Shared Vision

Current and Future Challenges

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

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

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

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

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

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

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

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

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

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

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

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