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This document is provided as a historical reference. It has been replaced by: FY 2007 Performance Plan for the Agency for Toxic Substances and Disease Registry [PDF, 399 KB]

Agency for Toxic Substances and Disease Registry
Strategic Plan 2002-2007

Table of Contents

Overview of the Agency
Development and Update of the Strategic Plan
Perspective and Outlook
ATSDR's Core Values
The ATSDR Vision
The ATSDR Mission
ATSDR's Strategic Goals for 2002-2007

Goal 1. Evaluate human health risks from toxic sites and releases and take action in a timely and responsive public health manner

Goal 2. Ascertain the relationship between exposure to toxic substances and disease

Goal 3. Develop and provide reliable, understandable information for people in affected communities and tribes and for other stakeholders

Goal 4. Build and enhance effective partnerships

Goal 5. Foster a quality work environment at ATSDR

Overview of the Agency

The Agency for Toxic Substances and Disease Registry (ATSDR) is the principal federal public health agency charged with the responsibility of evaluating the human health effects of exposure to hazardous substances. The agency works in close collaboration with local, state, and other federal agencies, with tribal governments, and with communities and local health care providers. The goal of the agency is to help prevent or reduce harmful human health effects from exposure to hazardous substances.


In 1980, Congress created ATSDR to implement the health-related sections of the laws that protect the public from hazardous waste and environmental spills of hazardous substances. The Comprehensive Environmental Response, Compensation, and Liability Act of 1980 (CERCLA), commonly known as the "Superfund" Act, provided a Congressional mandate to clean up abandoned and inactive hazardous waste sites and to provide federal assistance in emergencies involving toxic substances. As the lead agency in the Public Health Service for implementing the health-related provisions of CERCLA, ATSDR is charged under the Superfund Act to assess the presence and nature of health hazards at specific Superfund sites, help reduce or prevent further exposure, and expand the knowledge base about health effects related to exposure to hazardous substances. In 1984, amendments to the Resource Conservation and Recovery Act of 1976 (RCRA), which provides for the management of legitimate hazardous waste storage, authorized ATSDR to conduct public health assessments at hazardous waste sites when requested by the Environmental Protection Agency (EPA), states, or individuals. ATSDR was also authorized to assist EPA in determining which hazardous substances should be regulated and the concentration levels at which the substances might pose a threat to human health.

With the passage of the Superfund Amendments and Reauthorization Act of 1986 (SARA), ATSDR received additional responsibilities in environmental public health. This act broadened ATSDR's responsibilities in the areas of public health assessments, establishment and maintenance of toxicologic databases, information dissemination, and medical education.


ATSDR executes its statutory responsibilities through the following program areas:

Public Health Assessments Consultations
Toxicological Profiles Literature Inventory and Dissemination
Emergency Response Health Studies
Exposure Registry Health Education
Applied Research  

To carry out this diverse portfolio of responsibilities, ATSDR has evolved into an efficient operation with emphasis on a functional structure. ATSDR has headquarters in Atlanta, Georgia, and an office in Washington, DC, as well as 10 regional offices throughout the United States. ATSDR has a full-time staff of more than 420, and in fiscal year 2001 had an operating budget of $75,000,000. The agency's work ranges from conducting educational seminars for American Indians on the effects of consumption of Great Lakes fish to conducting epidemiological studies to determine links between toxic exposure and disease. The agency has made significant contributions to improve the health and quality of life of thousands living in unsafe environments.

ATSDR is organized into administrative offices, program support offices, and program-specific divisions (see Figure 1).

ATSDR's Organizational Structure

Figure 1. ATSDR's organizational structure.

Development and Update of the Strategic Plan

The development of the strategic plan followed a process that relied closely on input from internal and external stakeholders of the agency. Working with various stakeholders, ATSDR's approach began by creating a long-term vision of the agency and continued by developing strategies for achieving the vision. The agency has developed a strategic plan that focuses time and resources on those initiatives that will return maximum value to the American public by employing strategies that will most effectively use the skills and resources at ATSDR.

In an effort to maintain consistency in form and message with the Department of Health and Human Services (HHS), ATSDR staff members carefully reviewed and followed the format of the department's most recently published strategic plan. Therefore the spirit of the language in this document, including the goals and their respective strategies, is consistent with ATSDR's role within HHS. An objective of HHS in its first goal ("Reduce the Major Threats to the Health and Productivity of All Americans") is to "reduce the impact of environmental factors on human health." ATSDR has an important role in helping to meet this objective; in fact, the first two of the agency's five strategic goals directly address this objective

To ensure that the plan was balanced with both internal and external input, ATSDR sought out representation from numerous interested parties. Interviews or planning sessions were conducted with all of the following.

Each participant was asked to help identify areas in which ATSDR has performed well in the past, areas that need improvement, and what strategies could be used to best meet the growing needs of the different areas. The sessions and interviews proved to be extremely valuable, and the final version of the strategic plan reflects much of the input provided by both internal and external parties.

Critical to the success of this 5-year plan is the distinct understanding of the separate and discrete roles of various agencies and the responsibilities of each. This plan reflects a clear understanding of the agency's unique role and how it is expected to work within the framework of other federal agencies and in cooperation with state and local agencies.

ATSDR now has a modified vision and mission statement that reflects a somewhat more proactive approach to protecting public health. The supporting goals, objectives, and strategies were designed to produce the maximum effect with the resources available. The effort to develop the strategic plan also produced a list of key challenges that could affect the agency's success in reaching the strategic plans goals and objectives.

The 5-year strategic plan was drafted to work in concert with the development and implementation of annual performance plans for agency personnel and program areas. The strategic plan therefore includes a description of the relationship between strategic goals and objectives in the 5-year plan and the performance goals and objectives in the annual performance plans. For example, for each specific objective in the strategic plan, the annual performance plan will describe a baseline and provide a clearer quantification of the objective.

