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Meeting report: development of environmental health indicators in Brazil and other countries in the Americas.

This report summarizes the Brazilian experience on the design and implementation of environmental health, with contributions from Argentina, Canada, and Cuba, presented at the International Symposium on the Development of Indicators for Environmental Health Integrated Management, held in Recife, Pernambuco, Brazil, on 17-18 June 2004. The methodology for the development of environmental health indicators has been used as a reference in the implementation of environmental health surveillance in Brazil. This methodology has provided tools and processes to facilitate the understanding and to measure the determinants of risks to environmental health, to help decision makers control those risks. Key words: environmental health indicators, environmental health surveillance, integrated management. Environ Health Perspect 114:1407-1408 (2006). doi:10.1289/ehp.8486 available via [Online 12 June 2006]


From 1998 to the present, the Ministry of Health of Brazil has implemented environmental health surveillance (EHS) within the National Public Health System. The methodology for the development of environmental health indicators became one of the key issues for the implementation of EHS. The driving force, pressure, state/situation, exposure, effects, action (DPSEEA) model approach was applied to develop appropriate indicators (Corvalan et al. 1999). This matrix model takes into consideration the relationship cycle process among economic and social dynamics, environmental response, and human health. Thus, the driving forces consist of the economic and social processes, resulting in pressures such as the intensive use of particular natural resources. Both driving forces and pressures contribute to the situation/state scenarios where the environment is often contaminated or deteriorated, facilitating human exposure to environmental risk factors that might produce effects on health. For each of these categories, indicators and action proposals are developed to gain a more complete understanding of the problem as well as to visualize measures to be taken in each level of complexity of the cycle (Figure 1).

The Regional Experience

An international symposium on the development of indicators for integrated environmental health management, as a prior activity to the VI Brazilian Congress of Epidemiology, took place in Recife, Brazil, on 17-18 June 2004. The symposium involved presentation and discussions on the Brazilian experience with the development of environmental health indicators and exchange of experiences with similar initiatives in Canada, Cuba, and Argentina. The symposium was organized by the Ministry of Health of Brazil under the auspices of the Pan American Health Organization/World Health Organization and the Associacao Brasileira de Pos-Graduacao em Saude Coletiva's Health and Environment Working Group.

The main objectives of the symposium were to assess the use of the indicators for the environmental health integrated management in the countries of the Americas, to present the Brazilian experience in the development of indicators regarding the integrated management of environmental health, and to contribute, through the development of environmental health indicators, to the strengthening of the following initiatives: a) the Health and Environment Ministers of the Americas meeting, b) the Pan American Health Organization Environmental Health Collaborating Centers Network, and c) methodologies for the integrated assessment of environmental health in the Americas.

The experiences in developing indicators in some countries in the American continents were evaluated, with particular attention to their usefulness in the decision-making processes. A summary of the indicators developed and evaluated are shown in Table 1, and national and international examples of the application of indicators are described in Table 2.

Conclusions and Recommendations

The symposium, in addition to presenting the experiences in Brazil and other countries, assessed ways of adopting the proposed methodology for the development of environmental health indicators and their use in the integrated management of actions on related health and environment issues, with the following conclusions:

* The development of the environmental health indicators should be interdisciplinary and participatory, focused on the economic, social, and environmental contexts that represent risk situations to human health.

* The indicators should be built based on priorities, considering what society considers to be a problem, and should lead to health protection and the promotion of changes, as well as to facilitate decision making, considering health as a social value.

* The development of environmental health indicators should also respect and incorporate community-based knowledge, the interdisciplinary and intersectorial approach toward integrated management.

* The participation of government decision makers in the identification and development of indicators is highly valuable because it results in an improved future management of the problems identified.

The environmental health indicators matrix (DPSEEA) also proved useful for the analysis of complex problems and for the analysis of emerging issues, such as the products of nanotechnology, genetic manipulation, and nonionizing radiation among others.

DPSEEA, which is a framework that organizes information from economic and social dynamics, environmental response, and human health, addresses all the complex levels of a given problem, and it is more efficient in the analysis of such problems compared with other cause-and-effect models. It promotes a holistic view of the issues and is therefore effective in the identification of relevant indicators. It is also a valuable tool for learning, training, and deeper discussions on complex exposure-effect process relationships in environmental health.

Workshop participants commented that DPSEEA would have some limitations if understood only in a linear and vertical form without considering the complex socioenvironmental contexts and their relation with underlying health problems, environment, and quality of life.


Corvalan CF, Briggs D, Zielhuis G. 2000. Decision Making in Environmental Health: From Evidence to Action. London:E & FN Spon.

Corvalan CF, Kjellstrom T, Smith KR. 1999. Health, environment and sustainable development: identifying links and indicators to promote action. Epidemiology 10:656-660.

Maciel Filho AA, Goes CD, Cancio JA, Oliveira ML, Costa SS. 1999. Indicadores de vigilancia ambiental em saude [in Portuguese]. Inform Epidemiol 8(3):59-66. Available: [accessed 31 October 2005].

