Environmental health is the branch of public health that: focuses on the relationships

between people and their environment; promotes human health and well-being; and
fosters healthy and safe communities. Environmental health is a key part of any
comprehensive public health system. The field works to advance policies and
programs to reduce chemical and other environmental exposures in air, water, soil
and food to protect people and provide communities with healthier environments.

Environmental health is a broad area of study — everything from the

climate to the food we eat to the air we breathe plays into
environmental health. A few specific examples include:

 Air pollution: Living near factories or heavy traffic worsens air

quality and leads to health impacts on the lungs and heart such as
asthma and increased risk of heart attacks or stroke.
 Water contamination: Drinking lead-contaminated water can cause
IQ loss, behavioural issues, learning disabilities and more. Infants
and young children are most at risk.
 Toxic chemicals in consumer products: Phthalates, a class of
chemicals that are widely used in consumer products, are known
endocrine-disruptors, meaning they hijack your body’s hormones
and can cause a wide array of health impacts including increased
risk of cancer and fertility issues.

What is the role of environmental health?

The role of environmental health research is to examine areas of

the environment that impact our health so that we can make
personal and policy changes to keep ourselves safe and improve
human health and wellbeing.

There are many environmental health issues that affect human

health. These include:

Air pollution — nine out of 10 people currently breathe air that

exceeds the World Health Organization’s guideline limits for air
pollution worldwide. This mainly affects people in low and middle-
income countries, but in the United States, people that live in cities,
or near refineries or factories, are often affected as well.

Air pollution also ramps up during wildfire season.

Water pollution — as of 2014, every year more people die from

unsafe water than from all forms of violence, including war. Water
is the ‘universal solvent’, meaning it can dissolve more substances
than any other liquid on Earth. Thus, it is too easy for toxic
chemicals to enter our water supply.

Lack of access to health care — yes, this is an environmental

health issue! Having an accessible health care system is part of
one’s environment. Difficulty getting health care can further impact
one’s health.

Poor infrastructure — from “food deserts” to lack of transportation

services, living in an area with poor infrastructure can impact your
health.

Climate change — climate change-induced heat waves, increased

frequency and severity of large storms, droughts, flooding, etc. have
resulted in health problems and even death.

Chemical pollution — chemical pollution can be sneaky: the

chemicals in your everyday products, from shampoo to deodorant to
your clothing to the food you eat, can directly affect your health.
These chemicals are often not on the label or regulated at all.

What Is Environmental Health?

Many people often think of environmental health in terms of clean air and
water, but natural environmental forces—including things like global
warming—are only one piece of a greater puzzle.

Environmental health is the public health field that monitors and

addresses those physical, chemical, and biological factors that we might
not have direct control over, but can impact our health anyway. For
example, if you live in a neighbourhood with unsafe sidewalks or polluted
air, it’s difficult to get outside and exercise. Similarly, what your home
was built with, what insects live nearby, and what food you have access
to all can affect your health and the health of your family.

Simply put, environmental health is the area of public health that deals
with all the different ways the world around us can impact our physical
and mental well-being.

Areas of Environmental Health

Environmental health is one of the largest fields within public health

because of the myriad ways external forces can impact how we eat, live,
and grow. These forces can be about addressing our natural environment
(as in the case for clean water or sanitation), but they can also be the
consequence of human beings' actions—including societal norms.
Healthy People 2030's environmental health objectives highlight six key
areas that encompass the various ways environmental health is crucial to
the health of communities.

Air Quality

Air is non-negotiable for humans. We need it to survive, but we don't

always take care to keep it clean, and that can have a significant impact
on our health.

