The future of environmental health.

Cost containment for health careEnvironmental health and protection services are an integral and essential component of the continuum of health services which also includes disease prevention, health promotion and health care. Efforts to control the runaway costs of health care will be ineffective without adequate provision of environmental health and protection services in necessary quantity, quality and comprehensiveness.Research essential to the futureThe ultimate effectiveness of environmental health and protection services lies in the capacity to identify, understand and control environmental problems. As our technological society becomes more complex and population stresses increase, the need for increased environmental health and protection research is essential. Well designed, targeted research is a prerequisite to preventing and solving problems, as well as an essential tool in prioritizing and designing effective programs. Research and development funds have routinely been inadequate to address the research needs that exist. Without the development of new technology through research and development, it will be difficult to move forward in areas such as remedial action and cleanup design, improved laboratory analytical capabilities and product substitution, for example.Public education a "must"Increased environmental health and protection education is essential not only to address public concerns, but to provide students and other citizens with knowledge and skills to allow them to make informed decisions about environmental matters. Education will allow our citizens to factually understand risk and relative risk of the complex variety of potential environmental insults which they may face. Such education also will help them decide which risks are acceptable and which are not.When risk assessment includes active public education and participation, the outcomes are more likely to be supported by the public and the business community.Professional personnel essentialA wide variety of personnel from routine surveillance and inspection levels through management, policy, communication, education and research levels is essential to modern environmental health and protection efforts in the private, governmental and voluntary sectors. At the professional levels, this necessitates a supply of appropriately educated and trained personnel from the baccalaureate through the doctoral levels. It also dictates a need for both environmental health and protection professionals, and professionals in environmental health and protection.* Environmental health and protection professionals are those who have been adequately educated in the various environmental health science and protection technical (programmatic) components, and in epidemiology, biostatistics, toxicology, management, public policy, risk assessment and reduction, risk communication, environmental law, social dynamics and environmental economics.* Professionals in environmental health and protection include but are not limited to such other essential personnel as chemists, geologists, biologists, meteorologists, physicists, physicians, economists, engineers, attorneys, planners, epidemiologists, social marketing professionals, sociologists, biostatisticians, public administrators, toxicologists and planners.A U.S. Public Health Service Bureau of Health Professions report indicates shortages in a number of program areas; estimates that only 11 percent of the environmental health and protection work force have formal education in environmental health science and protection; and estimates a need for 120,000 more professionals to address problems in several key program areas.The 1990 EPA Science Advisory Board publication, Reducing Risk, states that:"The nation is facing a shortage of environmental scientists and engineers needed to cope with environmental problems today and in the future. Moreover, professionals today need continuing education and training to help them understand the complex control technologies and pollution prevention (emphasis added) strategies needed to reduce environmental risks more effectively."...Most environmental officials have been trained in a subset of environmental problems, such as air pollution, water pollution or waste disposal. But they have not been trained to assess and respond to environmental problems in an integrated and comprehensive way (emphasis added). Moreover, few have been taught to anticipate and prevent (emphasis added) pollution from occurring or to utilize risk reduction tools beyond command-and-control regulations. This narrow focus is not very effective in the face of the intermedia (emphasis added) problems that have emerged over the past two decades and that are projected for the future."The Department of Defense (DOD) Deputy Assistant Secretary for Environment has stated that the shortage of properly qualified and trained environmental health and protection professionals constitutes a major impediment to DOD's world-wide mission of environmental problem prevention and clean-up.The Department of Energy (DOE) Secretary has charted a new course for DOE toward full accountability in the areas of environment, safety and health to demonstrate that DOE is committed to complying with the nation's environmental laws and discharging its many responsibilities, which include protecting public health and safety. This has required strengthening the environmental, safety and health technical capabilities of line managers within DOE; to do this, DOE officials need sufficient numbers of appropriately skilled DOE line managers to support them. The DOE Secretary has also greatly expanded emphasis on comprehensive epidemiological data on DOE and contractor employees.The Congressional Office of Technology Assessment (OTA) concluded that a shortage of experienced and technical experts may be a factor in the current lack of quality performance and may cause a bottleneck in an expanded Superfund program. The OTA report also suggested that current educational programs may not be able to prepare some professionals in sufficient numbers.Leaders or followers?Environmental health and protection personnel managing programs and agencies should objectively evaluate their activities to ensure that they are providing effective leadership as scientists, managers, policy formulators