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

Chapter: 3 Environmental Health Monitoring at the Federal Level

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Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
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Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
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Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
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Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
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Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 39
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 40
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 41
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 42
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 43
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 44
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 45
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 46
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 47
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 48
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 49
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 50
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
×
Page 51
Suggested Citation:"3 Environmental Health Monitoring at the Federal Level." Institute of Medicine. 2004. Environmental Health Indicators: Bridging the Chasm of Public Health and the Environment: Workshop Summary. Washington, DC: The National Academies Press. doi: 10.17226/11136.
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Page 52

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3 Environmental Health Monitoring at the Federal Level∗ In recent years, the field of environmental health has been evolving from a narrowly defined focus to a more holistic approach due to a greater understanding of the complexity of the environment, the devel- opment of newer tools to answer more sophisticated research questions, and the changing needs of environmental health. After the Institute of Medicine (IOM) report The Future of Public Health (1988) was pub- lished, noting that the infrastructure in the area of environmental health was deficient and often fragmented, many federal agencies became ac- tively involved in mending the situation. Today, more than 50 federal agen- cies conduct environmental health monitoring. The five federal agencies that constitute the “traditional partners” in environmental health efforts— the Environmental Protection Agency (EPA), the National Institute for Occupational Safety and Health (NIOSH), the Agency for Toxic Sub- stances and Disease Registry (ATSDR) and the National Center for Envi- ronmental Health (NCEH) at the Centers for Disease Control and Prevention (CDC), and the National Institute of Environmental Health Sciences (NIEHS)—are the most recognized. The public relies on these agencies to safeguard them from the dan- gers of environmental hazards. Individuals and communities look to the CDC for protection against environmental diseases, to the EPA for pro- tection from environmental hazards, to NIOSH for elimination of work- place hazards, to ATSDR for its work on toxic exposures, and to NIEHS for research findings. At the workshop, speakers from these five federal ∗ This chapter was prepared by staff from the transcript of the meeting. The discussions were edited and organized around major themes to provide a more readable summary and to eliminate duplication of topics. 35

36 ENVIRONMENTAL HEALTH INDICATORS agencies outlined the contributions of their organizations to current envi- ronmental health monitoring efforts, and described the partnerships they have formed for collaborating on environmental health issues. GENERAL OVERVIEW OF EFFORTS OF THE CENTERS FOR DISEASE CONTROL AND PREVENTION The CDC has a long history of using surveillance to determine the cause and magnitude of public health problems. The CDC conducts epi- demiological studies that reveal risk factors and exposures and show linkages between them. These Uniform criteria are needed for re- studies are the basis for designing porting not just infectious diseases, interventions and evaluating their but all diseases. effectiveness. Effectively perform- -Michael McGeehin ing these tasks depends on having sound data, according to Michael McGeehin of the CDC. The CDC has 52 nationally notifiable infectious diseases—those for which regular, frequent, and timely information is considered necessary to control the disease. Uniform criteria are used for reporting each notifiable disease, and reports emanate from state and lo- cal health departments, health care providers, and laboratories. Uniform criteria are needed for reporting not just infectious diseases, but all dis- eases. Establishing a strong national health monitoring network, as a sin- gle source for uniformly collected data would make the data more reliable. In turn, the epidemiological findings would be more useful, and interventions would be more effective, stated McGeehin. The CDC oversees 15 surveillance systems, which are operated by eight agencies. Perhaps the largest problem with these systems is that they are fragmented, the information technology is outdated, and the data are often incomplete or untimely. They also place an unacceptable bur- den on respondents in the health care sector. Some of these problems are being addressed by the National Elec- tronic Disease Surveillance System (NEDSS), which is a standards-based approach for developing efficient, integrated, and interoperative surveil- lance systems at the state and local levels. The system includes tools for transferring data electronically from health care systems to health de- partments, and it follows strict security standards to protect confidential- ity. The CDC recently received $17.2 million from Congress to put into place the first step of the health monitoring effort for the nation. Recog-

