Highlighting Environmental  Health in Turning Point

By Gilbert S. Omenn, MD, PhD

When the foundations, the National Program Offices, and the National Advisory Committee created the Turning Point program announcement and conducted the applicant workshops, a special effort was made to emphasize inclusion of environmental health in the agenda of the local and statewide Turning Point coalitions.

There are several reasons: First, many lay persons appropriately ask public health officers and health care providers whether their medical problems may be due to exposures to chemicals or radiation in their home, work, or recreational environments; physicians are particularly unprepared to address such inquiries. Second, the media are loaded with stories about health risks from environmental exposures, which patients and community groups expect their public health and medical experts to be able to evaluate. Third, in our effort to broaden the coalition and activate or empower communities, we recognize that environmental advocacy groups are expert in doing so and could be potent allies. Finally, we realize that the environmental community desperately needs more public health  input. The Presidential/Congressional Commission on Risk Assessment and Risk Management (the Risk Commission), which issued reports to the Congress, the Administration, and the public in 1996 and 1997, urged a reunion of public health and environmental forces (see Omenn GS, "Putting Environmental Risks into a Public Health Context", Public Health Reports 111:514-516, Nov/Dec 1996).

Expanding Linkages Between Environmental Health & Public Health

Most environmental regulations are aimed at protecting the health of workers or the general public. During the emergence of the Environmental Movement in the 1960s and 1970s, the role of public health agencies receded as new agencies were formed, from the Environmental Protection Agency (EPA), Occupational Safety and Health Administration (OSHA), and Consumer Protection Safety Commission at the national level to their counterparts in state and local jurisdictions. Our present regulatory system is dominated by analyses and actions directed at one chemical, one particular health risk, and one medium (air, water, food, soil) at a time, usually in isolation from other parameters. This  approach reflects faithfully the current statutes and the organization and orientation of environmental regulatory agencies. Wider use of the public health concepts of total  exposure, multifactorial causation, and attributable risk is necessary, along with much greater engagement of the public health scientific and practice community.

The recent recognition of the continuing threats from infectious agents - from  tuberculosis resistant to most anti-TB drugs, to HIV/AIDS and other sexually-transmitted diseases, to exotic diseases like Ebola virus and Hanta virus infections - has excited the American public and revived interest in control of communicable diseases. Likewise, the outbreaks of severe illness, kidney failure, and deaths in children from meat contaminated by the toxic E. coli strain 0157 have put a spotlight on the modern methods, including DNA probes for the E. coli typing, and rapid response teams required to prevent and control such tragedies. Meat and restaurant inspections have new pizzazz!

During the Turning Point application process we found an overall lack of emphasis on Environmental Health, despite the clear guidance in the Program Announcement. Both NACCHO and the University of Washington Program Offices are eager to provide assistance to grantees in exploring partnerships with the environmental communities. Those grantees who have very good connections already will be asked to share approaches and experiences with others. Environmental agencies themselves are being challenged to reach out to a broad array of stakeholders - including elected officials, people from  communities and tribal nations affected or potentially affected by environmental  pollutants, other environmental regulatory agencies, the relevant scientific communities, labor and environmental groups, and regulated parties, so the time is right for bridging similar efforts with Turning Point.

A Public Health Context for Environmental Risks

The Risk Commission's focus on a public health context for environmental risks  emphasizes that we are all exposed to mixtures - a "chemical soup" it was called in public testimony - in the air we breathe, the water we drink, the food we eat, the things we touch. The Commission's framework encourages us to consider radiological and  microbiological hazards along with various chemical hazards. Doing so brings forth the common challenge in public health practice: tradeoffs among risks, as in disinfection of drinking water or incineration of medical wastes or choices of energy sources in the increasingly deregulated market for electricity generation and transmission. This  approach responds to real questions logically presented by many citizens: What dangers are most important in my community? How much does a particular industrial facility or agricultural practice contribute to the total exposure of our community to a chemical or set of chemicals? How much reduction in the present rates of cancers or birth defects or other diseases could result if a particular source of exposure were controlled or eliminated? What is the likely cost - and how long will it take - to reduce these risks? Are there other more significant risks that we are ignoring, some of which might readily be addressed? Is there some point of diminishing returns in reducing specific emissions or exposures, especially in light of the hazards or economic costs of doing so?

Many states and cities and several tribal nations have conducted priority-setting  exercises called comparative risk assessments. These are not comparisons of risks associated with specific chemicals and the related risk reductions efforts, but comparisons of categories of risks. Such efforts have been empowering for most participants, yet often end with frustration over the lack of any common measure for comparing different kinds of effects. For specific risks, the Risk Commission offered some suggestions, including use of EPA's new concept of "margin of exposure," to stimulate discussion among stakeholders and experts.

As in health care, theres is tremendous ferment in the world of environmental regulation under the rubric of "regulatory reform," in the best sense seeking public health and environmental protection in the most cost-effective way. Doing so offers the public health community a great opportunity to be proactive. Clearly, we are all stakeholders in the effort to make our system for reducing risks and improving the public's health as effective as possible. In each Turning Point coalition, we urge you to give explicit attentionto this challenge and include environmental agencies and advocates in your coalitions.

Dr. Omenn, currently the Co-Chair for the Turning Point National Advisory Committee, was the founding director of the Turning Point National Program Office at the University of Washington and Dean of the School of Public Health & Community Medicine there (1982-97). He is now the Executive Vice-President for Medical Affairs and Professor of Internal Medicine, Human Genetics, and Public Health at the University of Michigan.