Perspective and Outlook

Under the Superfund legislation, ATSDR was given the mission of protecting the public's health as it is related to exposure to toxic substances from hazardous waste sites or uncontrolled releases of hazardous substances in the environment. In 1980, CERCLA mandated that ATSDR (1) establish a National Exposure and Disease Registry; (2) create an inventory of health information on hazardous substances; (3) create a list of closed and restricted-access sites; (4) provide medical assistance during hazardous substance emergencies; and (5) determine the relationship between hazardous substance exposure and adverse human health effects.

Over the years, this mandate has been expanded by legislation and now the agency has been authorized to

As ATSDR's legislative mandate has increased, the volume, scope, and type of work performed by ATSDR has also expanded. The number of sites that ATSDR has worked on has increased substantially (see Figure 2). Sites on the NPL no longer represent a majority of the sites. This is significant for it indicates an increased need for the work performed by ATSDR and it underscores the need for the unique public health service that the agency provides.

Figure 2 shows comparison of NPL and non-NPL sites
Figure 2. Comparison of NPL and non-NPL sites.

In fiscal year 1996, ATSDR received $59 million in CERCLA funding. In fiscal year 2000, ATSDR's CERCLA funding increased to approximately $75 million. In a 4-year period, the number of sites ATSDR covered increased 56%, but the ATSDR budget increased only 28%. To meet increased workload demands, ATSDR supplements its staff activities by partnering with 28 state health departments and 9 tribal organizations. ATSDR also works closely with numerous federal agencies, including EPA, the Centers for Disease Control and Prevention (CDC), and the National Institute of Environmental Health Sciences.

Another indication of the increased scope of ATSDR activities can be seen in the increased number of telephone requests for information. From 1998 through 1999, toll-free calls to the agency increased by approximately 5,000 each year. ATSDR's web site has also been accessed by growing numbers of individuals (see Figure 3).

Table shows an increase of calls received by the toll free center from Fiscal Years 1997 through 2000.
Table shows an increase of visits to the ATSDR web site from Fiscal Years 1997 through 2000.
Figure 3. ATSDR continues to increase communication with stakeholders.

Outside organizations, such at the Pew Environmental Health Commission, have recognized ATSDR's success. For example, the Pew Commission's 2000 report stated "ATSDR has played an important role in rebuilding state-level public healthcare capacity, implementing a national exposure registry, and supporting numerous site-specific tracking projects that track populations exposed to hazardous substances."*

ATSDR is frequently asked to assist CDC, EPA, and other agencies involved with issues related to hazardous substances. ATSDR's unique expertise in toxic substances has been demonstrated in the debate over mercury in vaccines and in the use of pesticides to control mosquitoes, and ultimately malaria, in Africa.

ATSDR is a federal public health agency with a unique combination of skills and expertise that provides valuable services including

For 20 years ATSDR has effectively helped protect public health in the United States from the effects of exposure to hazardous substances. This was made possible by ATSDR's scientific abilities, applied research efforts and the knowledge gained for almost two decades, focus on specific communities, and by partnerships with community groups, tribal governments, and local, state, and other federal health and environmental agencies.

ATSDR's Core Values

ATSDR is a service agency created to protect America's health from toxic exposures. Accordingly, the agency, agency staff members, and the agency's partners commit to the following values:

The ATSDR Vision

ATSDR's vision is to

Protect America's Health from Toxic Exposures.

The ATSDR Mission

The mission of ATSDR is to

Serve the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent harmful exposures and disease related to toxic substances.

ATSDR's Strategic Goals for 2002-2007

To accomplish ATSDR'S stated vision and mission, the agency will

  1. Evaluate human health risks from toxic sites and take action in a timely and responsive public health manner.
  2. Ascertain the relationship between exposure to toxic substances and disease.
  3. Develop and provide reliable, understandable information for people in affected communities and tribes and for stakeholders.
  4. Build and enhance effective partnerships.
  5. Foster a quality work environment at ATSDR.

For each goal in the 5-year strategic plan, the agency has developed the following components to ensure success in achieving the goal.

Goal 1.   Evaluate human health risks from toxic sites and releases and take action in a timely and responsive public health manner

In 4 years, the number of toxic or potentially toxic sites evaluated annually by ATSDR has risen by more than 50% (see figure 4). Due to the increase in the number of sites being addressed, the number of persons living within a mile of ATSDR targeted sites-and potentially affected by the sites-has risen 200% over that same 4-year period. Thus the need has become more critical for ATSDR to evaluate human health risks near hazardous waste sites and take timely and responsive actions.

One table compares the number of sites worked by ATSDR staff during Fiscal Years 1996 and 2000, and the other table compares the number of people living within one mile of a site during Fiscal Years 1996 and 2000 .
Figure 4. More and more people continue to be exposed to toxic or potentially toxic sites.

ATSDR, CDC, and other recognized public health institutions, have found an association between exposure to toxic materials and adverse human health effects such as asthma, birth defects, cancer, lead poisoning, mental retardation, multiple sclerosis (MS), and Parkinson's disease. The incidence rates for many of these are on the rise. According to the 2000 Pew Report, "learning disabilities have risen 50% in the last decade. Incidence of MS has risen 20% between 1986 and 1995. The increase in asthma is staggering with no signs of slowing." *  Some examples from ATSDR's experience include the following.

Bunker Hill, Idaho-Two ATSDR studies found that people who were exposed to lead (a common contaminant found in about one-third of the sites assessed) during the 1970s at the Bunker Hill, Idaho, NPL site continue to have long-term health effects. As a result of exposure to children and young adults more than 25 years ago, this population is at risk for manifesting health problems such as high blood pressure, infertility, early onset of menopause, and neurological disease.

Libby, Montana-From the 1920s until 1990, extensive vermiculite mining was conducted in Libby, Montana. Vermiculite is a natural mineral, widely used in insulation materials and in garden soil additives. It was discovered that the vermiculite ore mined in the area contained asbestos and many people in the area had been exposed to asbestos. Even people who did not work in businesses involving vermiculite were exposed to asbestos, and the evidence of nonoccupational exposure in Libby residents was significantly higher than national norms. As a result of ATSDR's efforts and cooperation from multiple organizations, more than 6,000 Libby residents participated in a medical testing program. An interim report on the latest findings is currently being prepared for public distribution, but one of the findings is that mortality from asbestosis was approximately 40 to 60 times higher than expected. Also, there were an elevated number of deaths from mesothelioma, a rare type of cancer.