MONITORING AT THE FEDERAL LEVEL 37 nizing that the involvement of health departments and environmental departments at the state level is essential for creating a national system, the CDC set up four environmental health tracking workgroups to obtain input from those interested in working together with the agency. The CDC also set up meetings to bring environmental and health groups to- gether, not only at the federal level, but also at the state and local levels. The CDC has already begun pilot programs in several states to bring col- laboration between state and local health and environmental agencies, to evaluate existing databases, to examine linkages among databases, and to help develop a health outcome surveillance system. The CDC also plans to establish university-based centers for excellence in health monitoring to provide research and technical assistance to the states. When the CDC has had good surveillance, it has succeeded in safe- guarding the health of Americans, stated McGeehin. For example, the greatest environmental health success in the United States in the past 30 years has been the lowering of The greatest environmental health blood lead levels in children. The success in the United States in the environmental intervention that past 30 years has been lowering of brought these results—removing blood lead levels in children. lead from gasoline and other -Michael McGeehin sources—was a collaborative ef- fort of the EPA and various health agencies that was based on good surveillance data. Further analy- sis and interpretation of blood lead level data showed health disparities in the population. For example, an African-American child living in older housing in the United States was found to be 22 times more likely to have an elevated blood lead level than was a white child living in newer housing (see Figure 3.1). Efforts have shifted toward vulnerable popula- tions in recognition that eliminating childhood lead poisoning in the United States will require targeting the children who are most likely to be affected. The rapid response to the outbreak of toxic shock syndrome in the early 1980s is another example of the public health benefit of sound surveillance data. In this case, a disease emerged that had never been encountered before, and surveillance was put into place quickly.

38 ENVIRONMENTAL HEALTH INDICATORS FIGURE 3.1 CDC surveillance shows that blood lead level data indicate health disparities in the population. African-American and Hispanic children who live in older housing in the United States are found to be 21.9 and 13 times, respec- tively, more likely to have elevated blood lead level than white children living in newer housing. SOURCE: DHHS, 1998. Reprinted with permission. Good surveillance identified the affected population and showed that a specific type of tampon was the main source of the disease. Swift action was taken to withdraw the material from the market and to educate the public. Surveillance is considered essential to the work of the CDC and critical to all of public health. The CDC has taken on the task of improv- ing its use and uniformity to make it yield more useful data and to reduce the burden on state and local health departments, health care providers, and laboratories. Environmental health monitoring is considered an im- portant addition. Environmental health monitoring can be done, but it must be done collaboratively, it must be done innovatively, and it must be done right, noted McGeehin.

MONITORING AT THE FEDERAL LEVEL 39 CURRENT EFFORTS OF THE AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY (ATSDR) In 1980, Congress created ATSDR to implement health-related sections of laws that protect the public from hazardous wastes and envi- ronmental spills of hazardous substances. The Comprehensive Environ- mental Response, Compensation, and Liability Act of 1980 (CERCLA), commonly known as the Superfund act, contains the congressional man- date to remove or clean up abandoned and inactive hazardous waste sites and to provide federal assistance in toxic emergencies. As the lead agency within the Public Health Service for implementing the health- related provisions of CERCLA, ATSDR is charged under the Super- fund act to assess the presence and nature of health hazards at specific Superfund sites, to help prevent or reduce further exposures and the illnesses that result from such exposures, and to expand the knowl- edge base about health effects of exposure to hazardous substances (http://www.atsdr.cdc.gov/congress.html). The agency is a part of the Department of Health and Human Ser- vices (DHHS), but its funding comes through the Superfund stream asso- ciated with the EPA. Henry Falk of the ATSDR outlined the mission of the agency, which is to serve the public by using the best science, by tak- ing responsive public health actions, and by providing trusted health in- formation to prevent harmful exposures and diseases related to toxic substances. The ATSDR’s personnel work at about 500 Superfund sites through- out the United States each year. The question that the public most fre- quently asks ATSDR workers is, How does the environment affect the health of our community? To answer this question accurately, we need linked data from three sources—environmental hazards, environmental exposures, and health outcomes. We also need standardized ways of evaluating community concerns. ATSDR has set up exposure registries for people exposed to various chemicals at Superfund sites, including benzene, dioxin, trichloroethane, and trichloroethylene. Other registries have been proposed, including one for tremolite asbestos exposure in Libby, Montana; one for multiple ex- posures around the World Trade Center site in New York City; and a multisite registry for exposure to natural uranium in areas with high levels. The public is concerned about disease clusters, and communities are looking to ATSDR for answers. They are asking not only about clusters of diseases for which registries exist—cancer and birth defects—but also

