Strengthening the Role of Public Health in Environmental Policy

Policy Studies Journal, Vol 23, No. 1,1995 (76-84)

Strengthening the Role of Public Healthin Environmental PolicyThomas A. Burke, Nadia M. Shalauta, and Nga L. Tran

Over the past 25 years there has been a steady decline in the role ofpublic health agencies in environmental protection. This paper examines themajor factors that have contributed to that decline, including the impact offederal environmental laws, the disparity in funding between regulatory andpublic health activities in environmental protection, and the emergence of riskassessment as a basis for environmental decisions. The methods of riskassessment and traditional public health approaches are contrasted, and theadvantages of the involvement of public health agencies are discussed.Recommendations are presented for strengthening the role of public health inenvironmental decisionmaking to address more effectively public concernsabout environmental risks.

Introduction

The common roots of the public health and environmental protectionmovements may date back as far as the archeological evidence of the drainage systems,toilets, and water systems of the Minoans and Myceneans, from 3000 to 1150 B.C.(Pickett & Hanlon, 1990, p. 21). In the United States, the beginnings of organizedenvironmental protection efforts can be traced to the great sanitary movement of thenineteenth century. Infiuenced by the work of Edwin Chadwick in London (Richardson,1887), Lemuel Shattuck's 1850 Report of the Massachusetts Sanitary Commissionformed the basis for many of the nation's first environmental health programs. Thereport recognized the role of urban crowding and filth, specifically, the "foulness of theair created by the decay of waste in areas of dense population" (Institute of Medicine,1988). With recommendations that included regular surveys of health conditions andthe supervision of water supplies and waste disposal, the work characterized the focus ofthe first boards of health as being concentrated on environmental sanitation to combatepidemics of cholera, typhoid, and yellow fever. These early boards, which began in themajor cities, became models for the local and state public health agencies that assumedresponsibility for controlling disease through sanitation, the protection of watersupplies, control of air pollution nuisances, and the inspection of food.

Today, the protection of public health remains a fundamental goal of ournational environmental protection programs. However, with the advent of the firstEarth Day, in 1970, a dramatic shift has occurred in the organization of the nation'senvironmental protection efforts. The establishment of the Environmental ProtectionAgency (EPA), and the subsequent proliferation of similar state environmental agencies,has led to a steady decline in the role of public health agencies in environmentalprotection. This decline was pointed out in the 1988 Institute of Medicine report. TheFuture of Public Health, which concluded:

The removal of enviromnenlal health authority from public healthagencies has led lo fragmented responsibility, lack of coordination, andinadequate attention to the public health dimensions of environmental issues(Institute of Medicine, 1988).

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Symposium on Environmental Health: Burke/Shalauta/Tran

Ironically, the demise of the role of public health agencies in environmentalprotection has occurred during a period of steadily increasing federal and state spendingon environmental programs. Not surprisingly, it also has coincided with increasingpublic concern about environmental health effects and growing frustration with theinability of current risk assessment approaches to address basic public health concems.

In response to concems about the effectiveness of current environmental policystrategies, the United States Congress currently is working on a number of proposedbills that are aimed at revising agency risk assessment methods (Bureau of NationalAffairs, 1994). These bills promote a broader characterization of risks, a comparativeapproach to identify those problems that pose the greatest risks to health and to theenvironment, and the application of cost-benefit approaches to guide risk managementstrategies. As the nation debates the refocusing of its environmental priorities, perhapsit is time to reconsider the role of public health agencies. This paper examines thechanging role of public health agencies in environmental protection, and contrasts thetraditional public health approach with the risk assessment/risk management approachthat has become the basis for environmental decisionmaking.

The Federal Laws and the Shift from Public Health

The federal laws that shape EPA have led to enormous progress in the controland remediation of environmental pollution. However, these laws also have contributedto the fragmentation of environmental protection. The major federal statutes havecompartmentalized the environment by establishing a media-specific, risk-assessment-based regulatory framework. The costs of these efforts have been high, and difficultquestions remain conceming their effectiveness in protecting human health. TheEnvironmental Protection Agency's Science Advisory Board (United StatesEnvironmental Protection Agency, 1990) has concluded:

Because most of EPA's program offices have been responsible forimplementing specific laws, they have tended to view environmentalproblems separately ... and questions of relative seriousness or urgency haveremained unasked. Consequently, at EPA there has been little correlationbetween the relative resources dedicated to different environmental problemsand the relative risks posed by these problems.