Woburn, Massachusetts-As dramatized in the movie A Civil Action, residents in Woburn, Massachusetts, reported an unusual incidence of leukemia among children in the area. ATSDR was asked in the early 1980s to study the issue in conjunction with the Massachusetts State Health Department. A determination was ultimately made that contaminants being dumped close to the watershed of drinking wells had a strong association with the incidence of disease. As a result of the work done in this area, the contaminated wells were closed, health surveillance has been continued in Woburn, and the site has been cleaned up by the responsible corporations.

The incidence rate of chronic disease is significant, as is the cost of the care associated with it. The Robert Wood Johnson Foundation estimates that 60% of all health care costs in the United States (approximately $840 billion) can be attributed to chronic disease.**  CDC estimates that 90 million persons in the United States are afflicted with a chronic disease.

Knowing that strong associations exist between chronic disease and exposure to toxic releases and knowing the substantial costs incurred to treat chronic disease, the need to evaluate human health risks from toxic sites and releases can be clearly substantiated. If ATSDR activities were to result in a reduction in the incidence rate of chronic disease by even one-hundredth of one percent, the entire ATSDR budget could be offset by the health care cost savings alone.

Merely evaluating human health risk is not enough. Evaluations and actions taken need to be timely and responsive. Timely and responsive public health actions can enhance quality of life and save money. For example, the Hazardous Substance Emergency Events Surveillance (HSEES) system maintains valuable information related to hazardous waste spills and the public health consequences associated with the release of hazardous substances into the environment. Several states have responded to these HSEES system findings by changing programs and policies to reduce injuries or prevent other adverse health outcomes. For example, emergency response instructors have reported that they are updating training courses in response to HSEES data on the injuries first responders have suffered in dealing with illicit methamphetamine drug laboratories.

Also, ATSDR has had a real impact in helping improve the quality of life for residents of Glenola, North Carolina, who were exposed to toxic emissions from a local manufacturing plant that made polyurethane foam. In response to a petition from residents, ATSDR, in conjunction with EPA, the North Carolina Department of Environment, and the North Carolina Natural Resources Division of Air Quality, monitored ambient air in residential areas near the plant. This monitoring showed elevated concentrations of toluene diisocyanate and other volatile organic compounds (VOCs) in the air. These findings prompted ATSDR to issue a Public Health Advisory for the site in early fiscal year 1998. The state health director then issued an Order to Abate a Public Health Nuisance to the plant, which prompted the plant to stop production of polyurethane foam.

In recent years ATSDR has focused on children and other susceptible populations who are more vulnerable to exposure to toxic substances. At the Glenola site, for example, ATSDR staff members sought to identify children with asthma who lived near the facility during the period of highest emissions of diisocyanates. Parents of children who lived in the area were interviewed by telephone. Parents confirmed potential exposure for 204 children: 118 of the children had respiratory symptoms and were offered a clinical evaluation by two specialists in childhood asthma. A diagnosis of asthma was made for 28 of the 55 children in the study who were evaluated; asthma was considered possible for another 10 children. The specialists provided recommendations for medical care as appropriate. The information collected was most consistent with a high prevalence of asthma among the community's children. Two children had antibodies to diisocyanates, adding to the evidence of exposure in the community. The children with asthma received early diagnosis and referral, along with appropriate recommendations for medical care and followup. Findings were shared with the community and the state health department. ATSDR is also providing local health care providers with information on current guidelines for diagnosis and management of childhood asthma.

As an example of cost savings, ATSDR helped EPA save approximately $18 million by working to develop a new protocol for selecting which homes contaminated with methyl parathion needed remediation (which required temporary relocation of the residents). Methyl parathion is a potent agricultural pesticide that is restricted to outdoor use on nonfood crops because of its chemical similarity to nerve gas. ATSDR worked with its local, state, and other federal partners to develop a national public health response to widespread illegal indoor use of methyl parathion. As part of the response, a protocol was developed that integrated environmental sampling with biologic testing to measure exposure. This allowed for public health protection as well as improved risk management decision-making. The protocol enabled EPA to more accurately determine the public health risks of these exposures. The $18 million in savings was associated with a 96% decrease in the number of homes that needed comprehensive remediation.

Further, the need to achieve Goal 1 can also be attributed to public demand. As members of the public become more concerned with potential risks from exposure from toxic sites, the need to provide this public service will continue to increase. According to the Pew Commission, 90% of the registered voters in the United States believe that the environment plays a significant role in their health. Since 1998, phone calls to ATSDR from the public have nearly tripled, and the number of web site hits has increased by more than 50%.

Last, ATSDR needs to continue to achieve this objective because many local communities, states, and other federal agencies now look to ATSDR as the recognized expert in dealing with the evaluation of human health risks from toxic sites. ATSDR has leveraged its resources and relationships with local and state partners to provide this needed public health service. It is therefore vital that ATSDR remain focused on this objective as various local, state, and other federal entities rely on ATSDR to perform this critical task.

Strategies for Accomplishing Goal 1

ATSDR has developed a list of objectives and activities to enable the agency to evaluate human health risks from toxic sites and releases and take action in a timely and responsive public health manner. By identifying measurable objectives and specific activities, ATSDR has defined success in this goal and has charted a course of activities for achieving that success.


Objective 1.1-Annually, enhance participation of communities, tribes, local and state governments, and other stakeholders in planning, assessment, and intervention activities at sites. To increase the ability to achieve Goal 1, ATSDR needs to remain focused on enhancing involvement with its "customers" (communities, local agencies and governments, states, tribes, and other federal agencies) and on its "service offering" (planning, assessing, intervening site activities). This objective is not time specific; it needs to be ongoing, with continual improvements. Each annual performance plan will set a baseline of how participation was achieved and specific activities to define how participation has been enhanced.