Poor air quality has been linked to a wide range of health issues, including
SIDS, lung cancer, and COPD. Air pollution is also linked to low birth
weight.1 One study published in 2019 found that babies born to pregnant
women exposed to high levels of air pollutants in the early and late states
of pregnancy were more likely than their non-exposed peers to be born
with a lower birth weight or to be born prematurely.2

The Clean Air Act of 1970 sought to change all that. It marked the first
time the federal government took responsibility for protecting the air
quality for all U.S. citizens by regulating harmful emissions from things
like cars and factories. The act was later expanded in 1990 to address
acid rain and ozone depletion—and it’s working. In its 2011 prospective
report, the Environmental Protection Agency projected that the Clean Air
Act would prevent more than 230,000 early deaths by 2020.3

Water and Sanitation

According to the Centers for Disease Control and Prevention, an estimated

780 million people worldwide don’t have access to safe drinking water,
and a jaw-dropping 1.7 billion (or roughly a fifth of Earth’s population)
lack adequate sanitation services like clean bathrooms. 45 The impact of
this is staggering. An estimated 2,200 children die every day worldwide of
diarrheal diseases linked to improper water and sanitation. 6

The simple act of filtering and chlorinating water systems in the United
States has resulted in significant declines in once-common diseases
like typhoid. By one estimate from the UN, for every $1 invested in clean
water technologies, the world gains a return of $4.3 associated medical
and societal cost savings.7 Historically, clean water is responsible for the
bulk of the decline in childhood mortality in the country.8

Toxic Substances and Hazardous Wastes

Toxicology—that is, the area of science devoted to understanding how

chemicals and substances can affect people and their surroundings—is an
important field in environmental health. Many of the materials needed to
advance industries and technology, like heavy metals or even some
plastics, can also hurt the human body and even lead to serious medical
conditions.9

One of the most recent, highly publicized examples of this happening is

the Flint water crisis. When news broke in 2015 that the drinking water in
Flint, Michigan was loaded with lead, it prompted widespread outrage and
fear among families. If kids drink or digest lead, it can lead to long-term
health complications, including brain damage, and in the case of Flint, it
was the economically disadvantaged kids who were most affected. 10

More than 40 percent of the population in Flint lives below the poverty
line, roughly 2.8 times the national average poverty rate in the United
States.11 The county where the town resides has a history of poor health,
ranking 81st out of 82 Michigan counties for health outcomes. The crisis
was a prime example of how environmental health issues often hurt those
whose health status is already most at risk.

Homes and Communities

We spend the bulk of our time at home, work, or school, so it's important
that these places be safe with minimal hazards, as well as be conducive to
a healthy lifestyle. When a neighbourhood has a lot of violence, for
example, families might not go outside to exercise. When roads aren't
properly maintained, it can result in more car crashes.

An emerging field in this area of environmental health is that of food

access. Many neighbourhoods throughout the United States do not have
full-service grocery stores nearby. In their absence, residents often have
to rely on convenience stores, like those found at gas stations, to buy
their groceries. This can be expensive, but most importantly, it can mean
fewer or poorer quality options for fresh fruits and vegetables—a vital part
of a healthy diet.12 For families in these areas, it can be a struggle to
make healthy choices, exacerbating existing health disparities for low-
income and minority populations especially.

In an effort to offset the impact of these "food deserts," environmental

health professionals are urging communities to establish public gardens
where residents can grow and harvest their own fresh produce, improve
access to public transportation to full-service grocery stores and farmers
markets, and change zoning laws to incentivize retailers to offer healthier
food options.12

Infrastructure and Surveillance

A primary piece of any public health strategy is information. By

understanding what the risks are and where environmental health
professionals can better deploy resources to prevent or combat them.
This includes investigating and responding to diseases—a field
called epidemiology—as well as screening populations for hazards and
establishing surveillance programs.

Surveillance activities involve either going out and looking for particular
health concerns (active surveillance) or by asking professionals in other
fields, such as medicine or agriculture, to alert environmental health
agencies when they encounter them (passive surveillance).

An example of this in action is mosquito surveillance and abatement

activities. These programs test mosquitoes for certain things, including
the presence of dangerous infections like Zika virus, as well as monitor
populations to ensure control measures are working.13 This information
can help health officials know what to watch for in doctors' offices, direct
local governments on where and how best to spray for mosquitoes, and
alert the public if a mosquito-borne illness is spreading in the area.

