The future of environmental health and the need for public health leadership.

As one who spent some 17 years at the local level, and dealt with local agencies an additional 21 years while working primarily at the state level, the issues (to be discussed by this panel) intrigued me sufficiently to cause me to say "yes," while I try to make a habit of saying, "no." After preparing this paper, I happened to notice that I presented some similar thoughts in a paper entitled, "Environmental Health -- Everybody's Responsibility" before an American Medical Association meeting on Future Issues in Environmental, Public and Occupational Health in the early 1970s.

Obviously, the title (of the discussion today) is a play on words. We may ask, "who in health is in charge of the environment?", but we also wonder, "who in hell is in charge of the environment?" The issues are similar at the federal, state and local levels. Our colleague Barry Stern with the USPHS Bureau of Health Professions has a contract with the Johns Hopkins School of Public Health to identify the myriad agencies in each state which have environmental health and protection responsibilities. Preliminary results indicate that some 85 percent of state level environmental health and protection funds and efforts are expended by environmental health and protection agencies other than traditional state health departments. This finding is not startling, as it was anticipated by many of us. A similar study should be conducted to determine responsibilities at the local level, but such a local study would obviously be manifold more complex, difficult and expensive.

As an opinion, I suggest that the reverse may be true at the local level, with some 85 percent of local environmental health and protection responsibilities being assigned to health departments, and the remainder being assigned to other environmental health and protection agencies. But programmatic scope at the local level is typically somewhat different from that at the state level. As a dangerous generalization, state agencies are more apt to have responsibilities for activities such as water pollution control, air pollution control, solid waste management, hazardous waste management, public water supplies, occupational health and safety, pesticide regulation, and radiation protection, while local governments are more apt to have such responsibilities as food protection, milk sanitation, on-site liquid waste disposal, private water supplies, vector control, animal control, nuisance abatement, noise pollution control, swimming pool sanitation and safety, institutional sanitation, cross-connection elimination, private water supplies, and possibly housing conservation and rehabilitation.

It is imperative that we recognize that while each community or state has only one health department, every community and state has many health agencies and numerous environmental health and protection agencies. Several communities, particularly in the West, have local environmental health and protection departments separate from functions of the personal health department. For example, Sarah Kotchian is Director of the Albuquerque Environmental Health Department which is unusually comprehensive in scope. And many communities have assigned environmental health and protection responsibilities to special districts. For example, the Los Angeles County Air Pollution Control District is among the largest environmental health and protection agencies in the nation. A local environmental health and protection agency is simply an agency of local government charged with delivering identifiable environmental health and protection services. Many environmental health and protection practitioners have chosen to have their heads in the sand and have not recognized the continuing diversification of environmental health and protection functions.

Another dangerous but probably accurate generalization would be to suggest that environmental health and protection functions are assigned to a greater diversity of agencies within state governments than at the local level. We have long witnessed diverse assignments of such state responsibilities as water pollution control, air pollution control, solid waste management, and occupational health and safety, and there appears to be a current trend to transfer food and milk protection to agriculture departments.

As stated in the Report on The Future of Environmental Health, "These organizational changes occur for a variety of reasons, including political perception of the importance of the environment, demands of environmental advocacy groups, political responsiveness of the agencies, and differences regarding program emphasis and priorities in existing health departments."

The Future of Environmental Health Report also notes that, "The trend to organizationally separate environmental health and protection agencies from health departments will continue in response to the demands of environmental advocates, and in response to many health departments becoming substantially involved in health care issues. It is unrealistic to develop programmatic relationships between water pollution control, for example, and any one of a number of treatment and rehabilitation programs (health care). Further, the drift of federal, state and local health departments toward more and more health care (as providers of last resort) translates into less and less leadership for environmental health within health departments. The movement of environmental health and protection programs away from health departments is a part of our evolving governmental system."

A seemingly simple but basic issue which continues to confront environmental health and protection personnel, is the lack of a common definition for environmental health and protection. I could cite a dozen national symposia in which I have been involved wherein it became necessary to define environmental health and protection. Invariably, each group chose to redefine the term. The Committee on the Future of Environmental Health developed no less than six different drafts, each of which was peer reviewed by some 60 national environmental health and protection leaders from the USPHS, EPA, state and local environmental health and protection agencies, and various universities. After a number of revisions the definition utilized in The Report on the Future of Environmental Health is:

"Environmental health and protection refers to protection against environmental factors that may adversely impact human health or the ecological balances essential to long term human health and environmental quality, whether in the natural or human-made environment. These factors include but are not limited to air, food and water contaminants; radiation, toxic chemicals, wastes, disease vectors, safety hazards and habitat alterations."

And further confusion is created by the fact that some states and communities define the term on the basis of which environmental health and protection programs are assigned to the health department. Those programs outside the purview of the health department are called something else.

