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
Literature Inventory and Dissemination
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).
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.
ATSDR staff members in headquarters and in the field
Representatives from the Center for Disease Control and Prevention, the Environmental Protection Agency, and the Department of Health and Human Services
Representatives of tribal governments and representatives of minority groups (to ensure that their concerns were recognized in the plan)
Members of communities affected by hazardous waste (to reflect an understanding of specific concerns)
A number of state agencies (to reflect the opportunities that exist for cooperation)
Selected academic institutions (to ensure the inclusion of issues relevant to institutions of research and study).
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.
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
Conduct public health assessments at EPA's request
Conduct public health assessments at all sites on EPA's National Priorities List for Uncontrolled Hazardous Waste Sites (NPL)
Conduct public health assessments at other sites when petitioned by members of the public or other parties
Develop and update toxicological profiles
Institute a system of substance specific research
Disseminate information on the findings of assessment and research
Provide medical education in the area of diagnosis and treatment of exposure to toxic substances
Conduct epidemiologic studies
Conduct surveillance programs
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. 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).
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
Providing expertise on toxic exposure
Serving as an independent advisor to EPA or state agencies or both regarding clean-up decisions and community health concerns
Conducting epidemiologic studies to evaluate the human health effects associated with exposure to toxic substances
Conducting research and maintaining data on toxic exposure and adverse health outcomes for identification, evaluation, and-if appropriate-intervention
Establishing two-way interaction with communities and tribes in site investigations
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.
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.
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
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.
Conduct site assessment activities equal to or better than those conducted in 2000 - ATSDR must not retreat in the extent of services provided to the communities. ATSDR needs to ensure continued growth in the value that it brings to the public.
Create a customer relationship management database of customer groups as part of developing a customer satisfaction program - ATSDR must make use of tools that have become available in the marketplace such as customer management software. By maintaining information on the types of customers the agency serves, ATSDR can be far better equipped in the future to assess and meet the needs of new customers.
Deploy a new and improved customer-satisfaction survey mechanism - By implementing a customer-satisfaction mechanism, ATSDR will be better equipped to understand and act on direct feedback from its constituents. Included in this approach should be a process or mechanism to identify additional areas requiring scientific innovation.
Finalize a standard site activity planning kit - ATSDR's standardized approach to site activity planning and implementation must be continually enhanced and further developed. As scientific methodologies are evolving, so too must the methods, protocols, and quality assurance programs used for all site activities. Continuous improvement of the standard procedure will help ensure that ATSDR assessments are conducted in a manner that is consistent and of high quality.
Conduct meetings between targeted customer groups and key internal stakeholders - To be responsive and ensure that ATSDR continues to provide valued products and services to its customers, ATSDR should continue to meet with specific groups and stakeholders to define timely and effective actions. Customer feedback can be used to continuously improve ATSDR's activities.
Enhance and broaden the internal and external peer review process and program - ATSDR will broaden the scope of its internal peer review process to ensure input and understanding of site activities across the agency. External peer reviews will be utilized more fully to strengthen the quality of plans and protocols for site activities.
Fully implement the protocol for working with communities from the point of initial contact - ATSDR has developed protocols and a priority system for implementing community involvement and outreach activities for all sites. The agency also has developed health education needs assessments that define the scope and nature of understanding, awareness, and specific needs in a community. Needs assessments that help direct and define all agency site activities are being developed. Activities in each community are becoming more, and should remain, respectful of ethnic, religious, and cultural sensitivities and the various agency protocols should reflect consideration of these sensitivities.
Establish standard protocols that document community interventions - Community interventions should be based on the fundamental principles of social-behavioral research. Interventions should be theory based, follow fundamental educational practices, and be open for evaluation. Prior to implementing interventions, these principles should be outlined in an intervention protocol.
Document anticipated impacts and outcomes of agency activities, whether internal or through partnering agreements - As an expansion of the documentation of agency impacts and outcomes, begin to document expected outcomes (both quantitative and qualitative) in all funded agreements with tribes, local and state governments, and others. This approach will clarify expectations at the outset of these arrangements and will enable the agency to review actual performance in light of expected results.
Establish regular meetings nationally and regionally to coordinate site activities -Agency staff members should meet at least quarterly with EPA, states, and other agencies to develop site-specific timelines. Regular coordination with these groups will ensure that ATSDR performs its tasks on time and meets the needs of the agencies relying on ATSDR's assistance.
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.
EPA (headquarters and regional offices) - ATSDR must continue to work closely with EPA to ensure that the agency meets EPA remediation timelines. Close cooperation with EPA will ensure the maximum value of ATSDR's analysis. A particularly effective way to coordinate with EPA has been achieved by posting ATSDR staff members in each EPA regional office.
Affected citizens - A good example of working with affected citizens is exemplified by the Brick Township, New Jersey, Autism Public Health Assessment. For this assessment, ATSDR evaluated whether community members may have been exposed to hazardous chemicals in the environment. Both ATSDR and CDC emphasized the need for community involvement and outreach, and the cooperation of the citizens greatly enhanced the public health assessment process. ATSDR and CDC coordinated all their activities to ensure that a consistent message was conveyed to the community members.