40 ENVIRONMENTAL HEALTH INDICATORS about clusters of diseases such as autism, multiple sclerosis (MS), and amyotrophic lateral sclerosis (ALS), for which no data exist for compari- son (see Figure 3.2). The agency has started disease-monitoring pilot studies for some of these diseases, ATSDR has set up exposure regis- such as multiple sclerosis. The tries for people exposed to NHIS showed a rise of about 50 various chemicals, including ben- zene, dioxin, trichloroethane, and percent in the incidence of multi- trichloroethylene. ple sclerosis from the early 1980s to the mid-1990s, and cases in women accounted for most of the increase (see Figure 3.3). ATSDR responds to concerns about disease clusters and other health issues by conducting site-specific investigations of diseases, performing epidemiological studies, establishing exposure registries, and launching pilot studies to track diseases. Falk cited a study that illustrates the high degree of precision needed in site-specific investigations. ATSDR inves- tigated a cluster of childhood cancer cases that occurred in Toms River, FIGURE 3.2 ATSDR informs the public not only about well-known disease clusters such as cancer and birth defects, but also about clusters of diseases such as autism, MS, and ALS. SOURCE: ATSDR, 2002. Reprinted with permission.

MONITORING AT THE FEDERAL LEVEL 41 160 Females 140 Males Estimated number of cases (per 100,000) Total 120 100 80 60 40 20 0 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 Years FIGURE 3.3 ATSDR is monitoring such diseases as multiple sclerosis. Their data show that from the early 1980s to the mid-1990s the incidence of MS rose by 50 percent. SOURCE: Noonan et al., 2002 (unpublished). Reprinted with permission. New Jersey, from 1979 to 1995. Of the seven townships in Ocean County, only one—Dover—had an unexpectedly high childhood cancer rate. Dover Township has many Superfund sites and many well fields. ATSDR investigators calculated the contribution of water from different wells and were able to link water from contaminated wells to affected children, said Falk. The analysis showed an association that reached sta- tistical significance when water consumption factors were considered. The association would not have been found if investigators had examined the rate for the entire county, rather than for each township, and if they had considered only how far people lived from the wells and had not also factored in water consumption. The example illustrates that sound envi- ronmental data and good health data are needed for linkages to be ex- plored in proper detail.

42 ENVIRONMENTAL HEALTH INDICATORS As the incidence of diseases such as multiple sclerosis and asthma continues to rise, we can expect the public to press ATSDR harder for answers about the relationships of these diseases to environmental fac- tors, stated Falk. To answer these questions, we need better surveillance and better monitoring, and we need more background data on exposure for comparison. We also have to examine combinations of risk factors, such as genetic susceptibilities, environmental factors from the distant and recent past, life-style, and other risk factors. CURRENT EFFORTS OF THE NATIONAL INSTITUTE FOR OCCUPATIONAL SAFETY AND HEALTH The NIOSH has much to contribute to the national health monitoring effort because of its long history in occupational health surveillance and the wealth of data and experience it can offer, said Kathleen Rest of NIOSH. For the past 25 years, NIOSH has played a key role in the sur- veillance of work-related illnesses, injuries, fatalities, exposures, and hazards. It also supports an active program of state-based surveillance, which can provide a model for collaborative efforts needed in environ- mental health monitoring. According to Rest, the occupational health community received a wake-up call in 1984, when Congress issued a report on occupational illness data collection (Committee on Government Operations, 1984). At that time, occupational health surveillance was described as 70 years be- hind communicable disease surveillance. The report called for a national data collection system to advance understanding of the link between workplace exposures and hazards and their related health effects. The report noted many challenges, such as long latency periods, multiple ex- posures, illnesses with multifactorial etiologies, transience of the work- force, differential susceptibilities, lack of awareness among workers and employers, and lack of occupational health training among physicians and public health professionals. Environmental health tracking shares some of these challenges. The report also highlighted the fragmentation of existing surveillance systems and the resulting inadequacies. In 1987, the National Research Council expanded on this with its own report (Pollack and Keimig, 1987), again documenting inadequacies and offering a set of recommendations. These included the following:

MONITORING AT THE FEDERAL LEVEL 43 • improving classification of occupational illness in the Bureau of Labor Statistics survey; • maximizing use of existing data systems, such as mortality re- cords, national health surveys such as National Health Interview Survey (NHIS) and National Health and Nutrition Examination Sur- vey (NHANES), cancer registries, and hospital discharge data; • improving physician education and awareness; • improving worker notification; • integrating and expanding the role of state health departments; and • improving hazard surveillance. There has been progress in the intervening years. NIOSH has col- laborated with the National Center for Health Statistics and vital statistics departments to develop the National Occupational Mortality System (NOMS), which enables the use of national mortality statistics for peri- odic surveillance of cause-specific mortality in industries and occupa- tions. It has collaborated with the Consumer Products Safety Commission (CPSC) to collect work-related injury data in the National Electronic Injury Surveillance System (NEISS). In the 1990s, NIOSH began period publication of its Work-Related Lung Disease Surveillance Report. To complement population-based occupational health surveil- lance, NIOSH developed and now supports state-based surveillance pro- grams. The Sentinel Event Notification System for Occupational Risks (SENSOR) is a collaborative effort between NIOSH and states to im- prove recognition and prevention of selected occupational health condi- tions, some of which overlap environmentally related illness, such as asthma and pesticide poisoning. The Adult Blood Lead Epidemiology Surveillance (ABLES) Program is a state-based effort to identify and track cases of elevated blood lead levels in adults. The Fatality Assess- ment and Control Evaluation (FACE) Program has expanded from an internal program of fatality investigations to include cooperative agree- ments with states that investigate occupational injury fatalities to better understand their causes, formulate recommendations to prevent similar injuries, and disseminate the information to target audiences. In the past three years, NIOSH has worked with many stakeholders and partners from state organizations, other federal agencies, the private sector, and the academic community to develop a strategic surveillance plan. The goals are to advance the usefulness of surveillance information at the federal level, strengthen capacity at the state level, strengthen sur-

44 ENVIRONMENTAL HEALTH INDICATORS veillance of high hazard industries and occupations, promote effective occupational surveillance in the private and nongovernmental sectors, and increase research to improve occupational surveillance. To illustrate the link between and potential synergies for occupa- tional and environmental health surveillance, Rest offered three exam- ples from NIOSH-supported state-based programs. The first is from the SENSOR program in the Department of Health Services, Occupational Health Branch in California. Over a six-day period in May 1999, a grower used metam-sodium to fumigate two fields in preparation for planning carrots. The process involved pumping metam-sodium from a tank, via a closed system, into an irrigation system where it was mixed with water and pumped through sprinklers into the air and onto the fields. When diluted with water during the soil fumigation process, metam-sodium breaks down and releases methyl isothiocyanate (MITC). MITC is highly toxic; exposure to MITC vapors can cause severe irrita- tion of the eyes and respiratory tract, headache, dizziness, nausea, and diarrhea. Inhalation can result in long-lasting effects, such as reactive airways dysfunction syndrome (RADS). Workers at an automotive repair shop about a mile away from the treated fields were the first to complain; they called the Fire Department and the Sheriff about odors. Two days later, the fire department received reports of sick children at an elemen- tary school located near the treated fields, and the school was evacuated. There were reports that other community members may have experi- enced symptoms. Pesticide poisoning was identified in three of the ga- rage workers. The buffer zone around the metam-sodium-treated fields was deemed inadequate to protect the garage workers, as well as the school children and teachers. In this case, the garage workers were senti- nels for the school children and the broader community. The second example is a case supported by the ABLES program in California. In the course of being treated for a work-related injury, a day laborer expressed concern about lead exposure. He was tested and found to have a very high blood lead level—74 µg/dL. He was working with a crew to dismantle an indoor firing range. The ABLES program reported the lab results to the California SENSOR program, which triggered a medical and industrial hygiene follow-up. These investigations found the firing range to be highly contaminated with lead, with few precautions taken to protect the workers. In collaboration with the local childhood lead program, the SENSOR program found four other workers with lead poisoning, nine children with elevated blood lead levels, and one spouse