Objective 1.2-By 2006, enhance effective and timely site-related actions. The key to this objective is to define further measurements of effectiveness and timeliness for site-related actions and then to implement a monitoring program as part of a quality assurance program and of customer satisfaction programs. For example, ATSDR currently monitors the timeliness of its responses to petitioned requests for public health assessments. Each annual performance plan up until 2006 will outline incremental accomplishments needed to achieve a program that emphasizes effective and timely site-related actions and then monitors the achievement of such activities. For example, ATSDR has initiated the strike team concept (assembling a multidisciplinary technical team) to address specific public health issues that need fast responses. The first strike team, which often worked in partnership with EPA, provided a rapid response to requests for assistance. The team's average response time of 3 days has helped to ensure that protection of public health is factored into time critical-removal and remediation decisions.

Objective 1.3-By 2006, develop and apply innovations in identifying and evaluating exposure to hazardous substances and associated human health risks. Application of science is one of ATSDR's core competencies and reasons for success. It is one of the primary reasons for the magnitude of partnering arrangements and requests for assistance from other federal agencies. Accordingly, the agency needs to continue to improve in this area. This objective reflects a commitment to continue developing and applying innovative methodologies to enhance ATSDR's capabilities, effectiveness, and relationships with partners. One example would include new approaches or new technologies to identify susceptibility of specific groups to particular exposures. Each annual performance plan will describe specific activities needed to achieve this objective by 2006.

Objective 1.4-By 2003, enhance scientific quality of assessments, investigations, and interventions at all sites. The key word in this objective is all sites. To enhance the scientific quality of exposure and health assessments and investigations as well as interventions at all sites, a standardized set of site activity protocols and methodologies needs to be developed. For example, an updated Public Health Assessment Guidance Manual, reflecting the improvements in the assessment process since 1992, will be issued. Agency staff members believe that a set of standardized protocols and methodologies can be put in place for all sites by 2003.

Activities for Goal 1

Activities needed to achieve the objectives for Goal 1 are focused on gradual improvements in (1) service offering in terms of standardization, quality control measures, and innovation and in (2) relationships with customer groups. The following activities are anticipated to occur in 2002 and will be detailed in the 2002 annual performance plan.

External Coordination

To achieve Goal 1, ATSDR needs to effectively coordinate with several groups outside of the agency. Following are some examples of the type of interaction required.

Challenges to Goal 1

Some of the more significant obstacles to achieving the objectives, and activities for Goal 1 are listed in the following paragraphs.

Linkage to Annual Performance Plans and Success Indicators

Linkages to annual performance plans and success indicators are described in the activities for Goal 1.

Goal 2.   Ascertain the relationship between exposure to toxic substances and disease

ATSDR has profiled 480 chemical substances. According to the American Chemistry Council, there are an additional 75,000 known chemical substances in commerce that remain to be studied. In addition, there are 1,563 sites that EPA has identified as the most important areas for study and clean up and placed on its National Priorities List for Uncontrolled Hazardous Substances (NPL). The potential for human health effects from these sites is great. The total number of persons living within 1 mile of these sites is estimated to be 14.1 million. In addition to these NPL sites, there are approximately 11,177 additional Superfund sites with potential for harm to human health.

Resources to understand the effects of toxic substances and to take effective steps to protect the public's health are limited. To prioritize efforts and focus the nation's cleanup resources to ensure a safe and healthy environment, it is necessary to understand the relationship between toxic substances and disease. The strategic objectives of Goal 2 focus agency efforts on current threats from toxic substance exposure and on the long-term public health effects of exposure after site cleanup is completed.

ATSDR's work on benzene is a good example of meeting the second goal. Benzene is a chemical that the public and, in large part, the scientific community were previously not unfamiliar with. Today, based on the work ATSDR has done at sites and information presented in ATSDR's toxicological profile, ATSDR can provide the following information on benzene:

ATSDR maintains a National Exposure Registry that scientists can use to aid in understanding how long-term exposure to hazardous substances may affect human health. This is done by identifying individuals who have come into contact with specific substances at selected locations and continuing to monitor their health over time. The Registry also provides a mechanism through which participants can be notified of the results of research related to the substance to which they were exposed. The Registry program carries out its mandate by creating large databases (subregistries) of similarly exposed persons. These subregistries are used to facilitate epidemiological research in ascertaining any self-reported adverse health effects of persons exposed to low levels of chemicals over a long period. Each subregistry tracks individuals exposed to a particular substance and maintains longitudinal health information by conducting interviews with each individual. The benzene subregistry, for example, has confirmed an association between long-term exposure to benzene and blood disorders and cancer of blood-forming cells. The registry also includes reports of aplastic anemia in workers exposed to benzene.

In addition to benzene, ATSDR's work involving other volatile organic compounds (VOCs) has presented evidence of a link between exposure to those compounds and disease. VOCs have been shown to be associated with serious human diseases such as cancer and multiple sclerosis. The agency had made considerable impact by performing health studies at various VOC sites to determine the effects of chemical exposure. These health studies take the data from the subregistries one step further by examining them in more scientific studies. For example, ATSDR has conducted several health studies throughout the United States to see if the causes of unusual patterns of disease are associated with VOCs. Two examples of those studies are summarized in the following paragraphs.

Another aspect of ATSDR's site work is the evaluation of cost versus benefit. For example, it is estimated that medical and health-related costs associated with exposure to VOCs may be as much as $300,000 for each person exposed. Thus, prevention of these exposures may result in significant savings.

ATSDR's work in this area of linking exposure to hazardous substance and disease is regularly used in developing environmental laws and in prioritizing cleanup efforts. The better the understanding of the link between exposure and disease, the better equipped ATSDR is to direct cleanup efforts and ultimately limit the negative impact to affected communities.

Strategies for Accomplishing Goal 2

ATSDR has developed a list of objectives and strategies specifically geared to enable the agency to ascertain the relationship between exposure to toxic substances and disease. Following are the objectives and strategies for achieving Goal 2.