and risk communicators. Additionally, schools of public health, other environmental health science and protection programs, academic accrediting bodies, and funding agencies should evaluate their efforts and the proven competencies of graduates.The dearth of effective environmental health and protection leadership must be addressed. It may well be that leaders and potential leaders are not attracted to such governmental agencies. This may be due to lack of professional identity, inadequate financial reward, lack of challenge, lack of responsibility, lack of advancement, or lack of adequate career opportunity. Or, perhaps properly designed, targeted and effective education and training are not available.Leaders should:* be strategic planners addressing current and emerging issues;* lead rather than resist desirable changes in organizations, priorities, goals and programs;* be visionary, provocative, and become the agents in charge;* show the courage and ability to direct public and political attention and action to science-based priorities, rather than emotionally perceived priorities;* develop and effectively implement necessary public policy;* seek and capably fill positions at levels where policy is proposed, debated and adopted;* practice the art of networking, constituency development and diplomacy;* practice total quality management internally and externally to their agencies;* be sought by civic and political leaders for their expertise;* ensure that alleged problems are adequately defined prior to proposing expensive solutions and programs; and* understand and communicate the net environmental, health, economic and social impact of proposed programs.Education and training organizations and institutions should be teaching personnel the knowledge and skills essential to the foregoing.Professional organizations should also play an active role in the development of environmental health and protection leaders while practicing leadership as an organization.Part of the leadership issue can be addressed through formal academic training and part of it through the work of individuals, agencies and associations to identify and seize opportunities to provide leadership in addressing key environmental health and protection issues.Professional education and trainingThe public health community has not perceived development of the environmental health and protection work force as a priority for the past 20 years. This inattention has contributed to the widespread deficit of properly educated and trained environmental health and protection personnel. Individuals with little or no knowledge of epidemiology, biostatistics, toxicology, public policy, risk assessment, risk communication, and environmental health science and protection program issues are filling key positions where such knowledge is essential.Necessary competencies include:* managerial and organizational behavior skills* analytical skills* communication and marketing skills* policy development and implementation skills* cultural awareness skills* strategic planning skills* financial planning and management skills* basic environmental health and protection technical and scientific knowledge* risk assessment skills* risk management skills* risk communication skills* epidemiological skills* biostatistical skills* knowledge of the sciences of toxicology, chemistry, physics, biology and geology* communicable disease/chronic disease knowledge* environmental economics knowledge* environmental law knowledge* environmental health and protection planning knowledge (land-use, energy production, resource utilization, transportation methodologies, product design and development)* knowledge of federal, state and local environmental organizations* ability to understand the net impact of proposed actions* data collection and analysis skillsMany environmental health and protection professionals are now being educated by accredited environmental health science and protection programs, rather than by schools of public health as was the case in earlier years.Many accredited academic environmental health programs and schools of public health appear to believe that their market is the health departments, rather than the full range of agencies and industries responsible for environmental health and protection.The vast majority of personnel are professionals in environmental health and protection who are recruited from various professional disciplines such as chemistry, biology, geology, physics, administration, etc.Continuing education and in-service training opportunities are in extremely short supply, but there is a constant need and demand. Environmental health and protection problems associated with the modern environment are complex and constantly changing. Personnel who do not take affirmative steps to remain current are soon out-of-date and ineffective. Continuing education should be required and available in each state, or regionally.Academia-agency relationshipsSchools of public health, environmental health science and protection programs, and other environmental health science and protection education and training efforts will function most effectively when there is good two-way, continuing communication and involvement with the field of practice.Likewise, the efforts of practitioners will be enhanced through the continuing and effective involvement of environmental health science and protection faculty.Good rapport between academia and practitioners will not only enhance the quality of professional education and services, but will aid in ensuring the development of necessary applied research involving and benefitting both academia and practitioners.CredentialingCredentialing is the formal recognition of professional or technical competence. There are two distinct means of credentialing: 1) individual credentialing consisting of certification, registration and licensure; and 2) institutional accreditation of education and training programs, colleges and universities.Certification is the recognition granted by a non-governmental agency or association to environmental and protection personnel who have met specific educational requirements. Certification is granted by such groups as the American Academy of Sanitarians, the American Industrial Hygiene Association, and the American Academy of Environmental Engineering. Environmental health and protection