MONITORING AT THE FEDERAL LEVEL 45 with high blood levels associated with washing work clothes. This case illustrates that: • toxins can be carried home; • tracking both worker and community exposure can increase chance of finding more persons at risk of serious illness; • state and local health departments can work together on such ef- forts; and • collaboration between occupational and environmental health sur- veillance staff can create synergies and enhance the value of both surveillance systems. The third example is from the Massachusetts Department of Public Health SENSOR program. Through its surveillance of work-related asthma, the program found that cleaning agents were the second most common asthma-causing agent identified by affected workers completing interviews. The Health Department subsequently partnered with several state agencies to address exposure to cleaning agents that may contribute to asthma in workers and in the public alike. This led to the inclusion of non-asthma-causing cleaning agents on the state’s vendor list of envi- ronmentally preferable products. State agencies and municipalities are now encouraged to patronize these vendors and use these products. In this case, occupational surveillance helped identify a cause-effect rela- tionship between asthma and a workplace product, which resulted in an intervention that will benefit both workers and the public. According to Rest, all three examples illustrate the integral connec- tion between the work environment and environmental health. Indeed, the use of toxic substances in the workplace and their release into the air, water, and soil can be the source of environmental pollution, community contamination, and their appearance in human tissue. Moreover, there are a host of overlapping concerns in occupational and environmental health, related to both exposures and health effects. Yet despite the many direct and indirect links between occupational and environmental health, the work environment is generally overlooked in conversations and initia- tives related to environmental health and environmental health tracking. Given the integral relationship between occupational and environmental health, it is ill-advised to discuss bridging the gap between environ- mental hazards, exposures, and health effects without considering and tracking exposures and health effects in the work environment. The time is right to enhance both federal and state capacity in environmental and

46 ENVIRONMENTAL HEALTH INDICATORS occupational health tracking and to exploit potential synergies for ad- vancing public health. CURRENT EFFORTS OF THE ENVIRONMENTAL PROTECTION AGENCY The United States is still at an early stage in developing tools to un- derstand environmental conditions and to make the linkages between health and the environment. According to Kimberly Nelson of the EPA, this is akin to the situation in the 1700s when Great Britain lost most of its naval fleet. One of its admirals simply miscalculated their location and took the flagship up onto the rocky coast of Great Britain. It was not that they didn’t understand the concept of latitude and longitude, but that they were using very crude, rudimentary tools and methods such as throwing a log off the side of the ship and counting how long it took the log to get from the bow to the stern. They would use this measurement to calculate the ship’s speed and to calculate their actual location. Nelson noted that we are in an analogous situation today as we try to understand environmental health data. To assess what environmental data are available and what they mean for characterizing the state of the environment in the country, in 2002 the EPA generated a State of the Environment Report (IDEM, 2003). The report had both short-term and long-term goals, stated Nelson. In the short term, the EPA’s intent was to gather and develop information that will enable the agency to make sound strategic decisions and to inform the public about the state of the environment. The EPA’s long-term goal was to use the report to bring together national, regional, state, and tribal efforts in the area of environmental indicators and to begin an in-depth dialogue about the relationships between environmental and health con- ditions. The report aimed to: • describe current environmental conditions and trends using exist- ing data and indicators; • present what is known and unknown about environmental trends and conditions; • identify data gaps and research needs; and • discuss the challenges that government faces in filling these gaps.