Government researchers - ATSDR must continue to leverage the scientific advances of CDC, the National Institutes of Health, and others to ensure that the agency remains at the forefront of applied toxicology and epidemiology. For example, important studies have been published by CDC and the National Institute for Occupational Safety and Health to document asbestos exposure and related health effects. These studies continue to provide the framework for assessing asbestos exposure in affected communities.
Academic institutions - The agency must continue to facilitate coordination with academic institutions. Knowledge gained from academic research can be successfully applied by agency professionals. An excellent example of this would be exposure and dose assessment research that has been particularly helpful in correlating high consumption of Great Lakes fish with symptoms of the local populations.
State and tribal governments and associations - Local groups will continue to be the best source of information for local understanding of environmental impact. Any toxic exposure and surveillance program depends on the awareness and cooperation of local groups. Most agency success stories begin with the involvement of a local community or local organizations in a community (for example, the request for an investigation of sheep vats from the Bureau of Indian Affairs via the Navajo, Zuni, and Pueblo reservations).
Other federal agencies - ATSDR is working with an increasing number of federal facilities and other federal agencies and will continue to work with these other federal groups as ATSDR continues to receive requests for assistance.
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.
Budget - ATSDR continues to be funded at levels significantly below requested levels. For the past 3 years, there has been a significant gap between the funds requested and the funds received. At the same time, ATSDR site activities have increased by more than 50% without a corresponding budget increase. Without being granted the minimal funding requested in
ATSDR's annual performance plans, the agency may not be able to sustain existing activity levels or achieve the objectives outlined.
Ability to recruit and retain qualified staff - As a relatively small agency with a specialized mission, it is vital that ATSDR successfully recruits and retains qualified staff members. To this end, ATSDR has made fostering a quality work environment a separate goal in this 5-year strategic plan. ATSDR's success to date in reaching Goal 1 has been made possible by its dedicated, professional, and scientifically competent team of scientists, physicians, educators, engineers, and other staff members.
Community support/ managing public's expectations - As an independent public service entity with limited resources and a limited mandate within a larger public service entity, ATSDR must be very careful in engaging with communities. The agency needs to retain community support and meet the expectations of the community. Overcommitting support to the community could drain the agency's resources and exceed the agency's authority. Conversely, failure to provide a community with a mandated service that is needed could result in a lack of support for the agency. Accordingly, ATSDR activities are geared at improving core services, targeting innovation, maximizing resources, working within the authority mandated, and establishing clear communication with the various groups served.
Data challenges and responses - Data challenges will be a part in every goal outlined in the strategic plan. The key to overcoming this challenge is to continue to seek ways to standardize the data elements to be captured for each specific goal, enhance the process in which the data is captured, stored, or retrieved, and judiciously evaluate the data.
Limited legislative mandate - Although ATSDR's vision of protecting America's health from toxic exposures is quite broad and expansive, the legislative mandate is limited. Consequently, ATSDR needs to continue to learn effective ways to consult, influence, and interact without a specific mandate.
Multiple jurisdictions - ATSDR must navigate through many jurisdictions including city, state, federal, and tribal governments to ensure a coordinated response. The agency must continue to be adept at working through these jurisdictional issues to be effective in fulfilling the agency mission.
Limits of environmental health science - Knowledge of environmental health science alone is not enough to protect America's health from toxic exposures. Although the agency will continue to search out and apply the latest findings of scientific research, it remains aware that much more is needed to truly accomplish the agency's vision. Successful public health activities require the application of current science.
Linkage to Annual Performance Plans and Success Indicators
Linkages to annual performance plans and success indicators are described in the activities for Goal 1.
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:
Benzene is not only one of the top 20 chemicals produced in this country, but it is also the fifth most common chemical found in completed exposure pathways at sites evaluated by ATSDR. Benzene was present at 17% of the sites where people have reasonably been found to have been exposed to chemicals from the site.
Acute exposure to benzene at extremely high doses can lead to death, while somewhat lower doses can cause drowsiness, dizziness, headaches, tremors, and unconsciousness. Long-term exposure can lead to harmful effects on the bone marrow, decreased red blood cells leading to anemia, excessive bleeding, and negative impact on the immune system.
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.
Groton, Massachusetts - A health study found that an unusual incidence of learning disabilities in children existed in the Groton, Massachusetts, area. Research conducted by ATSDR, the Massachusetts Department of Public Health, and the Children's Hospital Medical Center of Boston found an association between the incidence of learning disabilities and the presence of trichloroethylene and 1,1,1 - trichloroethane in drinking water. The information learned from this study was presented to members of the Groton community. As a result, community members were better informed and thus led to take appropriate precautions to protect their children's health.
Camp Lejeune, North Carolina - ATSDR conducted a study to determine if offspring of women who were exposed to contaminated water during pregnancy would suffer adverse health effects (low mean birth weight, small-for-gestational-age, and preterm birth). In the past, drinking water at the U.S. Marine Corps Base at Camp Lejeune, North Carolina, was contaminated with tetrachloroethylene (PCE) and trichloroethylene (TCE). Tetrachloroethylene was the primary contaminant. Associations between PCE exposure during pregnancy and the study outcomes were observed in two potentially susceptible subgroups: infants of mothers 35 years of age or older and infants whose mothers had histories of prior fetal loss. The older mothers were four times more likely to have an infant that was small for gestational age. Mothers with prior fetal losses were more likely to have infants who weighed less and were small for gestational age.
