Environmental Health Workforce: Protecting Public Health and the Environment

Environmental health practitioners at the federal, state, local, tribal, and territorial levels play an important role in preventing illness. They ensure the safety of the food and water system, investigate environmental causes of foodborne and waterborne outbreaks, and respond to outbreaks and other disasters.

WHAT IS THE ENVIRONMENTAL HEALTH WORKFORCE?

Environmental health (EH) practitioners at the federal, state, local, tribal, and territorial levels are on the front lines in preventing illness. They ensure the safety of food service establishments, investigate environmental causes of foodborne and waterborne outbreaks, and respond to outbreaks and other disasters. EH programs are very diverse across the country but are often the home for permitting and inspection for drinking water and wastewater, restaurants, swimming pools, and other facilities. In addition to food and water, the EH service system is also engaged in sustainable development, climate change, vector control, air quality, and injury prevention.
Diseases spread by contaminated foods continue to challenge the public health system. And foodborne illness is often associated with environmental factors. For example, in the 2006 outbreak of Escherichia coli (E. coli)associated with spinach, contaminated irrigation water was a possible source of contamination. In addition, food and waterborne illnesses are a major concern during and after hurricanes and other natural disasters. People may be exposed to these illnesses through sewage-contaminated waters after floods and in mass sheltering environments when they are evacuated from their homes.
CDC's goal is to create a strong, sustained, and prepared EH workforce to meet today's challenges and improve the health and safety of all. Our country's ability to provide us with safe food and water rests on seamlessly integrating information and expertise related to the host, agent and environmental aspects of disease and outbreaks. EH service programs represent a key segment of the multidisciplinary approach required to ensure U.S. citizens of safe food and water.
EH professionals play a crucial role in decreasing illnesses in our communities and protecting people from traditional and emerging environmental factors that may adversely affect human health. As a result, the workforce challenges facing this critical component of the public health system are a concern for public and community health.

WHAT CHALLENGES FACE THE ENVIRONMENTAL HEALTH WORKFORCE?

The economic downturn has placed additional strain on an already vulnerable and fragmented EH system. A recent survey by the National Association of County and City Health Officials found that, in 2008 alone, more than half of the nation's local health departments had either laid off employees or lost them through attrition and have not replaced them due to budget limitations. With EH representing up to a quarter of the local public health workforce, these cuts have deep effects. Another challenge is that an estimated 40%–50% of the EH workforce in state and local agencies may be eligible to retire in the next 5 years. Also, in addition to training gaps among current EH professionals, the lack of accredited EH college programs poses a challenge in meeting the demand for much-needed practitioners that can perform necessary services.

WHAT IS CDC DOING ABOUT IT?

CDC's recently released report, "Strategic Options for CDC Support of the Local, State and Tribal Environmental Public Health Workforce," reinforces the importance of this sector of the public health workforce and the need to take action. To meet these challenges, CDC has identified the following strategies:

• Improving awareness of the EH profession.
• Improving recruitment, benefits, and retention for EH professionals.
• Improving skills of EH professionals by supporting accredited environmental health undergraduate programs and internships.
• Creating an EH Service Corps and a training academy.  
• Expanding CDC's Environmental Public Health Leadership Institute.
• Documenting current and needed capacity of the EH workforce.
• Supporting EH performance standards and accreditation.
• Improving skills in collecting, analyzing, and assessing environmental data in outbreaks to inform disease prevention strategies by expanding the Environmental Health Specialists Network.

• Broadening collaboration among epidemiologic, laboratory, and environmental health professionals.
  
  
  Fragmentation of Environmental Public Health Response:

Scientific Capacity Needed for Future Environmental Public Health Activities

A variety of expertise and tools are needed to address the environmental public health threats facing our nation to:

1. identify the problems,
2. treat or fix the problems, and
3. assess the effectiveness of our programs and interventions and replicate the best ones at the State, local, and international levels.