Global Environmental Health

In the coming decades, environmental health professionals are bracing for

a warmer, wetter climate that will likely prompt or exacerbate threats to
our public health across the globe.

As temperatures increase, for example, disease-carrying mosquitoes can

live in areas previously too cold for them to survive, upping the number of
people impacted by vector-borne illnesses like dengue and malaria.14 As
sea levels rise, whole coastal cities and island nations are at risk for
flooding, sending potentially millions of displaced people to crowded areas
where diseases can spread quickly.

As extreme weather events become more frequent, health officials

anticipate more years like 2017 where back-to-back storms and floods in
places like Houston, Florida, and Puerto Rico destroyed homes, facilitated
the spread of diseases, and left millions without power.

Protecting the health of the planet is critical to improving and maintaining

the health of the entire global population. Even though health outcomes
have improved significantly over the past century—in wealthy nations like
the United States in particular—environmental hazards and infectious
diseases know no geopolitical boundaries. People today are traveling
farther and more often than ever before, and conflicts in areas like Syria,
Afghanistan, and South Sudan are causing millions to flee their homes.

These increases in cross-border and cross-continental movements have

the potential to threaten disease prevention efforts and overextend
existing infrastructure.15 That's why it's crucial that countries look beyond
their borders to improve the health of the global population—not just their
own.
How You Can Help Protect and Improve Environmental Health

Unlike diet and exercise, many environmental health factors are not
something that can be exclusively managed at the individual level.
Combatting the risk they pose often takes laws, policies, and programs at
the local, federal, and international level.

It’s unrealistic, for example, for everyone to inspect the kitchens of

restaurants they frequent or to test their water for heavy metals. That’s
why we have trained and qualified food safety inspectors and toxicologists
who use rigid, standardized screening and inspection measures to ensure
our food and water are safe to consume. It takes a comprehensive and
coordinated effort across a vast environmental health system to protect
the health and safety of communities throughout the nation and globe.

That being said, there are many things you can do to protect the
environmental health and safety of your community and throughout the
planet. You can help improve air quality by riding your bike, taking mass
transportation, or switching to telecommuting instead of driving a car to
and from work.

You can check your own home for radon or lead paint or pipes to prevent
exposure to toxic substances.16 And you can talk with your local
governments and businesses about investing in environmental health
activities that ensure every neighbourhood has access to safe
environments to live, work, and play.

Q: What is noncommunicable disease surveillance?

Noncommunicable disease surveillance is the ongoing, systematic collection and

analysis of data to provide information on a country’s noncommunicable disease
burden, population groups at risk, estimates of noncommunicable disease mortality,
morbidity, risk factors and determinants, as well as the response of national systems.
It also allows for the tracking of health outcomes and risk factor trends over time.
Noncommunicable disease surveillance provides the information essential for
programme and policy development.
Noncommunicable disease surveillance is an integral tool in WHO’s work to prevent
and control noncommunicable diseases. (1, 2).
Q: What is the WHO approach to noncommunicable disease surveillance?

WHO developed the global monitoring framework for noncommunicable disease

surveillance, which revolves around three main pillars: 1) monitoring of mortality
(specific focus on premature mortality from cardiovascular diseases, cancer,
diabetes and chronic respiratory disease) and morbidity (cancer incidence); 2)
monitoring of risk factors; and 3) monitoring of national system response (a core
component of which is health system response and capacity) (3).
These three pillars are assessed using 25 indicators that evaluate whether or not the
9 global noncommunicable disease voluntary targets are met, including a 25%
relative reduction in premature mortality from noncommunicable diseases by 2025.
The 9 voluntary global targets address key noncommunicable disease risk factors,
including tobacco use, salt intake, physical inactivity, high blood pressure and
harmful use of alcohol. Under ideal national settings, these three pillars should be
integrated into a comprehensive health information system.
Q: What is the WHO STEPwise approach to surveillance?