requires such a broad and varied group of disciplines, that certification of all professionals within the field is not feasible. However, as the need for specialized personnel increases, certification may help prospective employers identify candidates with the desired qualifications.Registration is the acknowledgment by a governmental body that a person possesses a specific set of professional qualifications. Given the fact that the field of environmental health and protection requires the talents of scores of diverse professional groups and disciplines, registration of all such personnel is not possible. Some of these groups are required to be registered in accordance with non-uniform standards in many states. Many statutes provide for voluntary, rather than mandatory, registration. Some view registration acts as measures to protect and promote a profession, while others advocate such requirements on the basis of protecting the public from unprofessional practice.Licensure is the process by which a government agency grants permission to an individual to engage in a given occupation upon finding that the applicant has attained the minimal level of competence necessary to ensure that public health, safety and welfare will be reasonably well protected. With the exception of environmental engineers, environmental attorneys, environmental and occupational physicians and occupational nurses, most environmental health and protection personnel are not required to be licensed. Licensing requirements for engineers, physicians, attorneys and nurses relate primarily to their primary discipline, rather than to the field of environmental health and protection.Accreditation is the acknowledgment that an educational institution or program maintains standards of education which qualify its graduates for admission to higher or specialized institutions, or for professional practice. Accreditation of schools of public health is conducted by the Council on Education for Public Health. Industrial hygiene programs are accredited by the Relating Accrediting Commission of the Accrediting Board for Engineering and Technology. The National Environmental Health Science and Protection Accreditation Council accredits both graduate and undergraduate environmental health science and protection programs.Properly designed and applied, credentialing has the capacity to elevate the credibility and competence of specific components of the environmental health and protection work force through the establishment of minimum standards, continuing education requirements and demonstrated competence. At the same time, credentialing programs must be sound. Further, they must be developed for the purpose of improving the quality of the work force and protecting the public, rather than being incidental to protecting the work force or being a marketing or promotional effort.Financing the effortTotal funding utilized by the public and private sectors in the United States ostensibly to protect health and the environment may be adequate. The real problem lies in how the money is being spent and on which issues. Uncounted millions are being spent on relative non-issues in response to public perception and concern that has been turned into political action and public policy. The issue of environmental health and protection priorities has been discussed in the Risk and Priorities section of this report (JEH 55.4). If the funds being inappropriately utilized for such low priorities as asbestos removal, radon detection and control, elimination of alar, the Waste Isolation Pilot Project, infrequent low levels of atmospheric carbon monoxide and other such programs not adequately based on good epidemiology, toxicology, and risk assessment were utilized to prevent problems which offer substantial risk reduction, the public and the environment would be better served.Where funds cannot be reallocated from lower priority activities, state and local environmental health and protection agencies are increasingly required to rely on pollution taxes and fees for services.Fund reallocations and imposition of pollution taxes and other market-based incentives will require the very best in articulate and knowledgeable environmental health and protection leadership as outlined in the Leaders or Followers? section of this report, and the availability of professionals possessing the competencies iterated in Professional Education and Training.Concluding thoughtsThe future of environmental health and protection will, to a significant degree, depend on the ability of environmental health and protection agencies and personnel to:1) Assess, prioritize and communicate environmental problems on the basis of sound epidemiology, toxicology and risk assessment rather than hysteria and reaction to self-serving advocacy groups. Prioritization among myriad complex and competing demands may be the most important responsibility of environmental health and protection professionals.2) Exhibit a high measure of leadership and effectiveness in designing, promoting, gaining approval for, and implementing public policy. This may be the most difficult responsibility for most environmental health and protection practitioners as few have been trained or experienced in the public policy and constituent development process.3) Assure the public that effective environmental health and protection service are provided.To merely manage the environment in accordance with legislative and executive branch dictates is comparatively easy. Such legislative and executive elected officials, understandably, have their own priorities based on the demands of their constituents. Environmental health and protection may or may not be among these priorities, but the relative priorities of environmental health would be much different if they were based on sound epidemiology, toxicology and risk assessment rather than emotion and political perception. Frequently, it is not a matter of shortage of total budget, but rather how it is being spent, or in some cases, wasted on relative non-issues.Leadership on the road to improved environmental quality is not an easy route. There are many potholes in the way of providing effective, priority environmental health and protection services. The journey requires vision and steadfastness of purpose, as it is beset by emotional pressures, tempting comfortable