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
Select two diseases from those that have been identified as having a high priority for potential links to environmental exposure
Develop methods to measure and track these two diseases, keeping in mind the ultimate goal of assessing the association with environmental exposure, and
Evaluate the methods developed to confirm scientific value and begin documenting the effect of environmental exposure
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
Develop a disease-reporting system and create and contribute to the national chronic disease reporting system. There are two approaches to linking environmental exposure with disease. The first approach is to begin with the exposure and track forward to the resulting disease. The second approach involves tracking disease instances and linking them back to toxic exposure. ATSDR has become very adept in use of the first approach and has significantly expanded the nation's knowledge base. Little work, however, has been done with the second approach: tracking disease and linking it back to the environment. For example, there are no records in the United States that identify people suffering from neurodegenerative disease or give the addresses where those people live. Developing disease-reporting capabilities and maintaining the database will enable ATSDR to track disease clusters. An adequate database may allow the agency to begin to identify commonalities for the disease and ultimately determine plausible links to environmental causes.
Expand the National Exposure Registry. Expanding the National Exposure Registry is a clear and effective step toward meeting Goal 2. The National Exposure Registry and its subregistries track people exposed to toxic substances and maintain data related to health over time. The existing subregistries have proven to be considerably effective at moving the agency forward in the effort to link toxic exposure to disease. This very successful initiative will be expanded further.
Link databases for disease and for environmental exposure. Much information has been collected in databases related to environmental exposure and disease. ATSDR has collected a considerable amount of material on environmental exposure. Other health organizations have disease-tracking databases. Some examples of the disease-tracking databases are the National Hospital Discharge Survey, the National Health and Nutrition Education Survey, and the National Health Interview Survey. Each of these databases tracks, in some manner, health or disease factors nationwide. The opportunity exists to link health databases like these with exposure and environmental databases to aid in identifying associations between exposure and disease. The technology to correlate these databases is available. ATSDR not only recognizes the importance of this undertaking, but has the expertise to use these databases to show potential links between exposure and disease.
Conduct epidemiological studies. ATSDR's epidemiologists will continue to conduct studies to test the causal nature of associations between exposure to hazardous substances and disease outcome. As access to data continues to grow, ATSDR will continue to evaluate and search for links between disease and exposure.
Implement the agency's Agenda for Public Health Environmental Research. ATSDR, with extensive involvement from external experts, partners, and constituents, has carefully developed a comprehensive applied research agenda. Findings of research will greatly benefit numerous communities in the United States and throughout the world. This new initiative will expand ATSDR's funding and support for the Agenda for Public Health Environmental Research 2002-2010. ATSDR has identified six focus areas for research. This initiative will ensure that four to six projects will be supported that address the six research focus areas: exposure assessment; chemical mixtures; susceptible populations; community and tribal involvement; evaluation and surveillance of health effects; and health promotion and intervention. The agency allocated resources for development of several new research projects in fiscal year 2001. Among the topics studied in those projects were the following: acute organic mercury toxicity (as an outgrowth of the thimerosal in vaccines issue); an assessment tool to measure child stress levels in exposed communities; and development of a large and unique cohort with trichloroethylene exposure for a subsequent larger epidemiologic study.
Target improving exposure dose assessment for scientific innovation. Exposure dose assessment is a critical area for future scientific study. ATSDR needs to explicitly target this area to ensure that appropriate focus is placed on this important element.
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.
Universities - In conjunction with multiple universities in Michigan, New York, and Illinois, ATSDR has identified several important findings related to fish consumption in the Great Lakes region. These important research institutions are valuable on-site resources, gathering, testing, interviewing, and working with ATSDR to produce important information for residents who eat fish from the Great Lakes.
Another successful example of coordination with academic institutions is the agency's cooperative agreement program with the Minority Health Professions Foundation. This program is ATSDR's primary mechanism for filling gaps in knowledge about the effects of hazardous substances in the environment. In addition, this is the only university-based research program assisting the agency's efforts to address environmental justice concerns.
Federal agencies - ATSDR's public health consultations, public health assessments, and exposure investigations at sites are critical in assisting EPA in regard to cleanup decisions, addressing community health concerns, and in investigating possible increases in disease rates. For example, ATSDR will collaborate with EPA, CDC, and the National Institutes for Health in planning the Childhood Longitudinal Cohort Study.
State agencies - From its earliest years, ATSDR has supported states in conducting health studies on Superfund sites. For example, ATSDR has worked closely with the New Jersey Department of Health to determine links between drinking water and disease. Significant associations have been found between specific contaminants and various birth defects and adverse reproductive outcomes.
Local agencies and organizations - ATSDR worked in conjunction with the Children's Hospital Medical Center in Boston to conduct research on the link between learning disabilities and exposure to trichloroethane and trichloroethylene in drinking water
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.
Budget - ATSDR continues to identify toxic exposure issues related to individuals that require immediate research. These issues require funding, of course. The agency must continue to be selective in the initiatives undertaken to ensure that research is conducted using the latest science and the most effective and efficient methodology. Only by continuing its high standards can the agency's work continue to be of high quality and its reputation for solid research be maintained.