MONITORING AT THE FEDERAL LEVEL 47 The content of the report is organized around five themes: ecological conditions, human health conditions, cleaner air, purer water, and better land protection. Many questions, issues, and available national indicators surrounding these themes have already been identified from surveys and EPA workshops to determine the public’s interest. The EPA obtained data and input from its state partners and from other health agencies. Be- fore its release, the draft report was refined through external scientific peer review of the selection and description of indicators, the content and quality of supporting data, and the use of these data. The report is ac- companied by supporting technical information that is consistent with input received from the EPA Science Advisory Board, the National Sci- ence Foundation, and the Heinz Center’s indicator effort. The report was circulated for public review and comment. Producing a comprehensive national State of the Environment Report required coordinated information exchange among federal, state, and local partners and provided an opportunity to strengthen partnerships, said Nelson. An important partnership was formed between the EPA’s National Environmental Exchange Network, which offers a grants pro- gram to states to support the collection of high-quality environmental information, and the Health Tracking Network grants program of the CDC/ATSDR. The EPA has encouraged state applicants to view the two programs as synergistic opportunities and has received many applications that have included partnerships with multiple states or multiple agencies within the state. Such partnerships result in end products that will support both agencies. RESEARCH ACTIVITIES OF THE NATIONAL INSTITUTE OF ENVIRONMENTAL HEALTH SCIENCES The NIEHS primarily researches linkages between exposure and dis- ease, according to Samuel Wilson of the NIEHS. At the National Insti- tutes of Health (NIH) and other health agencies, they address questions such as why environmental diseases occur, how researchers can prevent them, and how much exposure is too much. Environmental health scien- tists know that there are many data gaps in the biology of environmental disease, and there are probably more data gaps than there are well-under- stood pathways. However, he noted that the field of environmental health has recently come of age scientifically. The number of environmental health articles published in leading journals of biomedical science rivals

48 ENVIRONMENTAL HEALTH INDICATORS that of many other fields. In fact, some of the best success stories in environmental health sciences are the overall success stories in biomedi- cal research. The underlying progress is occurring because scientists are developing a new set of tools for research on the biology of environmental disease that greatly increase our The field of environmental health has investigative capacity. For example, recently come of age scientifically. the application of genomics to the question of genetic susceptibility -Samuel Wilson represents a powerful new tool for the field of environmental health, according to Wilson. Toxicogenomics and genetic toxicology, tools that emerged from genomic sciences, are advancing our understanding fur- ther. Toxicogenomics, which includes proteomics and messenger RNA profiling, links gene expression with exposures to environmental stress- ors. Genetic toxicology has produced a large amount of information that we can use for biomarkers and for understanding cellular response. There has been a change in the toolbox, which makes our research capacity much more powerful. Animal models have been used in this field for decades; however with new genetic technologies, we can create animal models with specific types of experimental targets in mind and, thus, conduct more precise experiments. Instrumentations for analytical measurements have evolved and will continue to evolve in the coming decade. High-throughput assays in toxicogenomics and validation of as- says and surrogates will allow precise measurement of exposures. The national tracking system will benefit research by helping re- searchers and agencies to establish priorities, stated Wilson. Understand- ing national trends, and trends over time, can be a very persuasive feature for allowing the NIH to set priorities. Further, tracking will create a new science—the science of understanding what the information means, how to correlate it with information from other countries, and how to correlate it with trends over time. The status of the toolbox is excellent, but we are going to need new science to answer the more complicated questions in environmental health sciences. Scientists are constantly looking for new approaches, outside the box, to understand problems. In many ways the problems are the same, but the technology and the approaches are chang- ing and will undoubtedly get better over time, concluded Wilson.

MONITORING AT THE FEDERAL LEVEL 49 BUILDING PARTNERSHIPS FOR EFFECTIVE ENVIRONMENTAL HEALTH MONITORING Good dialogue with the public must be maintained while the national health monitoring system is created. Fortunately, the time has never been better for building relationships with the public and among agencies, noted Richard Jackson,1 of the Centers for Disease Control and Preven- tion. At the national level, the NCEH and ATSDR have recently com- pleted a consolidation of the two agencies around environmental health. Another collaborative step has been the establishment of the National Electronic Disease Surveillance System to create a common architecture for all information systems that collect data. A third step is the E-Health Initiative, which will allow electronic access to the disease reporting of large information systems run by health insurance companies, pharma- ceutical suppliers, and other reimbursement agencies. Three to four of the largest companies collect 85 percent of these data in the United States. Linking the CDC with that source makes more sense than having the CDC try to gather all of the information alone. The time is ripe for making this connection, and companies are open to working with the NCEH. The EPA has been a willing collaborator in many NCEH efforts, and communication has evolved over time. The NCEH is now in its third year of a collaborative program with more than 20 states, and its infrastructure allows workers to attend to a particular set of issues in environmental health. When the NCEH began its program, the state health officer typically did not know the state envi- ronmental director. Now, collaborative efforts within the states are common. A sound understanding of environmental public health issues at the state level is vital for developing intervention programs, because the re- sults of research generated at the national level otherwise may not trans- fer well to the local level. A prime example of a potential disconnect between research findings and their application in the community is the Institute of Medicine (IOM) report Clearing the Air: Asthma and Indoor Air Exposures (2000a), which cited evidence from academic studies showing that asthma morbidity and incidence of attacks could be reduced through elaborate environmental methods, such as vacuuming the sub- jects’ houses three times a week and setting up various controls, that may not be workable in the “real world.” 1 State Health Officer of California.

