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Major issues in the environmental health decision-making process.

Introduction

In 1965, the British statistician Sir Austin Bradford Hill commented, "All scientific work is incomplete - whether it be observational or experimental. All scientific work is liable to be upset or modified by advancing knowledge. That does not confer upon us a freedom to ignore the knowledge that we already have, or to postpone the action that it appears to demand at a given time" (1). His commentary is splendid and insightful. Presently, a challenge both scientists and decision makers face is determining how much knowledge or evidence is sufficient to initiate action and what the best approach is to transferring research into decision making.

In the area of environmental health decision making, many questions remain to be answered. For example, should we take any action on the basis of the available evidence about the possible health effects of exposure to residential electric and magnetic fields? Should we use alternatives to chlorination in drinking water because chlorination by-products may increase cancer risk? Do we need greater certainty before reducing greenhouse gas emissions? We have no easy answers to these questions. Clearly, decisions should be made on the basis of accumulated scientific evidence. Nevertheless, there is disagreement: People who advocate "precautionary principles" believe we should do something right now rather than wait and see; people who adopt a "conservative approach" insist that we gather more information before taking any action.

To make the best use of research findings in the formulation of environmental health policy, both scientists and decision makers need to break down current communication barriers. Also, we need to improve our understanding of key issues in the environmental health decision-making process.

What Is the Environmental Health Decision-Making Process?

The environmental health decision-making process may be defined as the formulation of a set of principles or standards for assessing, controlling, and preventing the health impacts of environmental hazards, as well as for improving the health status and well-being of the whole population by optimizing the underlying environmental determinants of human health. Since there has been little discussion in the literature about how to define the environmental health decision-making process, the definition proposed here is open for debate.

Why Is the Environmental Health Decision-Making Process Important?

Edmund Burke, the British historian and philosopher, noted more than 100 years ago that "all that is necessary for the force of evil to triumph is for a few good men to do nothing" (2). Likewise, scientists will contribute to the degradation of environmental quality and human health by doing nothing with the results of environmental health research. It has been increasingly recognized in the scientific community that environmental epidemiologists, exposure/risk assessors, and environmental health officers should take active and significant roles in the environmental health decision-making process.

Who Makes Decisions?

Decisions usually have been made, at least in part, within the wider government system, including federal, state, and local governments. Most decisions involve - and impinge on - a wide range of stakeholders and actors (3):

* Elected officials are charged with making the decisions. Their attitudes and beliefs have a significant impact on the decision-making process.

* Scientists may be involved in the initial research that has identified a problem, as well as in helping to devise solutions. They commonly play a limited role in the environmental health decision-making process.

* Business and industry may be implicated in the cause of the problem and may be partly responsible for implementing and financing solutions. Their concerns and attitudes usually influence the decisions of elected officials.

* Planners may be involved in translating general policies into local action and in monitoring implementation. They often have the most direct and relevant views about the potential impact of the decision on the local community.

* The media may be involved in raising awareness about the problem and may act as an unofficial watchdog on the action taken. Frequently, the media greatly influences the knowledge and attitudes of elected officials.

* The public must, in the end, accept, pay for, and live with the results of the decisions. Community residents rarely take part in the environmental health decision-making process. Increasingly, however, it is being recognized that the public should be directly involved in the decision-making process.

Which Tools Should Be Used?

A range of tools is available to the environmental health decision maker. Some of the tools are used frequently in setting environmental exposure standards and improving environmental health management. Table 1 lists the advantages and disadvantages of these tools.

[TABULAR DATA FOR TABLE 1 OMITTED]

Risk Assessment

This approach characterizes the potential adverse health effects of human exposures to environmental hazards (4). Risk assessment has several elements:

* description of the potential adverse health effects based on an evaluation of results of epidemiological, clinical, toxicological, and environmental research (hazard identification);

* extrapolation from those results to predict the type and estimate the extent of health effects in humans under given conditions of exposure (dose-response assessment);

* judgement of the number and characteristics of persons exposed at various intensities and durations (exposure assessment); and

* summary judgements about the existence and overall magnitude of the public health problem (risk characterization).

Risk assessment helps assess and record information about environmental hazards by

* assessing at a point in time;

* assessing changes of risk over time;

* assessing the actual or potential effects on risk of particular interventions (thus enabling cost-benefit analysis)'

* prioritizing issues in terms of their risks; and

* providing a consistent and transparent process (5).

The ultimate aim of risk assessment is "to provide complete information to risk managers, specifically policy makers and regulators, so that the best possible decisions are made" (6).

Cost-Benefit Analysis

This process weighs the benefits of an intervention against its costs by assigning monetary values to both (3). Cost-benefit analysis is widely used in the environmental health decision-making area. For example, the U.S. Centers for Disease Control and Prevention (CDC) has used cost-benefit analysis as a tool in formulating a strategic plan for the elimination of childhood lead poisoning (7).

Cost-Effectiveness Analysis

Comparisons are made between different forms of pollution control aimed at achieving a defined reduction in health risk. Cost-effectiveness analysis avoids many of the difficulties presented by cost-benefit analysis, but it is clearly more limited in scope (3,8).

Environmental Health Indicators

These may be defined as expressions of the link between environment and health, targeted at an issue of specific policy or management concern and presented in a form that facilitates interpretation for effective decision making (9). Environmental health indicators are more complex than health or environment indicators on their own. A link between environmental exposure and health effects is assumed, but this link may not hold for all persons or all groups at all times. Susceptibility varies among individuals, determined by genetic factors, exposure to other pollutants, and the presence of diseases that make individuals susceptible to the environmental factors considered to be indicators. Environmental health indicators, if well developed and sensibly used, can play an important part in supporting environmental health decision making.