To identify and manage environmental public health problems, we need to utilize the scientific model of determining exposure to environmental insults, including those associated with disasters; evaluating the health risk for various populations to these insults; and identifying and subsequently preventing adverse health outcomes in these populations.

	The following expertise and tools are needed to conduct health and exposure assessments to identify the problems:
	laboratory sciences		Together NCEH and ATSDR have a strong base in these areas with the notable exception of surveillance. We have only the beginnings of exposure surveillance and, as the Pew Commission pointed out, little in the way of disease surveillance. We need to develop tracking mechanisms for diseases and conditions such as multiple sclerosis, Parkinson's disease, amyotrophic lateral sclerosis, heavy metal and pesticide poisoning, autism, and asthma to determine their possible link to environmental causes.
		biomonitoring
		environmental monitoring
	epidemiology/biostatistics
	surveillance/tracking
		disease
		exposure
		behavior
	genetics
	toxicology
	medical sciences
		environmental sciences (air, water, soil, food,other physical agents)
		risk assessment
		risk analysis
		community/Tribal involvement
		information systems/informatics
		(including geographic information systems)

Addressing an identified problem involves:

• changing or controlling the environmental condition so it no longer causes a problem (e.g., providing a safe, alternative drinking water supply), or
• changing the behavior of individuals so they avoid contact with the environmental condition (e.g., avoiding eating contaminated fish), or
• changing behaviors to reduce the risk for disease development among populations exposed to past environmental insults (e.g., promoting smoking cessation among people with past exposures to radon), or
• providing, or facilitating the provision of, appropriate medical treatment (e.g., training physicians to use the most appropriate tools to more accurately diagnose disease among exposed populations).

The first approach is most often accomplished by enacting regulations, enforcing laws, and managing risk. NCEH/ATSDR are responsible for advising regulatory agencies (e.g., EPA, FDA, CPSC) about how best to eliminate the adverse environmental public health condition. The second and third approaches, both involving changing personal behaviors, are more challenging and require a variety of methods including health education, risk communication, media campaigns, and behavioral research. The fourth approach, providing medical treatment, is outside of NCEH’s and ATSDR’s purview; however, we do provide guidance to medical-care providers on how best to diagnose and treat illness in patients who have been exposed to environmental insults. Related to this approach, new ways need to be identified to better manage the transition from the public health infrastructure to the health-care infrastructure once disease and illness have been identified.

	The following expertise and tools are needed to treat or “fix” the problems:
	community and Tribal involvement		Although ATSDR has developed some capacity in these disciplines, both NCEH and ATSDR need to greatly strengthen their capacity in these areas if they are to effectively address environmental public health issues.
	public health ethics
	health education for communities
	risk communication
		(including media campaigns)
	advice/guidelines for the regulators
		(e.g., safe level of toxicants for human health and land-use policy)
	advice/guidelines for health-care professionals
	genetics
	behavioral change research
	medical screening/treatment facilitation

NCEH/ATSDR need to continue to assess the effectiveness of our public health interventions and transfer the best of them to our State and local public health partners. We also are obligated to share our knowledge with, and learn from, other countries. For example, assisting a country in conducting an epidemiologic investigation of an environmentally-related disease outbreak can ameliorate suffering and prevent disease; develop new scientific information of benefit to people worldwide, including the United States; and help build lasting public health capacity in the country. Environmental pollution and many disasters respect no boundaries, and can contaminate environments or affect populations thousands of miles from the point source.