The WHO STEPwise approach (STEPS) to surveillance is part of the WHO global
noncommunicable diseases risk factor surveillance initiative. It was developed in
response to the growing need for information on country-level trends in
noncommunicable diseases. It is a simple, standardized method for collecting,
analysing and disseminating data. The approach uses a standard survey instrument
and a methodology that can be adapted to different country resource settings and
assists in building country capacity.
By using the same standardized questions and protocols, all countries can use
STEPS information not only for monitoring within-country trends, but also for making
comparisons across countries. The approach encourages the collection of small
amounts of useful information on a regular and continuing basis (2).
Q: Why invest in noncommunicable disease surveillance?

Noncommunicable disease surveillance, monitoring and evaluation are tools that

capture country performance and enhance abilities to control noncommunicable
diseases. Adequate noncommunicable disease surveillance systems permit early
identification of both people at high risk, as well as noncommunicable diseases that
can be more easily managed with low-cost treatments, combined with other public
health actions, than if otherwise later detected.
Treatment of noncommunicable diseases and their sequelae is costly so prevention
of noncommunicable diseases is a key strategy. Prevention and control of
noncommunicable diseases requires surveillance of associated risk factors (tobacco
use, unhealthy diet, physical inactivity, harmful use of alcohol) and actions to
promote the desired changes and risk reductions.
Hence, investing in noncommunicable disease surveillance is more cost-effective
(although requires funding of systems, setting up the needed resources in addition to
capacity-building), compared with bearing the costly impact of noncommunicable
diseases, as well as their associated treatments and control.
For example, the magnitude of the noncommunicable diseases pandemic in the
Region is immense, causing 2.2 million deaths every year (4). Moreover, future
projections indicate there will be an alarming increase in prevalence with the four
main noncommunicable diseases causing as many as 2.4 million deaths in 2025,
unless serious action is taken. These projections are based on recently gathered
country-level data.
This information helps countries to formulate their strategies and national plans,
focusing efforts on areas which require most attention.
Hence, better noncommunicable disease surveillance at country level provides better
health information and thus better opportunities for countries to improve the health of
their citizens. By using comprehensive health data, governments can formulate
policies and programmes to prevent disease and measure progress, impact and
efficacy of preventive efforts already in operation (5).
Q: Why is surveillance important?

Surveillance is important in helping countries monitor and evaluate emerging

patterns and trends of disease. Surveillance is crucial because it contributes to better
prevention and management of noncommunicable diseases. Through the data
collected, countries are able to set their priorities and develop targeted interventions
to reverse the noncommunicable disease epidemic.
Q: What are the costs of surveillance (is it too expensive, especially for
developing countries)?

Surveillance costs include investment in human resources and infrastructure.

Standardized protocols are available to produce comparable, as well as change-
over-time, data to monitor risk factors, as well as policies being implemented. Using
standardized questions, such as Tobacco Questions for Surveys is a cost-effective
measure, and can be embedded in existing population-based surveys or censuses.
Also, partnerships with national statistics offices or universities, research institutions
and academia can expand surveillance capacity.
Q: How does WHO support surveillance at country level?

Surveillance is one of the areas of the Regional framework for action, which has
three strategic interventions (6). Accordingly, each country is expected to:
implement/strengthen the WHO surveillance framework (7) that monitors mortality
and morbidity, risk factors and determinants, and health system capacity and
response; integrate the three components of the surveillance framework into the
national health information system; and strengthen human resources and
institutional capacity for surveillance, monitoring and evaluation.
In 2014, two countries completed the STEPwise survey and six countries moved
forward in conducting their surveys. In addition, a training workshop on surveillance
for noncommunicable diseases was conducted with the Eastern Mediterranean
Public Health Network following the development of a regional training package (8).
In future, the strategic priority is to strengthen country capacity to implement and
strengthen the WHO surveillance framework.