The structure and priorities of the EPA are determined largely by the majorlaws that have shaped the agency's regulatory authorities and funding. Since most ofthe actual implementation occurs on the state level, these laws also have provided thestates with a blueprint for their organization of environmental programs. This has ledto the national proliferation of state environmental agencies that mirror the federal EPA,or mini-EPAs (Rabe, 1986). Figure 1 provides an example of a typical stateenvironmental agency that reflects the media-specific approach and clearly reflects theimpact of the federal statutes.

Just as the federal statutes have spurred the development of state environmentalagencies, they also have contributed to the declining role of health agencies. In a recentstudy of state-level environmental services conducted for the United States PublicHealth Service Health Resources and Services Administration Bureau of HealthProfessions, we found a continuation of the 25-year trend toward removingenvironmental regulatory responsibilities from state health agencies. In fact, statehealth agencies remain the lead agency for environmental health and protectionprograms in only eight states. In at least one of these remaining states, a change to the

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Figure 1Example of a State Mini-EPA Agency Structure

GOVERNOR

ENVIRONMENTAL QUALITYCCXJNCIL

INDUSTRIAL SITING COUNQL

DIRECTORDEQ

ENrORCEMENTATTORNEY GENERAL

ADMINISTRATION

ABANDONEDMINE LAND

DIVISION

LAND QUAUTYDIVISION

AIR QUAUTYDIVISION

WATER QUALITYDIVBION

SOUDANDHAZARDOUS WASTE

MGMT DIVISION

INDUSTRIAL SITINGDIVBION

AMLADVISORY

BOARD

LAND QUALITYADVISORY

BOARD

AIR QUAUTYADVISORY

BOARD

WATER QUALITYADVISORY BOARD

'adapted from Ihe stale ol Wyoming

EPA model is being planned (Burke, Shalauta, & Tran, 1995).To investigate further the impact of the major statutes in the declining role of

public health agencies, we evaluated which state agencies are responsible forimplementing the laws administered by EPA. Figure 2 presents a national comparisonof the number of state environmental and health agencies that have programmaticresponsibilities for these laws.

The dominant role of environmental agencies is shown clearly, particularly forthe media-specific Clean Air Act (CAA), Clean Water Act (CWA), Superfund(CERCLA), Resource Conservation and Recovery Act (RCRA), and Safe DrinkingWater Act (SDWA). For the implementation of these laws, environmental agenciesoumumber health agencies by a wide margin.

It is interesting to note that the statute with the largest role for health agenciesis Superfund. This fact refiects the public health assessments conducted by state healthagencies, in cooperation with the Agency for Toxic Substances and Disease Registry(ATSDR). On a discouraging note, during the ongoing debate about Superfundreauthorization, it has been proposed that financial support for ATSDR activities be

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Figure 2Number of State Environmental and Health Agencies ImplementingFederal Environmental Statutes

No. of Agencies

CAA CWA CERCLA FIFRA RCRA SDWA TSCA

NO.ENV. AGENCIES •NO.HLTH AGENCIES g

41

10

41

10

36

33

4

5

41

11

38

22

12

23

Federal Statutes

dropped (S. 1834, 1994), even though these activities represent a tiny percentage oftotal Superfund spending (Agency for Toxic Substances and Disease Registry, 1989).

In addition to Superfund, health agencies also have a predominant role in theToxic Substance Control Act (TSCA). This is due primarily to their responsibility forthe oversight of school asbestos control activities. In contrast to other laws. Table 1shows a small number of both health and environmental agencies involved in theFederal Insecticide, Fungicide, and Rodenticide Act (FIFRA). In the large majority ofstates, this law is implemented by agriculture agencies.