NCEH/ATSDR Leadership Role in Environmental Public Health

In infectious disease, CDC plays the traditional public health role of disease detection and tracking, prevention research, and health promotion. CDC’s public health role falls between that of NIH (which contributes biomedical research) and FDA (which provides the regulatory muscle). In environmental public health, NCEH and ATSDR play the same disease detection/prevention and health promotion roles, with NIH serving the biomedical research role, and with EPA and FDA filling the regulatory role.
NCEH/ATSDR apply the basic biomedical research findings of NIH (primarily the National Institute of Environmental Health Sciences) in their prevention program activities. Conversely, NCEH/ATSDR feed information back to NIH on the applicability of their basic research findings to disease prevention and identify where critical gaps of information exist so that NIH’s basic research programs can address these gaps. Ties between NCEH/ATSDR and NIH do exist, but they need to be strengthened.
The relationship between NCEH/ATSDR and the regulatory agencies is equally important. ATSDR has maintained a particularly strong relationship with EPA, providing environmental public health advice to the EPA Superfund program – primarily because of EPA’s and ATSDR’s statutory mandates. ATSDR has an excellent record of EPA acceptance of site-specific recommendations. NCEH has also worked extensively with EPA and FDA on a variety of specific environmental public health problems. To have a major impact on environmental public health issues, NCEH/ATSDR must strengthen their ties with all relevant programs at EPA and FDA and provide them with real-time health data that they can use in their regulatory decision- making. Too often regulatory decisions are based upon animal data rather than human data, or on data derived from mathematical modeling. To establish this more effective relationship with EPA, NCEH/ATSDR need expertise in the environmental sciences (e.g., geologists, hydrologists, physicists, and engineers) related to air, water, soil, food, and other physical agents not only so we can talk the same language, but also so we can effectively communicate public health messages to the public and into the regulatory and enforcement programs of these agencies

Positioning NCEH/ATSDR for the Future of Environmental Health

Although numerous agencies and organizations at all levels are working in various facets of infectious disease prevention, CDC is universally recognized as the “go-to” agency when leadership and assistance are needed. This unquestioned leadership role results from CDC’s well-honed and highly effective model that includes staff assignments internationally and to State and local health agencies, training programs, disease tracking, epidemiology support, linkages with all relevant players, health promotion, risk assessment and communication, laboratory expertise, and applied research. The same model is needed regarding health problems related to the environment. Jointly, NCEH and ATSDR can establish this same model and leadership role for environmental public health within the next 5 years while ensuring that NCEH’s and ATSDR’s current programs (e.g., childhood lead poisoning prevention and Superfund) are not attenuated.
NCEH and ATSDR and our partners need to be able to respond to all the environmental public health objectives presented in, Healthy People 2010. The critical importance of achieving these objectives is reflected in the “Environmental Health” component of this document where it states, “Poor environmental quality is estimated to be directly responsible for approximately 25 percent of all preventable ill health in the world...” As a reflection of the pervasive impact of the environment on human health, it is notable that the “Environmental Health” focus area crosscuts with 17 other Healthy People 2010 focus areas.
NCEH/ATSDR need to be able to respond to the challenges posed by many of the Nation’s most prominent public health leaders at the NACCHO focus group discussions. This diverse group of leaders represented academia, public interest groups (e.g., Physicians for Social Responsibility), nonprofit organizations (e.g., National Safety Council, American Lung Association), Tribal representatives, other Federal agencies with environmental responsibilities, and organizations representing the interests of the public health field (e.g., National Association of Local Boards of Health, Public Health Foundation, and National Environmental Health Association). Participants virtually unanimously indicated that expanded national leadership from NCEH and ATSDR must address critical needs such as ensuring National coordination and reducing fragmentation of activities at all levels, promoting the field of environmental public health, aiding in developing the public health workforce through training support, and providing strategic and flexible financial support to State and local public health agencies.
NCEH/ATSDR also need to be able to answer the questions posed by the Pew Commission such as:

• Are environmental exposures related to clusters of childhood cancer and autism?
• What are the impacts of pesticide exposures on children’s health?
• What proportion of birth defects are related to environmental factors?
• Are adult-onset diseases such as Parkinson’s disease and Alzheimer’s disease related to cumulative environmental exposures?
• Are learning disabilities related to environmental exposures?
• How does particulate air pollution increase the risk of death for the elderly?
• Are endocrine-disrupting pollutants in the environment related to the increasing incidence of breast and prostate cancers?