Overview of Environmental Health Monitoring and the Use of Indicators *

Monitoring and the use of indicators are standard in many aspects of government and
business practice as a means of assessing problems, developing policy, and measuring
progress. Indicators communicate information about conditions, and when recorded over
time, signal changes and trends. Often they signal that something more fundamental or
complex is occurring than what is actually measured, which makes them useful for guiding
policy and directing research (NRC, 2000).
The notion of environmental health indicators arose from the common use of economic
development, such as gross domestic product, according to Tord Kjellstrom of Australian
National University. Like economic indicators, they are needed because it is not possible to
measure everything. Acknowledging a critical environmental health gap, the Pew
Environmental Health Commission proposed in 2001 the establishment of a national tracking
system to monitor environmentally related exposures and diseases (Pew Environmental
Health Commission, 2001), said Thomas Burke of the Bloomberg School of Public Health.
The report noted a lack of basic information on the linkages between environmental hazards
and chronic disease.

CRITERIA FOR ESTABLISHING AN EFFECTIVE NATIONWIDE

ENVIRONMENTAL HEALTH MONITORING SYSTEM
The fundamental issues of monitoring are the basic aspects of public health and
environmental protection, and the establishment of this program should have occurred 25
years earlier, noted Burke. The concept of linking environment and health dates back to the
Council on Environmental Health in the 1970s and was again noted in the Institute of
Medicine (1988) report The Future of Public Health, which communicated that “the removal
of environmental health authority from public health agencies has led to fragmented
responsibility, lack of coordination, and inadequate attention to the health dimensions of
environmental problems.” The Pew Environmental Health Commission continued the
discussion and recommended that the nation's environmental health defense system be
strengthened, that the environmental precursors of disease be identified and controlled, and
that public health's readiness to respond be improved, noted Burke. The commission's
recommendations included establishing:
 a national baseline tracking network for diseases and exposures;
 a nationwide early-warning system for critical environmental health threats;
 state pilot tracking programs to test diseases, exposures, and approaches for national
tracking;
 federal investigative response capability; and
 tracking links to communities and research.
Acting on these recommendations, the Centers for Disease Control and Prevention (CDC) set
up four environmental health monitoring workgroups to obtain input from those interested in
working together with the agency, noted Michael McGeehin, the National Center for
Environmental Health, CDC. The National Center for Environmental Health (NCEH) held
three meetings in which 75 people from across the country—from the states, academic
institutions, and nongovernmental organizations—worked within the workgroups to advise
the CDC on the best way to set up a national monitoring system. They specified six
requirements for the system; the nationwide monitoring system must:
1.
make sense to people in local health departments;
2.
be keyed to local public health actions;
3.
receive adequate funding over the long term;
 4.
have a sense of stability;
5.
be based on sound science; and
6.
be linked to other federal agencies.
They also advised building the system from the “bottom up” (from state, local, and
community levels).

Scientific Underpinnings of Environmental Health Monitoring

According to Burke, three recent developments are helping to provide a stronger scientific
basis for monitoring activities. First, a “sound science” movement has been started with the
aim of strengthening the basis for environmental decisions. Solid scientific research provides
the means to assess whether a certain method works and whether public health goals have
been achieved; yet calls for perfection in scientific research in this time of uncertainty could
lead to difficult delays in environmental progress, noted Burke. Second, the cumulative risks
of environmental exposures are beginning to be assessed, as exemplified in the Clean Air
Act. Monitoring based on sound science and sound policy can help us develop better public
health intervention indicators. Third, epidemiology is being revived as a means of addressing
major environmental issues. Epidemiologic studies have led to progress in understanding the
risks posed by methylmercury, arsenic, and particulate air pollution, among others.