Objectives for Goal 2

Objective 2.1-By 2004, develop and evaluate methods to measure and track two high-priority diseases with potential links to environmental exposures. The process for linking disease with environmental exposure requires time and dedicated professionals with expertise in statistical analysis, clinical impact, and environmental dynamics. ATSDR is unique in that the agency can assemble internal teams with these capabilities. To reach this objective, ATSDR teams will

Objective 2.2-By 2003, enhance environmental exposure tracking by adding one new exposure subregistry. The National Exposure Registry is a critical, long-term effort that meets the need for collecting information concerning the potential impact of hazardous substances on human health. The registry is a listing of individuals exposed to hazardous substances and it contains subregistries for specific substances. There are currently four active subregistries: trichloroethylene (TCE), trichloroethane (TCA), benzene, and dioxin. An important purpose of the National Exposure Registry is to help scientists understand how long-term, low-dose exposure to hazardous substances may affect human health. This is done by following individuals who have come into contact with specific substances at selected locations and monitoring their health over an extended period of time. The registry also provides a mechanism through which participants can be notified of the results of research related to the substance to which they were exposed.

While the time and resources associated with adding a new subregistry are significant, the benefits realized from recognizing a link between exposure to a hazardous substance and disease are significant. For example, registrants on all four subregistries have reported increases of such problems as anemia, cancer, diabetes, skin rashes, strokes, and urinary tract disorders in higher than expected numbers. While these are self-reported conditions, the data from the registries may influence the design of further studies. Children on the TCE Subregistry had an increased reporting rate for hearing and speech problems. A follow-up study of these outcomes indicated that these disorders, while potentially treatable, were, in some cases, permanent. Analysis of the approximately 5,000 female registrants across all registries revealed statistically significant increases in reports of several health outcomes. Those diseases found predominantly in women included diabetes, kidney problems, liver problems, and urinary tract disorders. A more definitive assessment of these associations is currently underway. One of ATSDR's key objectives is to select the substance for a new subregistry and begin tracking by fiscal year 2003.

Objective 2.3-By 2006, establish the means to link data sets for health effects with data sets for environmental exposure. ATSDR has invested significant resources in building and maintaining data sets of information related to hazardous substances, hazardous waste sites, and human health. These collections of data yield valuable information and are regularly accessed by both private individuals and public groups. ATSDR's long-term goal is to develop a means to link these elements with health-related data sets to show causality between environmental exposure and disease. The agency's unique blend of scientific and technical skills and ability to develop and sustain partnerships, along with its independence as an agency and its legislative mandate, puts ATSDR in the best position to accomplish this task. ATSDR will identify a number of tasks in annual performance plans to enable the accomplishment of this goal in 2006.

Objective 2.4-Annually, ascertain through studies the health conditions present at toxic sites and releases. A fundamental role of ATSDR is to use its toxic exposure expertise to provide information to the public. For each site that ATSDR identifies for this annual review, the agency will collect up-to-date information related to exposure, impact, and disease. This objective will ensure that information is current as it is utilized by communities and by other governmental agencies studying the issues to make appropriate health-oriented decisions.

Objective 2.5-By 2004, implement the agency's Agenda for Public Health Environmental Research by initiating at least one project in each of the six areas of the agenda. The Agenda for Public Health Environmental Research has identified six areas of priority related to environmental exposure and disease. The agenda summarizes the critical elements of environmental research and presents a logical approach for reaching the goal of showing the link between disease and environmental exposure. Although this is a long-term agenda, ATSDR recognizes the need to show significant achievements in this process.

Activities for Goal 2

External Coordination for Goal 2

ATSDR recognizes that several organizations, public and private, local, state and federal, have related goals with regard to public health, exposure tracking, or public education. Significant opportunity exists to maximize the agency's impact by coordinating with these groups. Following are some examples of past success in this area.

ATSDR will continue to identify areas for cooperation to ensure that the limited resources available will be leveraged to the maximum extent possible.

Challenges to Goal 2

ATSDR recognizes that the road to meeting the agency's goals and objectives has certain challenges that must be managed or overcome.

Linkage to Annual Performance Plans and Success Indicators

For the long-term strategic plan to be successful, it must guide each of the successive annual performance plans. It must have objective ways of measuring success that the agency and its oversight bodies can look to for proof of success. Following are examples of specific success elements related to Goal 2.

Develop two pilot disease-tracking programs
Add one exposure subregistry
Implement six research projects
Link databases on disease and databases on exposure for two diseases
Conduct and complete epidemiologic studies

Goal 3.   Develop and provide reliable, understandable information for people in affected communities and tribes and for other stakeholders

With the growth of the Internet and the corresponding deluge of health-related information being made available at every desktop, it is easy for the public to obtain an immense quantity of data. The data are often confusing, contradictory, and unreliable. This underscores the importance of the role that public health agencies have in relaying information to the public. ATSDR is uniquely positioned to fulfill that role for the agency continuously seeks to verify scientific information on links between disease and exposure to toxic substances-and then presents the findings to health care professionals and to the public.

For those sites where ATSDR has been active and the public has become familiar with the agency, efforts to provide information and educational materials have been very successful. From 1995 through 2000, for example, the number of files accessed at the ATSDR website increased dramatically (see Figure 5). Local health officials and word-of-mouth communication were the main sources of publicizing this important informational resource. ATSDR also has a toll-free telephone service available to give individual responses to people with questions about public health concerns in their areas. There were more than 17,800 calls to ATSDR in 2000, indicating that this relatively low cost resource is appreciated by the communities served.

Figure 5 shows the number of files accessed at the ATSDR web site for 1995-2000.
Figure 5. Number of files accessed at the ATSDR web site for 1995-2000.

ATSDR communicates directly to people in affected communities through a variety of means. Following are some examples of targeted communication efforts.

One of the primary sources of frustration for residents in affected communities is that the media may publish conflicting information and overdramatize findings. A resident who gets information only from the local newspaper or from one of many hazardous substance-related websites is likely to be confused, and perhaps unnecessarily upset, about their immediate situation.

