects, and urged inclu- sion of the work environment in efforts related to environmental health tracking. 

4 ENVIRONMENTAL HEALTH INDICATORS Participants discussed the many challenges in developing and admin- istering a national environmental health monitoring system. Several speakers noted that such a system must be structured so that officials working at the state and local levels can use it effectively. The effort is complicated by the fact that no strategic plan is in place to move the pro- gram forward within the federal government. Further, no process exists for stakeholders to guide the process over time. Several participants sug- gested that a commission or advisory committee could be an avenue for providing continual input to the program. Participants also considered the challenge of improving coordination among the agencies involved in environmental health monitoring. Shel- ley Hearne of the Trust for America’s Health noted that monitoring must be a fully integrated operation, not only within the CDC as the epicenter of activity, but also among the 50 or more agencies that have some in- volvement in environmental health activities. Harold Zenick of the EPA cited the need to link separate areas of research to produce an environ- mental health continuum from source to exposure to health outcome. Mark Horton of Public Health Services, Orange County, California, de- scribed the need for a coordinated approach to environmental problems by institutions and agencies acting at the local level. Richard Jackson of the CDC noted that the federal Children’s Environmental Health Initia- tive provides a successful model of interagency cooperation on cross- agency issues. Speakers representing the current administration sug- gested that leaders in the administration might be able to establish the required coordination. A further challenge discussed by participants was finding ways to bridge the gap between environmental health and chronic disease. In health agencies, chronic disease research and public health interventions are often isolated from environmental research and environmental health interventions. Yet successful monitoring of environmental health re- quires the participation of the chronic disease community. For example, tobacco smoke may be considered a social issue, an environmental issue, or a chronic disease issue; addressing this issue requires a coordinated effort from all three standpoints. Participants noted that the gap between the science community and the public health community also must be bridged. Wilson mentioned that complementing the environmental health monitoring program with a strong research program will better enable public health officials to set priorities. Jackson added that good research requires adequate and sus- tained funding. Leahy called for a strengthening of partnerships and col- 

SUMMARY 5 laborative efforts between the natural science community and the public health community. Finally, many participants said that the next generation of experts must be trained in epidemiology, environmental health, laboratory sci- ences, and related fields, because their expertise will be required to en- able a national monitoring system to function properly. Funding is neces- sary to provide these experts with jobs in the areas that need them. Henry Falk of the Agency for Toxic Substances and Disease Registry noted that medical educators have to emphasize the role of the public health system and the links between medical care and public health. The nation has reached a pivotal time for establishing a national monitoring system. The Pew Commission report of 2000 was instrumen- tal in planting the idea (Pew Environmental Health Commission, 2001). About a year was needed for the concept to become known and accepted by health agencies, the government, and the public. Currently, efforts to develop the national monitoring system have begun, and support for the concept is growing slowly in many quarters. A surge in acceptance could bring a new set of concerns. Once legislation has been passed and the initiative has been funded, the monitoring process will be largely out of the control of environmental health experts. Thus, the time to act is now. What can be done today to ensure that the growth of the national en- vironmental health monitoring system is systematically achieved and well coordinated? One means is to achieve a central focus for the pro- gram, through either a federal task force or a single leader. A second means is to create a guiding body to help steer the effort so that progress is structured both from the “top down” (e.g., the federal level) and from the “bottom up” (e.g., the state, local, and community levels). A third means is to begin to fill the brain trust that must be in place to achieve a well-functioning monitoring system. Attaining any one of these goals may appear to be a daunting task, yet achieving all of them simultane- ously is vital to creating an effective monitoring system that will safe- guard the environment and human health.