50 ENVIRONMENTAL HEALTH INDICATORS How can these kinds of measures be translated into action at the lo- cal level, particularly in impoverished and disenfranchised communities, to bring progress in reducing asthma? The answer at NCEH was to invite each state to devise its own model for putting asthma controls into place. The states, in turn, have developed partnerships with local universities and with advocacy programs and have tried to develop the best model for an asthma intervention program. Creating 25 or so prototypes and exam- ining how each worked was time well spent. The NCEH was able to identify programs that worked in schools, in day care centers, in inner cities, and in a variety of other settings. Linked to these programs were surveillance programs that allowed the NCEH to monitor the number of asthma cases and identify sentinel events. The environmental public health community is beginning to recog- nize the value of working together. Agencies are beginning to understand that if common standards and common definitions can be agreed upon across agencies, information can be shared more easily. This cooperative effort will require compromise and a willingness to give up some sys- tems that are unique to a particular organization, but the potential benefit is an improved quality of information and greater access to that informa- tion by agencies, health professionals, and the public, noted Nelson. In the past, we’ve learned that if research is ahead of the public health en- terprise, things don’t work. Similarly, if the public health enterprise doesn’t communicate and work with local communities, then things don’t work, stated Nelson. Can a time be envisioned when the government issues a State of the Environment Report that involves not only the EPA but also the CDC, NIOSH, NIEHS, and other federal agencies engaged in environmental health work? Such collaboration would imply a new arrangement, a su- pra-departmental or supra-agency way of examining environmental health issues and deciding what the federal government’s priorities would be in this area, suggested Nelson. The EPA has begun the dialogue with other federal agencies and will be communicating with people from the states about its State of the Envi- ronment Report (USEPA, 2002). Agencies are beginning to under- The agency hopes someday to stand that if common standards and have the report involve more than common definitions can be agreed just the EPA and its state and upon across agencies, information tribal partners, noted Nelson. can be shared more easily. -Kimberly Nelson EPA representatives are meeting with the Council on Environ-

MONITORING AT THE FEDERAL LEVEL 51 mental Quality (CEQ) and other federal agencies to discuss how they wish to be involved in this year’s report. The EPA wants to work with its partners to do whatever can be done within the short timeframe available for producing the report. Such collaboration is only the first step. The ideal is to have merely a report that is issued not by one agency with help and support from others, but a single report that is produced by many partners working together. Conversations in that direction are under way with pertinent agencies. Although the 2002 EPA report was not produced in complete part- nership with other agencies, bringing the agencies together to cooperate on aspects of the report would not have happened 10 years ago, stated McGeehin. Today, agencies do come together, and public health officials are present when environmental regulations are considered. The federal government’s strategic plan to eliminate lead poisoning in children is a good example of collaboration among federal agencies in addressing an environmental health problem that also is a housing problem and a dis- parity problem. The approach has involved the Department of Housing and Urban Development (HUD), EPA, DHHS, CDC, and several other agencies. Another example of a collaborative effort that would not have taken place 10 years ago is the study of the childhood leukemia cluster in Fallon, Nevada. Two of the primary agencies involved in that study are the state environmental agency and the state health agency. However, the EPA also is involved, as are the ATSDR and NCEH at the CDC. All of these agencies have become involved in bringing their expertise to bear on this environmental health issue, to everyone’s benefit.

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This report is the summary of the fourth workshop of The Roundtable on Environmental Health Sciences, Research, and Medicine. Environmental Indicators: Bridging the Chasm Between Public Health and the Environment, continues the overarching themes of previous workshops 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.

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