In serving the public, one of ATSDR's primary responsibilities is to provide accurate and easily understood information to the general public. For example, linking neurobehavioral deficits with the consumption of Great Lakes fish is an important finding, but the real value is not realized until the people affected, all of them, understand the impact of the findings and understand how they may best adjust their dietary habits in light of the findings. Relaying this information is at the core of the agency's mission. To do so properly, ATSDR must continue to go beyond press releases to more direct forms of communication, using culturally appropriate materials, electronic access to information, and personal contacts.

ATSDR has a solid track record in this area. ATSDR's toxicological profiles continue to serve the scientific community. ATSDR experts routinely assemble and distribute information with the goal of full understanding of people in affected communities. ATSDR has expert toxicologists and other specialists who understand the link between exposure and disease and who work very hard at explaining the latest information clearly to the public. ATSDR is well-positioned to continue to spearhead the distribution of environmental information to the public.

Beyond direct interaction with affected communities, ATSDR leverages its capabilities by working through other organizations or entities. For example, the agency's relationship with the Association of Occupational and Environmental Clinics has been very successful. Through these clinics, ATSDR has assisted local health care providers and community members in responding effectively to health concerns associated with hazardous waste sites and unplanned releases of hazardous materials. There are a total of approximately 300 staff members in 65 member clinics across the country. This partnership was established in 1989 and has been very effective at leveraging ATSDR information and findings.

Last, ATSDR leverages its ability to provide information to affected areas through its various training programs. Responding to requests, the agency has provided public health assessment training to countries such as Taiwan, Portugal, Mexico, and Spain. In the United States, the agency has relayed significant information related to environmental hazards and medical intervention through distance learning programs. For example, in 2000, more than one thousand nurses across the United States completed an ATSDR-sponsored course and received continuing medical education credit. These nurses have been empowered to provide up-to-date information to address public health issues in their communities.

Strategies for Accomplishing Goal 3

ATSDR has developed a list of objectives and tactics specifically geared to develop and provide reliable, understandable information for people in affected communities and tribes and for other stakeholders. Following are the objectives and the supporting activities developed to guide the agency in meeting this third goal.

Objectives for Goal 3

Objective 3.1 -- By 2005, improve the capabilities of health care providers to recognize, diagnose, and treat exposure and related illness in their communities. One of the most economical approaches for providing factual, reliable information to communities in a manner that will be understood by community members is to work through local health care providers. Local health providers speak the language, know the culture, have direct access to medical history, and are familiar with community practices or lifestyles that may increase exposure to toxic threat. For example, primary care physicians who practice in communities around the Great Lakes were quite effective in relaying information related to the safety of consuming fish from the Great Lakes. ATSDR equipped these physicians with pertinent information to assist the local providers in recognizing, diagnosing, and treating people who had been exposed. This objective will be part of an overall provider awareness campaign to be fully implemented by 2005.

Objective 3.2 -- By 2006, improve public understanding of health risks from exposures in their communities. The value of the research done by ATSDR and other organizations in the area of toxic exposure and health is ultimately making a difference in how people behave in at-risk areas. The primary impetus for changing behavior is an understanding of the risks and the behaviors that put people at risk. For example, a press release confirming the presence of benzene in drinking water is not nearly as effective as an approach targeted to affected communities that documents the implications of exposure to benzene along with recommendations on how to protect a family from future exposure (using bottled water, for example) and what to do if you have already been exposed.

In a specific case, at the Hanford Nuclear Reservation in Washington, ATSDR worked with the Confederated Tribes of the Umatilla Indian Reservation and other tribes to provide information to the people in the communities about whether Hanford releases affected native food items and local materials in tribal products (such as clothing, mats, and baskets for storage and cooking). Annual performance plans will identify the incremental accomplishments towards achieving this objective. By adding to the knowledge base in the community, ATSDR provides a distinct value to the people in the area.

Objective 3.3 -- By 2004, improve the agency's ability to identify and reach targeted audiences. Currently, exposed communities receive information directly from ATSDR primarily through ATSDR's web site, from ATSDR's printed materials, and from community meetings. Information from ATSDR in press releases reaches community members through the media. ATSDR recognizes the importance of improving agency communications to affected communities. By improving the agency's ability to target specific groups with heightened risk profiles, ATSDR's health messages can be more effective.

Objective 3.4 -- By 2003, enhance the development, scientific quality, and accessibility of agency standard reference materials. In addition to the current toxicological profiles, case studies in environmental medicine, and medical management guidelines, each year ATSDR performs numerous studies and publishes academic papers. In conjunction with the objective of enhancing agency identity (a component of Goal 4), ATSDR will enhance this aspect of its mission by formalizing the development, quality, and accessibility of these scientific research documents. While continuing to produce as much (or more) in future years, the agency will continue to ensure that quality levels are monitored and maintained. This objective ties into the agency's overall quality assurance program.


External Coordination

ATSDR recognizes that several organizations, public and private, local, state, and federal, have related goals with missions not unlike those of the agency. Significant opportunities exist to maximize the agency's impact by coordinating with other agencies or groups. Following are some examples of this type of coordination.

ATSDR will continue to identify areas for cooperation to ensure that the limited resources available will be leveraged to the maximum extent possible.

Challenges for Goal 3

ATSDR recognizes that the road to meeting its goals and objectives has certain challenges that the agency must be prepared to manage or overcome.

Linkage to Annual Performance Plans and Success Indicators

For a long-term strategic plan to be successful, it must be a beacon for each of the successive annual performance plans. It also must have objective measures of success that the agency and its oversight bodies can look to for proof of success. Below are the specific success elements related to Goal 3.

Customer surveys
Increased number of web hits and telephone requests to ATSDR
Increased number of documents produced in other languages or written to be culturally appropriate
Increase in continuing medical education credit

Goal 4.   Build and enhance effective partnerships

Because it works with more than 75,000 known chemical substances at more than 1,500 known hazardous waste sites, ATSDR recognizes that the issues involved in toxic exposure and disease in the United States are enormous, and they impact the lives and health of millions of Americans. Identifying these chemicals, categorizing them, testing and educating those who come in contact with them, and cleaning up sites where they are found, are all formidable tasks.