Ability to recruit and retain qualified staff - The agency recognizes that ATSDR-trained staff members are in great demand from states and from other federal agencies. ATSDR must continue to attract well-qualified personnel and ensure that they have adequate room to grow throughout their careers with the agency.
Data challenges - ATSDR recognizes and understands that data take a long time to accumulate and that even then, is not always perfect. The agency's professional staff will continue to meet the challenge of validating, defining, and linking available data and databases to meet research and public health needs.
Differences in scientific ideology - The scientific community is constantly involved in disagreements about approaches and findings. This disagreement is healthy, and it is particularly evident in the field of environmental science, which is a relatively young and growing discipline. ATSDR must continue to be at the forefront of scientific discussion as it relates to epidemiology and toxicology.
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
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. 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.
Fact Sheets - ATSDR has produced several hundred fact sheets with information related to a specific location or a specific type of exposure. These are short but fact-filled brochures that address specific issues and are written in a clear straightforward manner. For communities with many people who speak a language other than English, fact sheets are often made available in both English and the other language.
Targeted Media and Press Releases - ATSDR understands the importance of the local press and the importance of ensuring accuracy in the media. The agency routinely issues press releases locally to keep the media informed and help ensure the agency's message reaches as many people as possible in the local community. The agency believes that clear communication between ATSDR and the press is essential for ensuring accurate reporting of the issues involved.
One-on-One Communication - ATSDR representatives in the field routinely offer their time to respond to individual requests for information or clarification.
Open House Meetings -ATSDR staff members typically hold open house meetingsor"town-hall" sessions to address issues affecting a community.
Public Availability Sessions - The agency will also post hours when concerned citizens can stop by to ask questions or seek clarification from ATSDR.
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.
Produce and disseminate high quality products and services. ATSDR must continue to produce products and services that are, and are perceived to be, valuable to the American public. The toxicological profiles must continue to be maintained as they serve as a reference to those working or living near sites contaminated with the hazardous substances profiled. Currently, the agency has produced 152 toxicological profiles covering 800 substances. The agency also produces case studies, medical management guidelines, and ToxFAQs.ToxFAQs are fact sheets that present information on a specific chemical in an easy-to-read style and give answers to the questions asked most frequently about the chemical. They are often immediately valuable to people in areas affected by hazardous waste sites. These are examples of ATSDR products that must continue to be maintained at a level of high quality.
Develop easy-to-understand and culturally appropriate materials. Fundamental to ATSDR's mission is to go beyond the science to bring relevant information into affected communities and households in a manner that is accessible. The agency recognizes that scientific journals are an inadequate method for relaying information to the general population. While that is an important part of the mission, ATSDR recognizes that relevant scientific findings on environment health status in a community must be communicated locally in a format that is easy to understand. This means that the agency must be aware of local culture. For example, ATSDR routinely translates site materials into the language of the local residents. The agency also recognizes the need to reach people who read at all levels and fact sheets are prepared with this in mind. Developing materials that are informative, relevant, and accessible by the public is a primary objective for ATSDR.
Use electronic media for distribution. Technology advances over the past 20 years have provided the agency with an unequaled opportunity to disseminate information to more people-and to disseminate it faster. The Internet makes it possible for people to access current information on issues that are of immediate importance to them. Local libraries are making it possible for people without a home computer to have this same accessibility. Electronic media, when used appropriately, can also be far more efficient with resources than conventional media. One important additional advantage is that the message can be presented using the lessons learned about effective risk communication. ATSDR can present the message in a clear and understandable manner that will give the audience the facts in a way that will enable them to make well-informed decisions about matters that affect their health. ATSDR will further leverage technology and electronic media to efficiently distribute materials to people in affected communities.
Collaborate with organizations and trusted institutions to disseminate information. Another means of leveraging agency resources to develop and provide information to people in affected communities and tribes and to stakeholders is to work through local organizations and trusted institutions. ATSDR has built a significant web of trusted partners and is adept at building relationships locally. To maximize the reach of the information that needs to be disseminated, ATSDR will continue to collaborate with these partners and will work to further extend the reach of the distribution of the information.
Foster the establishment of environmental health and medical subspecialties within the health care industry. ATSDR has built strong relationships with university and medical communities. An example of this is the agency's relationship with the Howard University School of Nursing, which resulted in the development of an environmental-health curriculum geared towards educating nurses who serve minority populations in the Mississippi Delta region.
Also, through ATSDR's relationship with the Association of Occupational and Environmental Clinics, the agency was able to pool medical providers with an interest or experience in environmental science and foster increased coordination with the agency. The agency's intent through this objective is to further those efforts by working in the medical community to establish an environmental health subspecialty. By doing this, ATSDR would be directly impacting medical education at the academic level-which will ultimately lead to better information and awareness of environmental medicine across the country in the medical profession.
Train environmental health and other health care professionals to evaluate and address exposures to hazardous substances. With increasing numbers of requests for on-site diagnoses and treatment of people who have been exposed, it is becoming difficult to meet the demands of those requesting the services of ATSDR. To the extent that ATSDR can train local health care professionals to evaluate and address exposures to hazardous substances, the better able ATSDR will be to reach an increasing number of communities seeking assistance.