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Table 1Comparison of the Risk Assessment and Public Health ApproachesGoal: The Protection of Public Health

Driver:Approach:Process:

HealthEndpoint:

Tools:

Agencies:Outputs:Actions:

Solution:

Public Values:

Decisionmaking:Success:

Risk AssessmentSingle HazardPollutant-specificHazard IDDose ResponseExposure AssessmentRisk CharacterizationRisk ManagementLimited (Cancer)

Toxicology, Modeling

Federal/StateStandards, RegulationsPermitting, EnforcementMonitoringHigh tech/PoUutant-specificNo Mechanism forInclusionTop-downRegulatory Compliance

Public HealthPopulation Health ImpactPopulation-basedAssessmentPolicy DevelopmentAssurance

Diverse/Multiple

Epidemiology,SurveillanceLocal/CommunityIntervention StrategiesOutreach, Screening,TreaunentLow tech/Broad-based

Essential Component ofIntervention StrategyBottom-upCommunity HealthImprovement

The Funding Disparity

Just as the federal laws have shaped the structure of the national environmentalprotection infrastructure, so, too, have they shaped the funding. Relative to theenormous sums allocated for enforcement, monitoring, and cleanup activities, very littleis spent to support the public health activities aimed at evaluating and preventingadverse public health impacts. For example, the cost of cleaning up existing hazardouswaste sites has been estimated to be as high as a trillion dollars over the next 30 years(Russel, Colglazier, & English, 1991). Questions concerning the public healthbenefits of these cleanups continue to undermine the credibility of the entire nationaleffort. Yet, a relatively minuscule amount has been directed toward understandingpopulation exposures and evaluating the public health risks.

Our analysis of state agency funding for environmental programs indicates thata comparatively small percentage of funding goes to support environmental publichealth activities. Nationally, for the years 1992-1994, only 20% of stateenvironmental protection spending went to support environmental health-relatedactivities. If natural resources protection programs are included, only 8 cents of everyenvironmental dollar spent are directed toward public health activities (Burke, Shalauta,& Tran, 1995). This is not surprising, since the federal mandates emphasize pollutioncontrol and enforcement.

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The Risk Assessment Paradigm and Public Health

Concurrent with the shift in environmental responsibilities came the rise ofquantitative risk assessment as an increasingly important metric for environmentaldecisionmaking. This four-step process—hazard identification, dose responseevaluation, exposure assessment, and risk characterization—was codified in the 1983National Academy of Sciences report that has become known as the "Red Book"(National Research Council, 1983). This paradigm contrasts with the more robust corefunctions of public health—assessment, policy development, and assurance—as definedby the Institute of Medicine (1988). However, since the publication of the "Red Book,"risk assessment has been adopted widely on the federal and state levels as a tool forevaluating risks. Risk assessments have served as the basis for policy decisionsranging from drinking water standards to the evacuation of Times Beach (Kimbrough,Falk, & Fries, 1983).

Ideally, the risk assessment process draws upon and complements thetraditional public health approaches of health surveillance and epidemiology. However,in practice, the risk assessment/risk management approach to environmental protectionhas resulted in a tremendously increased dependence upon animal toxicology tests and adeparture from human-population-based studies. Quantitative risk assessment seeks toidentify the toxicological properties of a substance, while public health assessment isbased upon evaluation of the prevalence of disease and the health status of a population(Silbergeld, 1993).

Although the evaluation of health risks should be a focal point for cooperationbetween the environmental and public health communities, in many ways it casts themapart. Table 1 compares the risk assessment/risk management approach with thetraditional public health approach to evaluating and managing health risks.

The risk assessment approach usually is focused narrowly on specificregulatory and health endpoints. Its dependence upon toxicology and mathematicalmodeling contrasts with the public health methods, which utilize epidemiologicaisurveillance of actual population morbidity and mortality for a broad range of healthendpoints. In addition, the risk assessment approach is "top-down," usuallyimplemented by a federal or state regulatory agency, whereas the public health approachis dependent upon community-based agencies and usually includes extensive publicparticipation in the development of intervention strategies. Perhaps the mostsignificant difference between the two approaches is their definition of success. Drivenby statutory mandates, environmental agencies often define success in terms ofregulatory compliance. The ultimate measure of success for public health agencies is ameasurable improvement in community health.

The risk assessment approach is the framework for decisions used by EPA andby many state environmental agencies. This approach has served as the basis for manyof the environmental regulatory programs that implement national statutes. In fact, theorigins of the approach lie in the statutory mandates that require the regulation of"unacceptable risk" or the development of standards requiring "no adverse effects"(National Research Council, 1983). The risk assessment approach is particularly wellsuited for providing a "number," that is, a quantitative estimate of risk for a specificsubstance and for a specific health endpoint. This is extremely useful for regulatoryprograms that require risk numbers to guide decisions regarding virtually everythingfrom air emissions to cleanup goals.

