Where the environment fits in public health.

For nearly three decades, there has been a debate about the relationship between traditional environmental health programs carried out by health departments, and environmental protection programs, usually managed by state and local environmental agencies. The environmental health specialist typically has knowledge of a wide range of factors that are important in understanding environmental issues as they influence community health. In contrast, environmental protection agencies focus on individual media (air, land, and water), unique sources of pollutant discharge, and narrowly focused control technology. They rely on disciplines like hydrology, geology, and various engineering specialties to implement the nation's environmental laws. Environmental protection agencies also have a tendency to reduce an environmental protection issue to its component parts to understand the problem and design a solution. Therefore, a holistic view of community health that incorporates many factors in the analysis of human health risk is often missing. The link between environment and human health also may become lost or may become secondary to process considerations such as the effectiveness of control measures, compliance with standards, and measurement of emissions. These measures, not health status, may become the indicators of success. The medium-by-medium approach to environmental protection is common among agencies and creates a barrier to the full integration of public health and the environment. That integration is a fundamental principle of community health protection.

The disconnect between public health and environmental protection is probably due, in part, to political and organizational management considerations that, in the 1970s, began a trend of separating environmental protection agencies from public health. Another contributing factor may be the absence of a common language between the disciplines of environmental health and environmental protection. Such a language would recognize the importance of the expertise offered by each organization while maintaining orientation toward the same goal: a healthy community. The use of common terms might make it easier for those approaching the environment from each side (health and protection) to recognize that neither approach is fully successful without the other. Similarly, each approach can make a unique contribution to identification and analysis of the factors that influence the management of environmental risks. Better understanding and acceptance of the interrelationship between health and environment might lead to better integration of efforts and improved collaboration between agencies. It appears that a common language may have emerged through some recent work in public health.

In an effort to improve support for the value of public health efforts in communities, the U.S. Public Health Service, federal and state agencies, and national associations have begun to refer to the "essential functions" of public health. Traditionally, environmental health has been defined in terms of discrete programs, but now increasing attention is being paid to the overarching functions and outcomes that encompass the activities within those programs. One objective of the initiative is to translate public health services into outcomes with which communities can associate value. Environmental protection programs are also amenable to reframing in terms of outcome-oriented services. This reframing could provide a clearer understanding of how the traditional environmental health programs and the more contemporary environmental protection programs are linked at a basic level. That is, programs of both types are integral to the protection of the health of the public. They also are grounded in similar concepts of investigation, response, analysis, and application of scientific principles. Ultimately, the quintessential environmental health and environmental protection programs (food protection and air quality, for example) converge at the intersection of the environment and health.

The first step in understanding the common ground between environmental health and environmental protection is to identify the essential public health functions developed through the work of the U.S. Public Health Service. These functions comprise actions that are critical to public health protection and include monitoring health status; informing, educating, and empowering people about health issues; enforcing laws and regulations; evaluating effectiveness; research; and ensuring the competence of the workforce. The following list of seven basic services goes one step further to provide a framework for measuring outcomes, defined as the protection of public health:

* preventing epidemics and the spread of disease,

* protecting against environmental hazards,

* providing assessments and evaluation of community health,

* preventing illness and injury,

* promoting and encouraging healthy behavior,

* responding to disasters and assisting communities in recovery, and

* ensuring the quality and accessibility of health services.

At a fundamental level, any program that has the responsibility of an environmental health or environmental protection agency also has, in its mission, the goal of providing one or more of the basic services listed. If all environmental health and protection programs are evaluated within the framework of those services, it becomes possible to study the enabling legislation and look beyond political strategy, organizational structure, and bureaucratic process to recognize that the mandate goes beyond prevention and control of emissions and toward protection of human health and the environment.

Those practicing in environmental protection agencies will likely agree that their job is to protect the health of the population near a regulated emission source. They may also, however, argue that the engineering and earth science focus of environmental protection programs is sufficiently different from the chemistry, bacteriology, biology, and epidemiology required in the traditional environmental health programs. Therefore, in their view, the separation of the organizations is justified. Environmental health professionals, by contrast, are prone to think the creation of environmental protection agencies at the federal level and in most states was unnecessary. Many believe they could have enhanced their skills to manage the wide range of issues associated with air and water quality, hazardous and solid waste, and noise.

Whether the division of programs was appropriate is a question relevant only for historical discussions of what might have been. Looking forward, both sides of the environmental arena need to evaluate their progress toward the goal of protecting the health of the public and the health of the ecosystem. To accomplish that mission two sides of the equation must be considered: human health and pollution control. If the focus remains on the common language of prevention, protection, promotion, and response as described in the services listed above, then the organizational structure of the agencies involved will be of little consequence. Environmental health professionals and pollution control specialists will work as a team and apply their expertise to solve problems of public health and the environment in a more effective manner.