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.
Communities -- ATSDR has established the Office of Urban Affairs and the Community Involvement Branch. Staff members of the branch work to create and maintain partnerships with communities near sites where ATSDR is conducting health assessments or consultations, including communities where environmental justice is a concern. In Libby, Montana, staff members developed communication strategies to inform residents about medical testing that was offered in connection with the asbestos found in vermiculite mined in the area. There were more than 6,000 participants in the study.
Tribes -- Through the efforts of the Office of Tribal Affairs, ATSDR ensures appropriate dissemination of information to any affected tribes or reservations. In 2000, an Alaska pilot project addressed formerly used defense sites, which included, among several agencies, the Alaska Native Health Board. Also, in 1999, ATSDR launched a cooperative agreement program with tribal colleges and universities to build environmental public health capacity. Four schools were awarded 5-year agreements in the first year of the program: College of Menominee Nation (Keshena, Wisconsin), Dine College (Shiprock, New Mexico), Northwest Indian College (Bellingham, Washington), and Turtle Mountain Community College (Belcourt, North Dakota).
Local agencies -- ATSDR realizes that local cooperation with its communication efforts in a given community is critical to the success of any outreach program. The Lincoln County Environmental Health Department in Montana provided a great deal of support in using multiple communication strategies and methods to reach the general public in Libby, Montana.
State agencies -- A prototype for ATSDR and state agency coordination is the response to metallic mercury concerns in the Chicago area. After jointly evaluating the extent to which homes were exposed to heightened levels of mercury (from removal of gas meters containing mercury), the Illinois Department of Public Health issued more than 700 letters to residents, sponsored an information "hotline," and developed pamphlets for the public.
Federal agencies -- ATSDR has probably been most successful in generating synergies with EPA, and consequently the affected communities have been well served by the coordinated communication efforts of the two organizations. ATSDR will seek to further leverage relationships with other federal entities that have a high probability of directly interacting with communities (such as the Department of Energy).
Health care providers -- A significant effort to educate health care providers was initiated in the Agricultural Street Landfill community in Louisiana. The site is a 95-acre property that was formerly a municipal landfill. It was developed, in part, for residential use. In order to address the residents' concerns about their health, ATSDR distributed environmental health information to all 462 health care providers who serve that community. In addition, the agency provided a training seminar that 165 of the health care providers attended; these attendees collectively serve more than 90% of the community.
Advocacy groups -- ATSDR partners with a diverse group of charitable organizations and advocacy groups including the Sierra Club, Children's Environmental Health Network, and the Girl Scouts of America. ATSDR recently partnered with the Kids for Saving Earth Network in developing environmental educational relationships with schools near toxic waste sites. The joint effort included educating children and teachers to help them better understand general environmental problems. ATSDR also provided educational materials and activities and informed children about the role of government agencies in environmental programs. In 2000, the Kids for Saving Earth Network created a poster and worksheets designed to show children how to deal with the aftereffects of toxic waste sites.
Industry -- ATSDR currently has a Memorandum of Understanding with General Electric (along with several other organizations) to address approximately 10 research needs for five substances that are commonly found at industrial sites. The findings will be used as profile references for toxic assessments at future sites. For example, a 1997 study by General Electric assessed the toxicity and cancer-causing properties of four PCB mixtures. The results indicated a propensity to cause liver tumors in rats. These findings were reflected in ATSDR's updated toxicological profile for PCBs.
Universities -- Academic institutions, particularly those with strong ties to their communities, are a fertile source for developing credible and effective outreach efforts. The Great Lakes project is one with a number of successful collaboration efforts between ATSDR and universities. An epidemiological study at the University of Wisconsin at Milwaukee examining exposure of the Red Cliff and Ojibwa tribes contributed greatly to the information on the connection between exposure to PCBs and several physiological symptoms.
International organizations -- It is not uncommon that the agency's findings have a much broader audience than just the American public. Aluminum compounds, commonly used as adjuvants to enhance immunologic response for several childhood vaccinations, were identified by the World Health Organization (WHO) as a potential contributor to Alzheimer's disease. ATSDR provided valuable research and findings to CDC and WHO, who concluded that such compounds were safe for human use. Both CDC and WHO used ATSDR's assessments to recommend the continued use of aluminum adjuvants in childhood vaccines.
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.
Budget - Developing and providing reliable and understandable information for people in affected communities and tribes and for other stakeholders inevitably costs money. One of the areas of real opportunity for this goal is the opportunity to invest resources in building partnerships and information technology infrastructure to fully leverage ATSDR's ability to continue to produce valuable scientific findings each year.
Ability to recruit and retain qualified staff - The strength of ATSDR continues to be the staff members of the agency, the knowledge they have gained, and relationships that they have developed. ATSDR is recognized as a leader in its field and as such can attract people of high quality who are interested in leading the science of hazardous substance research. The challenge for ATSDR lies in keeping these individuals as they advance in their careers with the agency.
Medical community acceptance - The agency recognizes that declaring a new environmental health subspecialty as an objective may be considered aggressive. This type of change will require significant effort at the national level of the American Medical Association or the American Academy of Pediatrics or both, as well as significant effort within other key elements of the medical community. ATSDR strongly believes that the rewards of such a visible change for medical providers would be very much worth the efforts.