Environmental Health Monitoring Priorities

Many participants noted that the currently proposed monitoring program has a number of
limitations and that priorities would have to be set in order to ensure the success of the
program. Burke noted that the Pew Commission identified specific components of a national
monitoring system that must be built within the next few years, and these components are
reflected in part in the nationwide health tracking bill before Congress. The following health
outcome measures were recommended by the commission for monitoring: chronic respiratory
conditions (asthma, chronic pulmonary obstructive disease), neurologic diseases, birth
defects, developmental disabilities, and cancer. Environmental exposures recommended for
monitoring include specific air pollutants and food and water contaminants. The commission
also recommended that the capacity of the country's emergency departments and poison
centers be increased to provide an early-warning system for specific environmental
contamination, a measure that would benefit antiterrorism efforts. Another recommendation
was to increase the laboratory capacity for biomonitoring around the country.
Burke presented an analysis of data from the National Health Interview Survey (NHIS) on
potential indicators from the public health side that show dramatic increases in self-reported
neurologic disorders, respiratory diseases, and endocrine and metabolic disorders over a
recent 10-year period (see Figure 2.1). These increases are indicators that can be used to
identify areas where more information is needed and where we must move ahead with
monitoring and research.
Issues of Privacy in Environmental Health Monitoring
A crucial issue is balancing the need for environmental health monitoring with the need for
privacy and confidentiality. The right to privacy is an issue of high interest in this country.
Burke noted that our population has been served well by existing mechanisms for
safeguarding privacy; these measures were questioned and put to the test when HIV
prevention strategies were developed and cancer registries were created. Thus, the privacy
issue should not be a stumbling block to monitoring if we build on existing mechanisms, and
set the best academic minds to the task of ensuring that we move forward while respecting
individual rights.
Kjellstrom suggested that studying the way other countries handle the privacy issue may help
avoid negative experiences. For example, a study of the Swedish system would reveal
potential ramifications because Sweden represents an extreme in monitoring systems. A
number assigned to each individual at birth reveals the infant's sex, birth date, location of
birth, and order of birth among all Swedes at the same location who share a birth date. The
number is used later on the person's passport, driver's license, bank accounts, and health
records. In New Zealand, a number also is assigned at birth, but it reveals nothing about the
person. The number is used for all subsequent medical records, cancer registries, and
mortality registries and can be used to link data in investigations of environmental risks, such
as asbestos exposure. A system that assigns a meaningless number may raise fewer ethical
problems than one that reveals information about the person, according to Kjellstrom. Public
health research that tracks data for individuals by number creates ethical responsibilities for
researchers. However, failing to study the health effects of a possible risk factor also poses
ethical issues.

ENVIRONMENTAL HEALTH INDICATORS

The cornerstone of an environmental health monitoring effort is the selection of indicators.
Although the participants did not discuss which indicators should be selected, they did
discuss the definition of indicators; the identification of indicators, including the components
of environmental health monitoring; and the process and criteria for the selection of
indicators.

Definition of Environmental Health Indicators

Several organizations have crafted comprehensive definitions of environmental health
indicators. The National Association of County and City Health Officials (NACCHO) has
called them “tools for quantifying, through direct or indirect measures, a significant aspect of
an environmental health issue,” which “can be used to assess and communicate the status of
and trends in overall environmental health” (NACCHO, 2000).
A definition of an environmental health indicator, developed by the World Health
Organization (WHO) and others, is that it “provides information about a scientifically based
linkage between environment and health”; thus, “an indicator which purely describes the state
of the environment or a pure health status indicator with no obvious link to environmental
causation, cannot be considered an environmental health indicator.” The term environmental
health indicator “implies monitoring and action” (Kjellstrom and Corvalan, 1995).
According to the Council of State and Territorial Epidemiologists (CSTE), “Environmental
public health indicators provide information about a population's health status with respect to
environmental factors. Core indicators can be used to measure health or a factor associated
with health such as a risk or intervention in a specified population” (CSTE, 2001). Burke
suggested that indicators are tools that can be direct or indirect measures.