Other Indicators

A range of other methods is available to support policy formulation and decision making, including health impact assessment, distribution analysis, decision trees, sensitivity analysis, expert systems, and decision support systems. In general, these tools are used for particular concerns or in specific circumstances.

Toward More Effective Decision-Making

The Decision-Making Process

Decision making is a social and organic process (3,5). As a result, no single model can apply in all circumstances. The process varies substantially according to the organizational and administrative context, the issues and individuals involved, levels of knowledge, local perceptions and beliefs, and many other factors, including

* value placed on health, environmental protection, and future generations;

* strength of data;

* public understanding and perceptions of risk;

* costs of intervention;

* leadership;

* public input into policy setting;

* emphasis on planning for future;

* degree of collaboration;

* regulatory and judicial process;

* seriousness of outcome;

* involvement of mass media; and

* targeted message for policy makers.

Formulation of environmental health policies usually occurs in two stages: the scientific stage and the administrative stage (8). The following issues are considered at the scientific stage:

* knowledge of the environmental health hazard,

* evaluation of the risk, and

* assessment of the environmental hazard.

At the administrative and political stage, we need to

* judge acceptable risk;

* determine the population to be protected;

* consider the human ecology and the biophysical system;

* choose control technology and risk reduction strategy;

* assess social, economic and environmental impact; and

* formulate legislation or standards.

Common Problems in the Policy-Making Process

The decision-making process is far from simple; numerous conflicts and uncertainties can arise. A number of constraints are involved, such as the need to

* determine actual risk,

* quantify the extent to which prevention can be achieved,

* extrapolate from evidence derived at high doses to determine risk at lower doses,

* extrapolate from animal data to human risk,

* extrapolate from past or current data to future generations,

* allow for the effects of combinations of exposures and multiple routes of exposure,

* ensure adequate control for all possible confounders,

* select an appropriate model and verify the model,

* define and value quality of life, and

* cope with communication barriers between scientists and elected officials (3,5,9).

As Schwartz and Corvalan have noted, there is, sadly, commonly a gulf between the scientist and the decision-maker. Scientists are often reluctant to become embroiled in what has been called "the corridors of power" for fear of prejudicing their scientific objectivity (and simply because of lack of time). Those with decision-making responsibilities are not expected to be directly involved with the scientific technicalities behind the information they use. This cultural gap between science and decision-making is clearly not healthy It requires both groups to attempt to close it (3).

In addition, the major interests of the scientist and the elected official differ in some fundamental ways (Table 2). These differences are determined by knowledge, skills, professional requirements, and political and bureaucratic pressures.

Conclusions

Decision making is an interactive process of information exchange and gap bridging. Communication is one of the key issues in the decision-making process. In the area of environmental health, communication barriers appear to separate people in different sectors, particularly the scientists and the decision makers. To break down these barriers and make communications more effective, the authors propose the following strategies for scientists and decision makers. Scientists need to

* be encouraged to interpret their findings for decision makers in explicit and succinct language;

* use mass media effectively and efficiently;

* communicate regularly with decision makers about environmental health hazards; and

* increase their awareness that, if the results of their studies are not interpreted for key decision makers and used to formulate environmental health policy, the work has not been completed.

Elected officials need to

* understand the importance of applying scientific knowledge in the policy-making process;

* be encouraged to list environmental health issues on the election agenda;

* communicate regularly with scientists about environmental health hazards; and

* find ways of handling long-term impacts, which are often complex and uncertain.
TABLE 2

Major Interests of Elected Officials and Scientists

Elected Official Scientist

politics-oriented issues science-oriented issues
votes scientific findings
case report well-designed studies
mass media scientific journals
short-term impacts both short- and long-term impacts
simplicity and certainty complexity and uncertainty


The authors anticipate that the environmental health decision-making process will be greatly improved if the gap between science and decision making can be bridged. The quality of information available and the approach to communication will have a significant impact on the decision-making process. Scientists and decision-makers need to work together more closely, and involvement of the public and other stakeholders should be strongly encouraged. An effective environmental health decision-making process can be established when discussion is stimulated and a partnership approach is taken.

Corresponding Author: Shilu Tong, Centre for Public Health Research, Queensland University of Technology, Victoria Park Road, Kelvin Grove, Qld. 4059, Australia. E-mail: <S. Tong@qut. edu.au>>.

REFERENCES

1. Hill, A.B. (1965), "The Environment and Disease: Association or Causation?" Proceedings of the Royal Society of Medicine, 58:295-300.

2. Hill, B.W. (1975), Edmund Burke on Government, Politics and Society, London: Fortana.

3. Schwartz, E., and C. Corvalan (1996), "Decision-Making in Environmental Health," In D. Briggs, C. Corvalan, and N. Nurminen, eds., Linkage Methods for Environment and Health Analysis, Geneva: World Health Organization.

4. Guideline for Risk Characterization (1995), Washington, D.C.: U.S. Environmental Protection Agency.

5. National Environmental Health Forum (1998), Environmental Health in Australia, Canberra: Commonwealth of Australia.

6. Paustenbach, D.J. (1989), A Risk Assessment of Environmental and Human Health Hazards: A Textbook of Case Studies, New York: John Wiley & Son.

7. Strategic Plan for the Elimination of Childhood Lead Poisoning (1991), Atlanta, Ga.: Centers for Disease Control and Prevention.

8. Koning, H.W.D. (1987), Setting Environmental Standards, Geneva: World Health Organization.

9. Kjellstrom, T., and C. Corvalan (1995), "Framework for the Development of Environmental Health Indicators," World Health Statistics Quarterly, 48:144-54.
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Author:Lu, Ying
Publication:Journal of Environmental Health
Date:Jul 1, 1999
Words:2132
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