detours, political surprises, and frequently offers no short-term gratification or pay-off. There are few if any rest stops along the way.The foregoing will require that schools of public health and other programs educating environmental health and protection personnel ensure that all graduates be competent in analytical skills, communication skills, policy development, program planning skills, cultural skills, basic public health sciences skills, and financial planning and management skills. It is also essential that incumbent personnel be "retreaded" with these skills through effective continuing education mechanisms.Ensuring a quality environment will require the combined efforts of government, individual citizens and citizen groups, the private sector, professional and trade groups, and academia. Effectively addressing the challenges and recommendations contained in this document will help ensure a quality environment for this and future generations.Policy recommendations1. Comprehensive and effective environmental health and protection services should be available to every citizen of our nation.2. Environmental health and protection personnel, agencies, and other groups are urged to base priorities and programs on good epidemiology, health risk assessment, ecological risk assessment and toxicology; and agencies must have adequate analytical, data, legal and fiscal resources.3. All agencies must be encouraged to give priority to the basic concepts and practices of prevention. Pollution prevention must be established as the management tool of first choice. Public policy must reflect the need to establish pollution prevention incentives and rely less on allowing environmental degradation with the response and remedy being the enforcement of command and control regulations directed at cleanup.4. Agencies must become effectively involved in environmental health planning to be in a position to prevent problems created by land use, transportation, energy production, resource development and utilization, and product design and development.5. Environmental health and protection personnel and agencies must effectively coordinate their activities with those of other public and private agencies and advocacy groups.6. Programs should provide appropriate balance to issues of human health and ecological degradation.7. Practitioners must recognize that environmental health and protection programs are organized within a wide variety of agencies at the federal, state and local levels, not just in traditional health departments.8. The U.S. Public Health Service and/or the Environmental Protection Agency should fund a study to identify the agencies responsible for the various environmental health and protection programs in each state. This study should also determine expenditures, and numbers and types of personnel engaged in such programs.9. The current confusing non-system of delivering environmental health and protection services should be evaluated and recommendations made regarding the roles of federal, state and local agencies.10. All environmental health and protection personnel must learn and practice the art of risk communication.11. Every agency and educational institution should fulfill their responsibility to ensure that the public understands the complex variety of environmental insults which they may encounter.12. Agencies should emphasize recruiting and retaining professionals who have the knowledge and skills essential to effectively prevent and solve the complex environmental issues of our society.13. Educational institutions developing environmental health and protection personnel should review their curricula and ensure that graduates possess the competencies essential for their future responsibilities.14. Educational accrediting bodies should modernize their criteria and ensure that graduates possess the essential competencies.15. Inasmuch as most major environmental health and protection programs are federally mandated, the U.S. Congress should enact and fund a National Environmental Health Education and Training Act to ensure a continuing supply of environmental health and protection professionals to meet the nation's needs.16. Every environmental health and protection agency and every appropriate environmental educational institution should develop a continuing, coordinated system in order to enhance the quality of professional education and training efforts, develop targeted research, improve operating programs, and enhance recruitment and marketing efforts. This must include a strong component of academic-practice interaction to enhance the transition from the educational system to the work place, and enable the academic sector to maintain a current perspective of issues of applied environmental health and protection.17. Schools of public health and other environmental health science and protection programs should carefully define and target the various issues and design their programs to address all public and private sector needs, rather than just those of "health departments."18. Emphasis should be placed on educating and training a balance of generalists and specialists. Specialization has moved efforts farther away from the desired integrated approach necessary to focus on human and ecological issues.19. Efforts to collect information about environmental health and protection activities should be expanded to include complete reporting at all levels of government. The Public Health Foundation should be the lead group to implement this recommendation.20. Adequate research funding must be available to accurately identify and manage the complex variety of threats to health and the environment and provide the data required to address the legitimate threats to human health and the environment.21. Environmental health and protection research institutes should be established in a leading university in each state to ensure timely research that addresses local and regional issues.22. Providing essential funding for preventing and solving the nation's environmental ills will increasingly require the best in creativity. Those charged with such responsibilities must develop competencies in environmental economics. This competency will also aid the practitioner in understanding the impact of programs on the economy, and the impact of the economy on programs and the quality of the environment.@ @