By now you have noted that I always attempt to use the term environmental health and protection instead of simply environmental health. I do this because: 1) there is really no difference between environmental health and environmental protection; both are based on public health goals, and 2) the terminology is artificial in that they simply indicate the agency responsible for the programs. There is no logical way the two terms can be defined separately, except by some artificial agency organizational settings.

If we keep inventing new definitions based on the task of the moment or the organization involved, we cannot hope to develop broad support and understanding, and successfully market our concepts.

A very short historical review reminds us that most of the programs currently assigned to the federal EPA were previously in existence in the U.S. Public Health Service's Consumer Protection and Environmental Health Service prior to the creation of the EPA. Two notable exceptions included water pollution control within the Interior Department, and pesticide regulation within the Agriculture Department.

As environmental health and protection professionals, we must be equally interested in all environmental health and protection issues, without regard for the organizational settings. All such organizations are environmental health and protection agencies, whatever their titles. As I stated earlier, all such agencies have public health goals, and are mandated to attain public health goals. All require the same type of program methods, laboratory support, legal resources, epidemiology, risk assessment, risk communication, risk management, surveillance and data.

I want to emphasize that the Future of Environmental Health Report's definition of environmental health and protection incorporates ecological issues within the field. The report notes that: "Globally, priority issues include species extinction, possible global warming, stratospheric ozone depletion, wastes, desertification, deforestation, planetary toxification and (most importantly) overpopulation." The Future of Environmental Health Report also quotes Reducing Risk, the 1990 report of EPA's prestigious Science Advisory Board, as follows: "...there is no doubt that over time the quality of human life declines as the quality of natural ecosystems declines...over the past 20 years and especially over the past decade, EPA has paid too little attention to natural ecosystems. The Agency has considered the protection of public health to be its primary mission, and it has been less concerned about risks posed to ecosystems... EPA's response to human health as compared to ecological risks is inappropriate because, in the real world, there is little distinction between the two. Over the long term, ecological degradation, either directly or indirectly degrades human health and the economy... human health and welfare ultimately rely upon the life support systems and natural resources provided by healthy ecosystems."

I could keep discussing some of the other issues and problems facing environmental health and protection personnel and agencies as related to "who in health is in charge of the environment," but I'll utilize the remainder of my time to articulate some recommendations.

1. We must realize that the movement of environmental health and protection programs from health departments is part of our every changing governmental system.

2. We must be willing to believe that the environment and the public may be served effectively by agencies and groups separate from health care organizations.

3. We must ensure that schools of public health and environmental health science and protection programs produce graduates attuned to serving in any of the various environmental health and protection agencies.

4. We must recognize and accept the fact that every state and community has numerous environmental health and protection agencies.

5. We must understand that such organizational diversification is real, will continue, and indicates the high priority of all environmental health and protection issues in the minds of the public and our political leaders.

6. We must successfully vie for leadership roles in all environmental health and protection agencies, not just in health departments.

7. We must show leadership and creativity rather than stubborn and self-defeating resistance when new environmental health and protection programs or agencies are being developed.

8. We must study, understand and apply principles of public administration and organizational behavior in order to most effectively design new programs and agencies.

9. We must attempt to minimize fragmentation of the total spectrum of environmental health and protection services wherever possible, based on valid public administration concepts. We must attempt to transfer all environmental health and protection activities when new lead agencies are being created, rather than being parties to fragmenting the administratively and ecologically interdigitated issues within the field.

10. We must ensure that lead environmental health and protection agencies are comprehensive in programmatic scope and staffed by personnel possessing essential competencies; ensure that such agencies have programs prioritized on the basis of sound epidemiology, toxicology and risk assessment data; and ensure that they have adequate legal, fiscal, laboratory and other resources to be effective.

11. We must constructively involve and communicate with all the various personnel, departments, groups and agencies involved in the struggle for a quality environment.

12. We must utilize a common definition of environmental health and protection which includes ecological and global issues.

13. We must enhance our knowledge and skills relating to public policy development, organizational design, risk communication, and ecology through formal environmental health science and protection education, as well as in-service training and continuing education.

14. We must recognize that the field of environmental health and protection is profoundly interdisciplinary and requires the involvement of a vast array of disciplines and talent from the surveillance and inspectional levels through research, teaching, managerial and policy levels.

Those environmental health and protection professionals affirmatively accepting and, if appropriate, leading organizational changes, have a bright future. Others may be endangered species eking out an existence in perfunctory roles in shrinking organizational environments.

Larry Gordon, M.S., MPH, Visiting Professor of Public Administration, University of New Mexico, Albuquerque, New Mexico. Mr. Gordon chaired NEHA's Committee on the Future of Environmental Health; Gordon retired as New Mexico Cabinet Secretary for Health and Environment.