Because ATSDR cannot undertake these tasks alone, many tribal, local state, and other federal agencies have assumed responsibilities for managing the effects of toxic exposures. For ATSDR to be as efficient and effective as possible in its use of resources, it is critical to seek out organizations with common goals. Then areas can be identified where ATSDR's resources can be best leveraged, thus bringing more benefits to affected citizens.

The value of effective partnerships is substantial. For example, the State Cooperative Agreement program, established by ATSDR with the states, expands the agency's capacity for research and study and, ultimately, reaches more lives than the agency could have done on its own. And partnership brings quality assistance. By teaming with local representatives, ATSDR can expand its scope and response time, thus improving its service and overall product delivery. Last, effective partnerships accelerate the flow of knowledge, both to and from the agency. Each of these partnership attributes represents benefit for the agency and for the people it serves.

The partnership concept is not new for ATSDR. Over the years, the agency has continued to modify this model and has achieved substantial success. Following are some examples.

Many concerned public and private organizations are willing to expend resources on issues related to hazardous substance exposure. ATSDR should take the lead in encouraging and structuring these partnerships to ensure these issues are met in the most efficient and effective manner possible.

Strategies for Accomplishing Goal 4

ATSDR has developed a list of objectives and strategies specifically geared to build and enhance effective partnerships. Following are the measurable objectives and specific strategies that the agency has developed to reach this goal.

Objectives for Goal 4

Objective 4.1-- By 2006, build and enhance the capability of state and tribal partners to evaluate human health risks posed by exposure to toxic sites and releases. For ATSDR to maximize its impact over the long term, it must grow the capabilities of its partners, allowing them to perform some of the duties currently performed at the agency. As such, ATSDR is refining its partnering program over a 4-year period. Each annual performance plan will describe specific activities to achieve this objective.

Objective 4.2-- By 2006, collaborate with both domestic and international partners to address shared priorities and achieve common goals. Partnerships can accomplish multiple goals more efficiently. By collaborating with entities with common goals, ATSDR can achieve those goals with fewer resources, thus enabling it to achieve more of its goals with the same or less money. It can learn from the experiences of other national and international research organizations, and can learn from state and local entities that have specific knowledge in specific areas.

One example of the effectiveness of this objective is the public health site-related activity funded through a variety of Cooperative Agreements. During the past 5 years, the combined state cooperative agreement program awarded more than $10 million annually to 28 states for conducting public health activities at hazardous waste sites. ATSDR provides technical and administrative oversight and guidance for state activities at these sites. Staff from funded states actively coordinate with local, state, and federal health and environmental officials to provide public health expertise on human exposure issues related to site characterization, removal activities, health studies, site remediation, and site-specific health education for community and health professionals. Staff numbers include 72 health assessors, 28 health educators, and 29 epidemiologists, all of whom are deployed locally to address issues requiring immediate attention. This improved coordination of all aspects of site activity leads to the increased ability to evaluate public health implications and conduct or recommend appropriate activities to prevent or mitigate exposures. Some evidence of this cooperation includes health education activities and public health documents completed and distributed to local communities.

ATSDR has had notable success with international collaboration. By working with foreign agencies and governments, ATSDR has provided valuable information as well as having gained equally valuable knowledge on population exposures. Successful initiatives range from work with the government of India to share information on multiple and timely environmental health issues to joint training for public health programs in Israel and Palestine. The agency is currently working with organizations in Mexico to grow environmental health capacity and infrastructure so that Mexican citizens can benefit from some of the progress made by the agency.

Partnerships help ATSDR respond to hundreds of requests each year-more than it could respond to in the absence of those partnerships. Partnerships also allow ATSDR to provide more timely responses to public health emergencies, provide a vital link among federal, state, local, and tribal health professionals, expand ATSDR's resource base of technical experts and public health professionals, and provide a mechanism for building and enhancing local, state, and federal public health capacity.

Objective 4.3-- By 2004, enhance ATSDR's internal and external identity for more effective partnerships. Through careful planning and execution, ATSDR has developed into an agency adept at studying and solving problems related to toxic exposure. Local, state, and federal entities increasingly invite the agency to perform additional studies and provide additional expertise. To further leverage this unique model, ATSDR should further enhance its identity with other government agencies and with external entities. For example, for those entities familiar with ATSDR and its distinctive role, substantial progress has been made in partnering and working toward common goals for communities. But lack of ATSDR's name recognition often hinders the value that can be provided to a community when the agency first enters it. Until the public learns ATSDR's role and reputation, the public will not fully benefit from provided services.

Activities for Goal 4

External coordination

ATSDR recognizes that public, private, federal, state, local, and tribal organizations have related goals, and missions not unlike those of the agency itself. Real opportunity exists to maximize the agency's impact by coordinating with other agencies and entities. To facilitate this effort, ATSDR has segmented its partnerships into the following categories:

ATSDR will continue to nurture and expand its relationships with its current federal partners and continue creatively to seek ways to extend the services it provides to other agencies.

ATSDR will continue to identify areas for cooperation to ensure that the limited resources available will be leveraged to the maximum extent possible.

Challenges for Goal 4

The agency recognizes that the road to meeting its goals and objectives has certain challenges that must be managed or overcome.

Linkage to Annual Performance Plans and Success Indicators

For a long-term strategic plan to be successful, it must act as a beacon, guiding the development of successive annual performance plans. It also must have objective measures that the agency and its oversight bodies can look to for proof of success.

Below are representative success elements related to this particular goal:

Goal 5.   Foster a quality work environment at ATSDR

Workplace harmony and job satisfaction reflect an environment that values employee morale, productivity, and collaboration. Unfortunately, to many organizations the phrase "quality work environment" is merely a stock utterance without any supporting objectives and tactics to reach such a goal. Management studies have consistently shown private and public organizations that strive to create work environments where employees share an organizational kinship and "esprit de corps" outperform those of their competitors that do not have similar programs. Moreover, employees in a positive work environment tend to be happier and less likely to leave the organization. Achieving such an environment can have a profound effect-not only in retention of desirable employees, but also in both the creation of a distinct competitive advantage and recruitment of qualified and scarce specialists.