Identifying Environmental Health Indicators

Burke suggested several criteria for a useful environmental health indicator. The indicator
must be:
 simple—measure only one item;
 measurable—comparable and quantifiable;
 understandable—comprehensible to policy makers and the public; and
 defensible—support a relationship between environmental factors and health status.
The term “environmental indicator” implies an association, or a suggestion of an association,
between a factor and an outcome. Some participants speculated about how broad a view
should be taken about which kinds of outcomes are “suitable” for environmental health
indicators. Should only those outcomes be used for which there is a proven association with
an environmental hazard? Alternatively, should outcomes or linkages be considered that have
not yet been proven conclusively, but for which there are possible associations? Burke
suggested that a true indicator should have an association and/or should indicate the presence
of a risk, but we must not be too narrow in our focus because “perfectionism is sometimes the
enemy of progress.” The issue is whether our goal is prevention and precaution or proof
because they are fundamentally different. In environmental public health, indicators are
essential for understanding risk and evaluating interventions.
William Pease of GetActive Software suggested that an environmental health indicator also
must be credible, relevant, and able to be acted on. Because complete information is lacking
in vast areas of environmental health, we must be realistic about the credibility we can expect
from the indicators that we provide to the public, noted Pease. Scientists working with
environmental health indicators tend to place a high value on establishing clearly the entire
causal chain from source to effect. Because this amount of information is seldom available,
we must learn how to accept statements as credible in the absence of full information. If we
take a rigorous, science-based approach to environmental health indicators, we risk missing
information critical to assessment. The scope of environmental problems and the activities
that generate adverse environmental consequences require a large number of indicators.
Another aspect of credibility involves the role of the entity that develops and promotes the
indicator, its so-called social status. Indicators have to be viewed as objective, or at least
science-based, and not distorted by any conflict of interest, in order to engender trust, noted
Pease. In many cases, environmental organizations or other nongovernmental organizations
may be in a better position than federal regulatory agencies to produce environmental health
indicators that are trusted.
A trade-off may be needed between having core indicators that are valuable nationally, and
even internationally, and having indicators that are relevant to local needs, noted Burke.
Identifying the indicators that will allow health and environmental health officials and
regulatory agencies to better understand the environmental risk at the local level is a
particular challenge. A national exposure report, such as the one being compiled by the CDC
on chemical exposures, provides a profile for the nation but may reveal little about risks in a
particular region—for example, the risk of mercury exposure by women of childbearing age
near the Chesapeake Bay who consume contaminated fish from areas with closures and
advisories.

Components of Environmental Health Monitoring and Corresponding

Indicators
Environmental health monitoring has three major components: hazard monitoring, exposure
monitoring, and health outcome (health effects) monitoring. Each component has
corresponding indicators—hazard indicators, such chemical spills, and motor vehicle
emissions; exposure indicators, such as blood lead level in children; and health outcome
(health effects) indicators, such as pesticide-related poisoning in children, and melanoma. A
step beyond these three indicators is the intervention indicator. Examples of intervention
indicators are laws pertaining to smoke-free indoor air, boil-water advisories, and alternative
fuel use in motor vehicles.
As a nation, we have been quite successful at hazard monitoring, and legislation has pushed
us to identify sources and potential routes of exposure, stated Burke. The work of the
Environmental Protection Agency (EPA), exemplified in the EPA inventories, regulatory
programs, and monitoring programs, has helped illuminate and, to a certain extent, control
environmental hazards. We have not been as successful with exposure tracking, although we
have made some progress recently with the National Report on Human Exposure to
Environmental Chemicals (CDC, 2003), a CDC effort to monitor national exposure to a range
of environmental toxicants. This report will be a cornerstone of the new monitoring-based
approach to environmental health. However, the report is still in its infancy, and the tools it
describes are not yet available for use by the public health and environmental health
communities to help with outcome monitoring.