Lack of brand recognition within the government and among potential stakeholders - The ATSDR name is not widely known within the federal government or by other constituents. Agency staff members recognize that there are significant benefits associated with doing a better job of tying agency accomplishments to the agency's name. As predominantly a scientific body, ATSDR has accepted academic recognition as its main reward. The agency, however, now recognizes that a lack of name recognition among the public and even within other federal agencies lessens the agency's ability to accomplish its mission of serving the public, taking responsive public health actions, and providing trusted health information.
Audience identification and prioritization - ATSDR recognizes that the agency cannot develop and provide the best information for everyone. ATSDR must understand its "market" and prioritize the distribution of information. Technological tools can help the agency reach a wider audience, but ultimately the agency will have to identify subsets of the full population in order to focus resources in the most effective and efficient manner.
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.
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
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.
State Cooperative Agreements - ATSDR currently has cooperative agreements with 28 states, providing funds and technical oversight to conduct health assessments, consultations, and studies, and providing health education in communities near hazardous waste sites. In fiscal year 2000, ATSDR provided approximately $10.4 million for the partnered states in support of activities related to the public health impact of hazardous waste sites.
Association of Occupational and Environmental Clinics - The cooperative agreement with the Association of Occupational and Environmental Clinics (AOEC) was designed to implement site-specific medical education and health promotion activities. Health promotion activities include clinical evaluation (of individuals meeting specific criteria), distance-based learning, and other health initiatives related to children. One notable example of effective collaboration with AOEC on children's health issues is the creation of Pediatric Environmental Health Specialty Units in all 10 regions. These clinics provide services for children as well as training for health care providers.
Voluntary Research Program - ATSDR maintains a number of effective research programs. They include a voluntary research program through which the chemical manufacturing industry is encouraged to conduct research into the toxicity of chemicals that ATSDR has identified as "high priority." Data needs for many high-profile substances, including trichloroethylene, tetrachloroethylene, PCBs, and vinyl chloride, have been addressed in this program. Also, through partnerships with General Electric, the American Chemistry Council, the Halogenated Solvents Industrial Alliance, and the Electric Power Research Institute, ATSDR has been able to coordinate timely and important studies, paid for by the private sector. It is estimated that savings from this program have exceeded $4.5 million.
Tribal collaboration - ATSDR's Office of Tribal Affairs provides liaison between the tribes and ATSDR, creating an avenue for tribes to acquire timely environmental health services. Partnerships with tribes across the country have enabled ATSDR professionals to extend services and assistance to those who might not have been able otherwise to receive the benefits. For example, Tribal Cooperative Agreements are used by tribes to increase their self-sufficiency in evaluating and preventing exposures to hazardous substances (for example, the Hanford Nuclear Reservation in the state of Washington).
Border collaborations - Last, evidence of successful partnerships is evident in the efforts between Mexican and Canadian agencies. Much of the work regarding the Great Lakes has been conducted in close coordination between US federal agencies and Canadian provincial agencies. In fact, ATSDR jointly produced a research paper with Canadian officials documenting the human health impact of Great Lakes fish consumption. Also, ATSDR has worked with the Pan American Health Organization to provide training to health care providers in communities along the United States-Mexican Border.
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
Fund cooperative agreement partners - Cooperative agreement partners give ATSDR an opportunity to leverage its unique skills, thus increasing its impact in more areas. ATSDR will continue this successful initiative by funding further cooperative agreement partners and will look to expand those existing agreements that have proven successful.
Build brand equity in partnership activities - ATSDR must gain more goodwill from its efforts. In funding studies or activities in an area, it should focus its resources and talents specifically where they are needed. Today, a state department of health can leverage ATSDR funding and resources to affect positive influence over a wide area. Unfortunately, the credit or goodwill generated from such activities is rarely directed back to ATSDR. Rather, it accrues to the agency or department actually carrying out the initiative. ATSDR must build into its cooperative agreements explicit language related to brand names and use of logos and attribution so that it can further build on its established good reputation. Ultimately, this name recognition and reputation for quality will further enable ATSDR to build effective partnerships throughout this and other countries.
Establish relationships with university-based environmental health centers - Environmental health continues as an important field of study in colleges and universities. ATSDR employs top-tier researchers in toxicology and epidemiology who informally work with researchers in the university setting. Much, however, is to be gained through formalizing these relationships. Formal relationships set the groundwork for data and research sharing, for joint study and for access to leading-edge thought. These types of partnerships will advance the ATSDR mission.
Find additional opportunities to create international and domestic partners with which to address shared priorities and achieve common goals - ATSDR should continue to identify and pursue opportunities to extend partnerships domestically and internationally-with both for-profit and not-for-profit groups, including advocacy groups and industry.
Train tribal, state, and local health department professional staffs to conduct exposure and health assessments at sites - ATSDR increasingly receives requests to perform exposure and health assessments at designated sites. Communities want to know immediately whether their residents have been exposed to hazardous substances and whether there has been a health impact. This crucial first step after a site has been identified follows a repeatable methodology developed by ATSDR that can be followed by tribal, state and or local health departments-insofar as their professionals are familiar with the methodology and have been trained by experienced ATSDR personnel.