These questions and issues such as health effects that may result from chronic, low-level exposures to a given toxicant or from mixtures of toxicants need to be addressed both for specific communities, and for the population of the United States in general.
To respond to increasing environmental health concerns by the public NCEH/ATSDR need to:

• Establish NCEH/ATSDR teams to provide consultation on and, as warranted, investigate environmentally related disease clusters and outbreaks following the public health model.
• Ensure that NCEH and ATSDR programs complement each other and function in concert.
• Provide assistance to State and local health agencies, professional organizations, and others to broaden their capacity in environmental public health through training, assignment of staff, and funding through grants and cooperative agreements.
• Establish the “Nationwide Health Tracking Network” proposed by the Pew Environmental Health Commission.
• Develop effective methods of preventing environmentally related diseases and effectively diagnosing and facilitating treatment when prevention fails.
• Expand emergency preparedness and response capacity to address the many complex issues of natural and technologic disasters and bioterrorism threats.
• Define and implement a joint applied research agenda for environmental public health.
• Pursue linking biomonitoring, environmental data, and disease tracking to further inform environmental and public health decision makers.
• Aggressively pursue the implications of the “new genetics” to better understand environmental exposure and gene interactions.
• Ensure that environmental justice principles are appropriately considered in all NCEH and ATSDR activities.

Additionally, NCEH/ATSDR need to share technical expertise with other countries and learn more about environmental public health impacts from exposure to toxic substances world wide

	The following tools and expertise are needed to determine whether our efforts have prevented or controlled disease, and then to replicate successful programs in other venues:
	program effectiveness evaluation		NCEH and ATSDR have grant and cooperative agreement programs with State and local health departments. Both organizations need to ensure the provision of resources to these departments to cover an array of environmental public health issues and to build State and local laboratory, epidemiology, health promotion, and surveillance capacities as well as to promote community and Tribal involvement
	cost-benefit analysis
		(prevention effectiveness)
	capacity building
		technology transfer
		training and education
		funding for grants and cooperative agreement

From the publication of The Future of Public Health in 1988 to the 2000 publication of the Pew Environmental Health Commission’s report, America’s Environmental Health Gap, these and other reports have documented that “environmental health” is the most fragmented and poorly defined area of public health. In 2000, the National Association of County and City Health Officials (NACCHO) conducted focus groups comprised of senior staff of State and local health agencies, Tribal governments, Federal agencies, and volunteer and advocacy organizations. The purpose of these focus groups was to obtain individual advice and recommendations on ways to strengthen the practice of environmental public health in the United States. One overriding theme that emerged from these focus groups was that “fragmentation among agencies at all levels is a barrier to effective protection against environmental health threats.” It is clear that today’s complex environmental public health problems require coordinated responses of multiple agencies and organizations and various professional disciplines. 

Federal agencies other than CDC and ATSDR that have major environmental missions that include public health are the National Institutes of Health (NIH) and the Environmental Protection Agency (EPA) and to a lesser degree, the Department of the Interior, the Department of Transportation, the Department of Housing and Urban Development, the Department of Energy, the Department of Defense, the Department of Agriculture, the Food and Drug Administration (FDA), the Department of Veterans Affairs, the Federal Emergency Management Agency (FEMA), the Indian Health Service, and the Consumer Product Safety Commission (CPSC). 

Even within CDC, programs that have major environmental components, such as food borne and water borne disease prevention, injury control, vector control, and occupational safety and health are housed in multiple Centers and Institutes. The wide distribution of related Federal programs results in uncertainty among State and local health agencies and the public we serve as to whom they can turn to at the Federal level if they need assistance in managing environmental public health problems. 

At the State and local levels, programs that address environmental quality, largely through regulation and enforcement mechanisms, and classic human health protection programs are almost always housed in different agencies. Likewise, State-and local-level programs such as disaster preparedness and response, zoning/land use planning, pesticide safety and regulation, public safety, and parks and recreation are distributed among various departments. Great disparities exist in the funding “health” of these various agencies and departments, but as a rule environmental public health units in State and local health departments are the most underfunded. In addition, environmental public health concerns such as urban sprawl and its accompanying destruction of “green space,” over-population and traffic congestion, and overloading existing infrastructures that provide essential services such as clean water and waste treatment are often overlooked from a public health perspective. 