INTERNATIONAL FRAMEWORKS FOR DEVELOPING ENVIRONMENTAL

HEALTH INDICATORS
In the early 1990s, the Organization for Economic Co-operation and Development (OECD)
published its Pressure-State-Response (PSR) framework to promote a common set of
“environmental performance indicators.” Many indicators provide an easily interpretable
measure of the state of the environment or the health of a defined population. Examples are
urban air quality variables and life expectancies of populations. These “one-dimensional”
indicators have been widely adopted internationally and are important for describing time
trends and geographic variations. According to Kjellstrom, U.S. government agencies,
academic institutions, industry, and other interested parties have been active in developing
such indicators. However, creating indicators that can be interpreted in terms of linkages
between environmental quality and public health has been a major challenge.
A series of activities was begun in 1992 at the World Health Organization to establish a
method for how such indicators could be developed and tested. A new framework, the
DPSEEA framework, was devised that incorporates transparent linkages between various
one-dimensional environment or health indicators and places the focus on public health.
DPSEEA stands for Driving force-Pressure-State-Exposure-Effect-Action. Numerous case
studies have shown that this framework is helpful in developing indicators. Indicators at all
levels in the DPSEEA framework could apply locally, nationally, or internationally,
depending on the context. According to Kjellstrom, this framework has the potential to
“bridge the chasm between public health and the environment.”
The character of the environmental health problem defines the level of the policy decision.
Kjellstrom gave an example of how, in New Zealand, a ban on burning coal is a local issue,
and no decision is involved at the national level. In contrast, the ban on lead in gasoline
required a national decision because New Zealand has only one oil refinery. Some issues,
such as global climate change, must be dealt with at the international level.
In New Zealand and Australia, there has been interest in a core environmental health
indicators list. However, such an approach may be unproductive because each community has
its own concerns. As long as a nation does not commit to some “magical” core national set of
indicators, without responding to the needs and concerns of individual communities, progress
will be made.
Kjellstrom has concluded that the ultimate environmental health indicator would be the
number of people affected by a specific environmental hazard. The Ministry of Transport in
New Zealand recently used such an indicator—the number of fatalities from vehicle-related
air pollution in the country (annually estimated at 400)—as an argument for better-quality
fuels, better testing of vehicle emissions, and the use of catalytic converters. A related
indicator is the number of “obesogenic” car-related deaths, that is, deaths caused by
environmental factors that create obesity. Tentative estimates for the city of Auckland, New
Zealand, indicated that the number of such deaths related to lack of daily physical activity
because of car use instead of “active transport” could be at similar levels as the numbers of
car crash deaths (annually estimated at 40). Kjellstrom suggested that this indicator would be
particularly relevant to the United States, where the dramatic rise in obesity rates in recent
years may be strongly related to environmental factors, such as increased driving time,
decreased exercise, and greater availability of high-calorie fast food.

USING INDICATORS TO RANK ENVIRONMENTAL HEALTH RISKS

In the United States, the EPA and the Office of Science and Technology Policy (OSTP) have
been grappling with prioritizing risks and ensuring public participation, said Baruch
Fischhoff of Carnegie Mellon University. OSTP has called for an approach to risk
prioritization that is scientifically sound, understandable to the public, comparable across
programs and agencies, and cumulative so that it produces a predictable record over time.
Creating a scientifically sound method of ranking environmental health risks that includes
public input involves first establishing criteria for the content of environmental health
indicators and then selecting criteria for the risk prioritization process, noted Fishhoff.
Subsequently, five steps must be taken, as shown in Figure 2.2.

Summary of Environmental Health Monitoring and Indicators

During the workshop, speakers and panelists used many definitions to help describe what
environmental health monitoring is, the definition of an indicator, and what the selection
criteria are. The first call for environmental health monitoring occurred more than 25 years
ago. The Institute of Medicine (1988) questioned the removal of environmental health
authority from public health agencies, which led to a lack of coordination and inadequate
attention to the health dimensions of environmental problems; the Pew Environmental Health
Commission (Environmental Health Tracking Project Team, 2000) further recommended that
the nation's environmental health defense system be strengthened, reinforcing the basic need
for environmental health to respond to a myriad of health challenges.
Speakers further suggested that the currently proposed monitoring program has a number of
limitations and that priorities would have to be established to ensure its success. This has led
to many individuals and organizations to lay the groundwork for the program, by defining
what the program would include and defining what environmental indicators are.
According to some speakers, environmental health indicators are tools for quantifying the
scientific linkage between environment and health. They must be:
 simple—one item;
 measurable—comparable, quantifiable, and rankable;
 defensible;
 understandable—able to access information in a usable form;
 credible—“unbiased source,” best science;
 comprehensible;
 actable;
 responsive to local needs; and
 reflective of societal values on environment and health.