Monitor outcomes of partnerships and modify agreements and relationships to ensure effectiveness - A key element of a partnership is vigilance to ensure each relationship continues to benefit all parties. ATSDR should continue to monitor its formalized relationships to ensure value continues to flow to the agency. ATSDR will implement objective measures for partnership evaluation, and protocols for tracking performance against those measures. Lastly, the agency will develop steps for modifying existing agreements if those agreements no longer meet ATSDR's requirements.
Measure peer recognition - By measuring and tracking external recognition and accomplishments of ATSDR professionals, the agency can measure accomplishment and professional growth. Tracking items such as awards, publications, and patents will establish baselines for annual improvements.
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:
Communities - Though a priority within the entire agency, three specific ATSDR units: the Office of Urban Affairs, the Community Involvement Branch, and the Office of Tribal Affairs, will continue to focus on working with communities and tribes to find novel ways of emphasizing their roles in environmental health situations.
Tribes - Tribal sites require carefully considered and politically sensitive strategies. Through the Office of Tribal Affairs, ATSDR will continue to address carefully the issues, and craft the most appropriate solutions regarding those hazardous waste sites within and near reservations.
Local agencies - Collaborating with and supporting local agencies will serve to increase the agency's capacity to deal with an ever-growing list of toxic sites. ATSDR will continue to innovate methods-such as funding a brownfields cooperative agreement with six local health departments-to maximize the value of local-agency cooperation. For example, the National Association of City and County Health Officials has and will continue to be a productive partner in fostering innovative and effective local partnerships.
State agencies - State participation is necessary for the successful site evaluation. ATSDR will seek to strengthen further its ties with all state-level public health agencies.
Federal agencies - All federal agencies share a common element: they serve the American public. The agency has a growing list of federal partners, including:
Bureau of Indian Affairs
US Agency for International Development
US Forestry Service
US Department of Agriculture
The Small Business Administration
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.
Health care providers - Since 1989, ATSDR has recognized that one of the most effective means of building the knowledge and support of the medical community for public health issues is the active participation in and financial support of the major healthcare professional organizations. This is a vitally important component of ATSDR's outreach program. The agency will continue to seek ways to build upon its relationships with current potential audience of more than 80,000 health professionals.
Advocacy groups - Expanding ATSDR's partnerships among private organizations has great value. For example, the March of Dimes has been an important addition to the agency's Child Health Initiative, along with other longstanding partners, including:
Learning Disability Association of America
National Parent Teachers Association
Children's Health Environmental Coalition
Industry - ATSDR will continue to encourage private industry to make research contributions toward the toxicity of priority chemicals.
Universities - ATSDR will seek additional partnerships with universities to expand important programs such as The Minority Health Professions Foundation's Environmental Health and Toxicology Research Program. This research program is the agency's primary vehicle to address data gaps for hazardous substances but also the only university-based research program that currently supports its efforts to address environmental justice issues.
International organizations - Toxic waste sites are not unique to the United States and the work that ATSDR performs is an important and directly beneficial service for the greater human community. Creating synergies with noble institutions such as the World Health Organization is an excellent way to syndicate the value that ATSDR provides.
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.
Lack of brand awareness - Repeatedly ATSDR field workers are questioned as to exactly who they work with. ATSDR has worked in all 50 states and every US territory. The agency has held training sessions and offered testing to thousands of individuals and yet very little name recognition exists. ATSDR believes that the more potential partners know the name and are familiar with the work that has been done by the agency, the more they will be interested in entering into mutually beneficial long term partnerships.
Budget - ATSDR's partnership and cooperative agreements leverage each dollar of funding received. As an agency, ATSDR must continue to be selective in its initiatives to ensure the agency's quality levels and reputation for solid research are maintained, and that the partnership funding is being used in the most effective manner possible.
Data challenges - Without question, data takes a long time to accumulate and is not always perfect. To gain a baseline of data for existing partnerships will take time. During that time though, ATSDR will work to measure objectively existing partnerships, using the best means possible.
Balance any prescriptive reporting requirements with the ability of grantees to respond - A common government contracting challenge is the desire to over-prescribe or to control the relationship with a grantee. ATSDR will balance that desire, and will maintain the quality of the relationship with the need to offer flexibility and latitude.
Limited legislative mandate - Despite significant opportunities from international organizations, ATSDR must continue to work within the confines of a limited legislative mandate. An expansion of the mandate to facilitate partnerships with foreign academic institutions, foreign health organizations or both would greatly expand the agency's ability to share knowledge, learn from the experience of others, and continue to bring value to American residents.
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:
Measure a sampling of physicians and other health care providers to determine whether they have changed how they practice medicine based on ATSDR recommendations, training, or both.
From state cooperative agreements, obtain measurements of the effectiveness and impact of their actions.
Measure effectiveness of tribal activities.
Baseline survey of specific target audiences and populations to determine effectiveness and impact of ATSDR products and services.
Measure a sample of communities to determine whether they have changed their behaviors based on ATSDR recommendations and training (for example, protecting themselves from exposure to hazardous substances)
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
Encourage recognition of achievements - A key element of any human resource retention program is recognition of significant achievements. In some cases, when salary increases or cash bonuses are not available, recognition can serve as a positive reward for employees. ATSDR will improve on the process for recognizing employees who have excelled in their areas of operation.