Need for Focused National and International Leadership: Information from key decision and policy makers (e.g., The Pew Environmental Health Commission and NACCHO focus groups) highlight the need to “...rebuild the nation’s public health defenses against environmental threats...” The Pew Environmental Health Commission in its 2000 report indicated that Federal leadership and assistance have lacked disease and environmental exposure tracking, ensuring training for State and local environmental health practitioners, developing strategic partnerships, and providing financial support to State and local health agencies and other entities. These reports underscore the urgent need to establish environmental public health leadership at the Federal level. Areas of greatest concern that need to be addressed include: creating and promoting a unified identity for environmental public health, developing national performance standards and best practices, providing technical assistance, ensuring workforce development at the State and local levels, and securing resources to promote environmental public health at all levels. Leadership is also needed at the international level because environmental public health threats respect no national boundaries. 

Emerging Threats: Within the past ten years, dramatic and tragic disease outbreaks involving tens of thousands of people have resulted from breakdowns in the Nation’s defenses against environmental threats or are legacies of exposures that occurred decades ago. For example, ATSDR recently began investigating what is believed to be the single most significant source of vermiculite asbestos exposure in the United States as a result of mining and processing operations in Libby, Montana. Additionally, weaknesses in the environmental public health infrastructure in the United States have led to large-scale vector borne, water borne, and food borne infectious disease outbreaks. 

Newly recognized threats are emerging such as mercury in vaccines, illegal use of pesticides, abandoned methamphetamine labs in suburban homes, the rapidly increasing incidence of asthma, and the threat of terrorist attacks. Additionally, natural disasters overwhelm and disrupt public and private health systems, often requiring mobilization of substantial internal and external assistance and expertise. Although acute natural events, such as tornadoes, garner the most publicity, slower-onset environmental events such as floods, droughts, heat waves, and extreme cold also present unique public health challenges. The threat of terrorist attacks with biologic or chemical weapons in the United States has become a major public health concern. All these threats have the potential to cause significant morbidity and mortality and overwhelm public health and medical-care systems. 

Problems once considered to be solved in the United States have proven to be more intractable than once imagined. Air pollution in urban areas has led to routine public health warnings, including warnings against physical activity for children and other at-risk people. Closure of ocean beaches because of contaminated water are now common–at least in States that have beach water monitoring programs. Unhealthy home and neighborhood environments result in problems ranging from childhood lead poisoning to injuries to the lack of recreation opportunities. 

International threats include natural and technologic disasters, complex humanitarian emergencies, lead and heavy metal poisoning, and pesticide exposures. For example, flooding in Venezuela from Hurricane Mitch resulted in significant contamination of the Caracas harbor with industrial waste, and led to a request to CDC to participate in a response team to address this environmental crisis. 

“Few would dispute that we should keep track of the hazards of pollutants in the environment, human exposures, and the resulting health outcomes—and that this information should be easily accessible to public health professionals, policy-makers and the public. Yet even today we remain surprisingly in the dark about our nation’s environmental health.” (From America’s Environmental Health Gap.) Although NCEH and ATSDR and their collaborators are working to develop disease and exposure indicators, no comprehensive system is in place in the United States that tracks and links human environmental exposures and the relationship of these exposures to disease causation. It is believed that environmentally related disease outbreaks are relatively common and that many are unreported. 

The mapping of the human genome offers an unprecedented but as yet not fully realized opportunity to study gene-environment interactions and their relationship to disease causation. 

In recognition of the critical importance of these threats, “Emerging Diseases,” many with environmental factors associated with their causation, and “Ecological Issues” are pointed to by CDC as being among the top 10 major health risks in the 21st century