Unfortunately, as the application of the risk assessment approach has

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increased, support for the public health approaches of epidemiology and surveillance hasnot kept pace. This has contributed further to the erosion of the role of public healthagencies in environmental decisionmaking.

The Link Between Public Health and Ecological Health

Ironically, the demise of the role of health agencies and the increasing role ofenvironmental agencies at the federal and state levels has not resulted in an increasedemphasis on protecting the natural ecology. According to EPA's Science AdvisoryBoard, the Agency has paid too little attention to risks posed to natural ecosystems overthe past 20 years. In its landmark report. Reducing Risk, the Board recommended thatEPA recognize the strong links between human health and ecological health and that itdevelop priorities reflecting a more appropriate balance of the two (United StatesEnvironmental Protection Agency, 1990). Up to this point, the risk assessmentapproach has not supported the inclusion of appropriate consideration of ecologicalrisks.

Discussion and Recommendations

There is a growing concem that current national policies may not be addressingthe most important risks to public health and to the environment. This has led to acredibility crisis in environmental policy. As described by Lave (1993), the riskmanagement system is "broken." The credibility crisis in no small part has been due tothe seemingly continuous controversy surrounding the assessment of risks. From Alarto radon, dioxin to environmental tobacco smoke, current practices of risk assessmenthave failed to provide the public with consistent, understandable information aboutpublic health risks.

Successful environmental policies require considerations that go beyond thecurrent limitations of risk assessment. Environmental decisionmaking must considernot only science, but also economics, public values, and political and legalimplications. Ultimately, success depends upon the establishment of effectivecommunication strategies (Burke, 1993). As the Congress debates approaches toimproving risk assessment and risk management, it is time to reverse the declining roleof the nation's public health agencies and to involve more actively the public healthcommunity in a cooperative approach to environmental decisionmaking.

The following recommendations are offered for consideration as possibleapproaches to strengthening the public health infrastructure and improving theassessment of environmental health risks:

Representation from the field of public health should be increasedamong appointed officials in environmental agencies at both the federal andstate levels.

As existing national statutes are considered for reauthorization,opportunities to expand beyond the narrow scope of media and substancespecific regulations should be pursued. The profound impact of these laws onthe state infrastructure must be considered.

Legislation to promote the use of comparative risk approachesshould recognize the essential role of epidemiology and health surveillance inunderstanding risks and in evaluating the effectiveness of risk managementstrategies.

The disparity in funding between environmental regulatory andremediation activities, and public health activities, should be addressed.

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The community-based perspective of public health should berecognized as a vehicle for enhancing public participation in enviroranentaldecisionmaking. This is relevant particularly to comparative risk prioritysetting and to addressing issues of environmental justice.

The public health training of the environmental workforce shouldbe evaluated, and increased opportunities for training of environmentalprofessionals in the core functions and basic sciences of public health shouldbe developed.

Efforts should be made to foster a more cooperative workingrelationship between the environmental regulatory and public health ageiKiesat all levels of govemment.

The evaluation of the relationship between human health and the environmentposes an enormous challenge for the scientific, regulatory, and public healthcommunities. Over the past 25 years, there has been a clear decline in the role ofpublic health agencies in environmental decisions. The solution to this decline will notbe found in a retum to past organizational structures or in a shift of regulatoryauthorities to health agencies. The nature of environmental protection has evolved fromthe earlier infectious disease model, and now requires a broad, multidisciplinaryapproach. However, the population perspective of public health always has been, andwill continue to be, an essential component of the effective protection of theenvironment

***

Thomas Burke is an associate professor of health policy and management atthe Johns Hopkins School of Hygiene and Public Health. He served formerly asDeputy Commissioner of Health for the state of New Jersey and as Director of theOffice of Science and Research of the New Jersey Department of EnvironmentalProtection.

Nadia Shalauta is a research associate at the Johns Hopkins School ofHygiene and Public Health, and a doctoral candidate at the Boston University School ofPublic Health.

Nga Tran, formerly at Johns Hopkins, is now with the United StatesDepartment of Energy, Office of the Assistant Secretary for Environment, Safety, andHealth.

Note

Supported in part by a grant from the Pew Charitable Trusts.

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Strengthening the Role of Public Health in Environmental Policy