Share knowledge and information throughout the agency - Another factor affecting the work environment at ATSDR is the degree to which knowledge is shared and transferred throughout the agency. More importantly, a major foundation for the agency's organizational unity is effective communication throughout the ranks. To ATSDR, knowledge-sharing is more than improving and standardizing the processes by which knowledge and information is shared among all employees; it is also the promotion of a culture that will support this technology-enabled activity. There must be a willingness to involve everyone-a sense of "boundarylessness" among ATSDR professionals who work throughout the country.
Improve the agency's intranet - To operate effectively in today's real- time information environment, the appropriate infrastructure must be a significant business model component. ATSDR will work to augment the current system, and foster an environment encouraging the free flow of information and ideas.
Improve the agency's employee performance systems - ATSDR recognizes the value associated with establishing goals and striving to meet them. ATSDR currently provides management with substantial autonomy in performance planning and year-end employee evaluations. Introducing more standardization into this process will allow for a greater sense of fairness among agency employees-thus ultimately improving workplace quality. ATSDR managers currently are evaluated in a largely subjective manner, which sometimes leaves room for dissatisfaction. To improve the overall quality of the work environment, ATSDR will implement a more objective performance measurement process to include more objective goal setting at the beginning of the performance year.
Recruit to achieve and retain a diverse and competent workforce - A component of improving the overall quality of the work environment at ATSDR means working to ensure the agency's workforce represents a diversity of cultures, ideas, and experience. ATSDR will benefit from such an environment and will take steps in recruiting and retention efforts to ensure this goal is met.
Support staff use of online and distance learning to enhance skills - Technological advancements have made self-improvement courses far more accessible in terms of time and resources than they have in the past. For example, the agency continually sponsors training opportunities so employees can advance knowledge and skill sets. Recognizing the inherent value associated with providing training to all professionals, ATSDR will work to continue to leverage distance learning and other online applications to bring additional training to those in the field.
Provide staff with appropriate IT tools and support - A fundamental indicator of quality in work environment is access to the tools and support necessary for performing the assigned task. ATSDR employees should be equipped at all times with adequate tools and support to perform their jobs. ATSDR will ensure that minimum standards are established and met regarding each position in the agency.
Implement cross-functional training - ATSDR employees represent a wide range of experience and roles. Because a component of a quality work environment is variety in the day-to-day experience, ATSDR will work to encourage and facilitate cross-functional training within the agency and among other agencies within the federal system. Maintaining a diversity of experience in a challenging environment will be a specific ATSDR goal.
Improve leadership training programs and opportunities - ATSDR will develop a strategic approach to human resource management, including improvements in leadership training and career advancement planning.
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.
Budget - The lack of adequate financial resources is probably the most commonly identified challenge for any organization. ATSDR must continue to emphasize its value in the most visible manner possible to ensure sufficient funding for program growth. Specifically, budgetary allocations for employee compensation must be competitive with comparable positions in other federal agencies.
Recruitment and retention - In every organization, employee turnover is a real concern. ATSDR must foster an environment that minimizes the loss of quality personnel.
Employee perception of inequitable pay grades between ATSDR and CDC - Total employee compensation is the foundation for both recruitment and retention. While ATSDR pay grades are in line with CDC's, a lack of upward mobility, as highlighted by the agency's relatively small size, is seen as a hindrance to achieving career advances. As a sister to the CDC, ATSDR must creatively seek ways to overcome the glaring problem of losing employees to not only its parent organization, but also to other organizations competing for its talent.
Promotion limitations - A true meritocracy rewards and promotes its high achievers. Ultimately, the most talented and upwardly mobile employees will find success in an organization that recognizes their potential and recognizes them for the contributions that they make. ATSDR must be mindful of this fact and seek to find opportunities for the organization's current and future leaders.
Small size of agency - ATSDR's overarching reality is its limited size and status as a subsidiary of a larger public service entity. ATSDR's goals and objectives must be qualified by its available resources, its mandate, and its authority.
Limited IT Infrastructure- ATSDR will continually strive to improve infrastructure shortcomings in information management and sharing. Effective administration of this resource must be one of the keys to success in carrying out the agency's mission.
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:
Acceptance rate of job offers - Measuring this will provide an opportunity
to identify areas in which recruiting tactics can improve.
Response to calls to the computer help desk- This will measure how
well and how quickly the agency meets the technology needs of its employees.
Annual HHS survey - A tool already employed by the HHS, this survey
will indicate general morale within ATSDR.
ATSDR employee survey - A tool allowing the agency to formally solicit
opportunities for improvement.
Diversity data - Where possible, ATSDR will strive to achieve appropriate
diversity levels that will enhance and enrich its workforce.
Pay grade review of comparable jobs and job ratings - Regular analysis
of this indicator will provide an objective and quantifiable, positive correlation
with both recruitment and retention.
Retention rates - In addition to industry benchmarking (for example,
salaries and total compensation packages), periodic review in this area will
provide management with an ultimate report card on whether employees agree
with ATSDR's direction, are satisfied with their current status within the
organization, and would support the organization and its people.