Fernando F. Carneiro, (1) Mara Lucia C. Oliveira, (2) Guilherme F. Netto, (1) Luis A.C. Galvao, (3) Jacira A. Cancio, (2,4) Estela M. Bonini, (1) Carlos F. Corvalan, (5) and the Participants in the International Symposium on the Development of Indicators for Environmental Health Integrated Management

(1) General Coordination for Environmental Health Surveillance in Health Surveillance, Secretariat/Ministry of Health of Brazil, Brasilia, Brazil; (2) Pan-American Health Organization, Office in Brazil, Brasilia, Brazil; (3) Pan-American Health Organization, Environmental Health and Sustainable Development, Washington, DC, USA; (4) Catholic University, Brasilia, Brazil; (5) World Health Organization, Geneva, Switzerland

Address correspondence to Fernando Carneiro, Rua Angelin, Lote 1, Condominio Verde, Lago Sul Brasilia, DF, CEP: 70680-608 Brazil. Telephone: 55 61 3448-6333. Fax: 55 61 3448-6287. E-mail:

List of participants: A.R. Martins de Sena, A.T. Tambellini, A. Monteiro, A.C. Lima da Silva, A. Carvalho de Miranda, A.L. Carneiro de Freitas, C. Corvalan, C.R. Costa, C.T. Souto Bezerra, E.W. Dias e Silva, E. Monteiro, E. Domingues, E. de Tito, E.M. Bonini, F.F. Carneiro, F.P. Nunes, G.M.S Goncalves, G.F. Netto, H. Castro, I.M. da Silva, J. Cancio, J. Finkelman, J. Alves, J.A. Escamilla, J. de Paula, J. Villardi, L.C. Amorim, L.G. da S. Augusto, L.G. Timbo Aragao, L. Rafael de Barros, L.A. Galvao, M. Romero, M.L.B. Carneiro Oliveira, M.M. Fachinni, M. Moises, M.A. Magalhaes, M.C. Dantas, M.C. da Silva Souto, M. de Lourdes Lima, M. de Lourdes Neto, N. Gouveia, P.C. Borja, P.I. Batista, R.R. dos Santos, R.M.S. Souza, R.S. Bernardes, R. Coelho, R. de Lima Gomes, S. Hacon, S. Rocha, S. Bartlett, S. Pereira, S. Batista, S.C.A. Rocha de Almeida, T.N.G. Wanderley, V. Blank, V. de M. Camara, W. Roque de Sa, W. Waissmann.

Support for the symposium was provided by the Health Surveillance Secretariat, Ministry of Health of Brazil; Associacao Brasileira de Pos-Graduacao em Saude Coletiva; Pan-American Health Organization Office in Brazil; World Health Organization; Ministry of Health of Argentina; Ministry of Health of Canada; and Ministry of Health of Cuba.

The views expressed in this article are those of the authors and do not necessarily reflect the position of the World Health Organization.

The authors declare they have no competing financial interests.

Received 10 July 2005; accepted 15 November 2005.
Table 1. Some examples of environmental health indicators in use,
selected from applying the DPSEEA matrix to different situations.

Country/topics Indicators developed categories

Brazil Per capita consumption Pressure
 Water Water bacteriologic quality Exposure
 (Maciel Filho et al. 1999) Residual chlorine Exposure
 Water supply services coverage Situation
 Water supply regularity Situation
Cuba Economic policy of healthy Driving
 residences development force
 Healthy residences Percent of resources for the Pressure
 construction of healthy
 (Placeres MR et al., Percent of households with Situation
 unpublished data) appropriate ventilation
 Percent of households with Situation
 appropriate lighting
 Percent of households with Situation
 appropriate kitchen
Canada Release of substances that Pressure
 damage the ozone layer
 Ultraviolet radiation Ozone layer reduction rate Exposure
 Cumulative radiation doses Exposure
 (Bartlett S, unpublished Ultraviolet radiation Exposure
 data) indicators
 Incidence of melanoma Effects
 Eye damage Effects

Table 2. National and international experiences in the use of

Country Source Program Description

Brazil Guimaraes MJB, EHS drinking Good example of the use of
 Melo NGDO, Lima water environmental health
 AAF, Camarao F, program indicators for decision
 Fillho JAN, Lyra making: Ministry of Health
 TM, unpublished developed database allowing
 data local-level data entry
 accessible on line at
 municipal, state, and
 federal levels
 Database can potentially be
 analyzed together with
 mortality and morbidity
 data: Successes include
 drinking water risk maps
 generated by the
 Municipality of Recife that
 served as a base to
 restructure and reinforce
 health surveillance actions
 to priority areas
 Recognized as a useful
 application and given an
 award by the Health
 Surveillance National
Cuba Placeres MR, Rojas DPSEEA Has been used in the family
 MC, Diaz VIP, health program, orienting
 Toste MA, Melian doctors and nurses to
 CMG, unpublished consider social, political,
 data economic, and geographic
 factors in identifying
 environmental problems that
 affect people's health
 Has oriented the
 establishment of the
 environmental primary
 health care strategy by
 choosing environmental
 health local indicators to
 achieve an integration of
 local health development
Canada Bartlett S, Environment Has been reporting on
 unpublished data Canada environmental indicators
 since 1990 in its National
 Environmental Indicator
 Series and State of the
 Environment reports
 In the Environment and
 Sustainable Development
 Indicators initiative's
 final report, the National
 Round Table on the
 Environment and the
 Economy (NRTEE) proposed
 six new indicators,
 developed in collaboration
 with Environment Canada and
 Statistics Canada (released
 May 2003): forest cover,
 freshwater quality, air
 quality, greenhouse gas
 emissions, extent of
 wetlands, and educational
 Health Uses the DPSEEA framework to
 Canada organize the environmental
 health indicators
 Currently collaborating with
 Environment Canada on the
 development of an
 air-health indicator (AHI)
 The potential AHI builds on
 ongoing work on improved
 air quality index to
 develop a multipollutant
 trend indicator that
 directly links potential
 health impacts to exposure
 to pollution, as
 recommended by NRTEE
 Such an indicator has also
 helped to assess the
 effectiveness of pollution
 mitigation strategies and
 public health interventions
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Title Annotation:Research
Author:Corvalan, Carlos F.
Publication:Environmental Health Perspectives
Geographic Code:3BRAZ
Date:Sep 1, 2006
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