In the agency's effort to support this critical goal-which is aligned with HHS's Quality of Work Life Initiative launched in 1996-ATSDR embraces, with some tailoring to its specific mission, the initiative's broad-based objectives. They include, but are not limited to, improving employee satisfaction and strengthening workplace learning. Tangible examples include the agency's active participation in "family-friendly" programs such as flexitime, flexiplace, flexitour, and maxiflex. In essence, ATSDR believes it not only has external customers in the American public, but also has internal customers who, through their hard work and dedication, enable the agency to deliver an important public health service.

Success of these initiatives can be demonstrated by the Human Resource Management Index, which provides a summary of employee perceptions of the work environment. Since March of 1997, the index has shown steady improvement in this important measurement within HHS-which includes ATSDR-rising from a composite score of 95 in March 1997 to 98 in March 2000. The agency will continue to seek new and innovative ways to improve the work environment and, ultimately, its employees' perceptions of the agency.

Strategies for Accomplishing Goal 5

After reviewing many of the successful quality workplace improvement initiatives in other federal agencies, ATSDR has crafted objectives that not only support the government's quality work place philosophy, but also address the unique nature of this organization and its employees.

The ATSDR staff is exemplary. They have received recognition from several sources, including the president of the United States, scientific peers, and nationally recognized organizations and associations. By fostering an environment of quality and success, the agency intends to continue this record. Additionally, the agency has nurtured an environment of volunteerism, both in the office and in external communities. Staff members participate in committees internally, such as the quality of work life committee and the STRESS team, and externally, in groups such as Partners in Education. Additionally, ATSDR employees continue to strive professionally through a culture of achievement that includes continuing education, professional certifications, work with health promotion and communications, and continuous contributions in the science of toxicology and epidemiology. Following are the objectives and activities developed to foster a quality work environment at ATSDR.

Objectives for Goal 5

Objective 5.1-- By 2004, create an agency culture promoting collaboration, growth and development opportunities. Organizational success demands continual investment in employee skill and capability development. A highly-skilled workforce tends to have greater job satisfaction and appreciation for its given vocation. This is critical to work force retention. If employees are convinced that diligence, commitment to quality and excellence, and teamwork all lead to future growth in a given organization, they are more likely to remain with that organization. A specific component of this objective is to cross-train and enhance the skill base of employees by encouraging them to participate in rotational assignments.

Objective 5.2-- By 2002, promote a culture of effective leadership and management. In its contribution to the growing discipline of toxic exposure and its effect on human health, ATSDR is an organization with ample opportunity for growth. A leadership team must effectively promote this important service to the public through the ability to influence, motivate, and direct internal and external constituencies.

Objective 5.3-- By 2002, review workforce diversity and adjust targeted recruitment and hiring practices. This objective is an important element in achieving successful recruitment and retention results. Currently, the agency works closely with Morehouse and Howard Universities in sponsoring internships allowing medical students to work at ATSDR; indeed, environmental health issues is one of their rotational assignments. This program is an effective tool for developing a greater awareness of how to deal with medical issues related to toxic exposure as well as generating interest in the agency itself. To build upon this, an agency-wide workforce plan should develop and implement human resources management policy and decision-making. Also, the agency will increase collaboration with those colleges and universities, organizations and community associations that reflect the diversity of the communities the agency serves.

Objective 5.4-- By 2003, promote improved facilities and services for agency staff. With access to proper tools and support to accomplish organizational goals and objectives, employees will be able to leverage fully their skills in support of ATSDR's efforts.

Activities for Goal 5

External Coordination

As an operating division of HHS, ATSDR will not only work-to the extent possible-in concert with CDC and HHS to cultivate a seamless work environment throughout the all operating divisions, but will also ensure employees perceive the agency as a leader in workforce commitment. For example, ATSDR was included in CDC's contract award to an outside firm to provide dependent care information and referrals to CDC/ATSDR employees. On an annual basis, the agency works with CDC both in determining the focus of training courses and serving as a representative on the Occupational Work and Safety Committee.

Given the specific expertise required for many of the positions at ATSDR, recruiting quality employees can often be a difficult and time-consuming effort, unnecessarily diverting the attention of senior employees from their primary duties. Therefore, ATSDR will seek to partner with outside organizations that can assist with recruitment efforts.

Finally, the agency will coordinate its efforts with GSA to ensure that work place standards are maintained and improved on a continual basis.

Challenges to Goal 5

As with any set of objectives an organization seeks to achieve, roadblocks can impede satisfactory progress.

Linkage to Annual Performance Plans and Success Indicators

The successful goal achievement is marked by an emphasis on results rather than the duties and activities associated with those results. Accordingly, ATSDR has devised a set of results-oriented indicators that will serve as a barometer for the organization's performance in fostering a quality work environment:

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*America's Environmental Health Gap: Why the Country Needs a Nationwide Tracking Network, The Pew Environmental Health Commission

**$840 billion=$1.4 trillion x 60%; $1.4 trillion is the Health Care Financing Administration's estimate of total health care costs in the United States; 60% represents the Robert Wood Johnson Foundation's estimate of health care costs attributable to chronic disease.

†   ATSDR's 2001 budget = $74,835,000, which is equivalent (approximately) to costs associated with 8,035 chronic cases (approximately .01% of the total) with an average annual cost of $9,314.00 each.

This document is provided as a historical reference. It has been replaced by: FY 2007 Performance Plan for the Agency for Toxic Substances and Disease Registry [PDF, 399 KB]

This page last updated November 8, 2001. Historical note added May 10, 2006

For more information, contact CDC Contact Center: 800-CDC-INFO • 888-232-6348 (TTY) or e-mail (public inquiries)

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