The Protocol for Assessing Community Excellence in Environmental Health (PACE EH) guidance document drafted by the National Association of County and City Health Officials (NACCHO) and the National Center for Environmental Health of the Centers for Disease Control and Prevention (NCEH of the CDC) is designed to assist local health agencies with the facilitation of a community-based environmental health assessment. The tool has been undergoing field-testing at ten pilot sites across the country for the past two years. Based on lessons learned through the experiences of PACE EH pilot site coordinators, there exists myriad difficulties in integrating environmental health, environmental protection, and public health efforts in local health agencies facilitating community-based assessment activities. Nevertheless, PACE EH pilot site experiences clearly demonstrate both the value and necessity of working through such difficulties. This article describes examples of the obstacles hindering linkages as well as the long-term benefits of overcoming such obstacles.

Describing the Obstacles

The last twenty years have seen a gradual widening of the rift between agency roles and responsibilities with regard to environmental health, environmental protection, and public health activities. At the federal level this is most clearly represented by the existence of distinct institutions (such as the Environmental Protection Agency and the Department of Health and Human Services) whose professional obligations and responsibilities often serve to separate environmental health and protection activities from other public health practices. This separation translates at the local level to, among other things:

•a lack of coordination among agencies working toward (what should be recognized as) related goals;

•a scarcity of quality data relating environmental conditions and human health effects;

•work forces in public health without sufficient knowledge of environmental health (and vice-versa); and

•separate and established funding streams for environmental health and public health programs.

PACE EH pilot site coordinators have reported encountering problems such as those listed above in a number of instances. We learned that prior to their involvement in the community-based environmental health assessment project, they had not met or worked with representatives of local environmental protection initiatives. And while most reported that, once seated around the same table, public health and environmental protection professionals identified a great deal of common ground, a few suggested that, even in the context of the project, their relationship was initially adversarial.

One coordinator suggested that the difficulty in working together was the result of unstated "turf battles." She implied that while both professions are dedicated to improving the health of communities, both are also under the impression that the other is focused on the "wrong" elements in need of improvement. According to her impression, local environmental protection interests focus on how protecting and maintaining the physical environment benefits community members, while public health workers focus on protecting and maintaining human health as it relates to specified physical environments.

All the pilot site coordinators believed their projects were hampered by a lack of data. The different ideological approaches suggested by the widespread institutional division of environmental and public health agencies have supported the development of two very distinct bodies of data for each. Environmental protection has tended to collect data focusing on the "state" of the environment. Public health has concentrated on morbidity and mortality data collection. The gap, increasingly obvious, is data collection that joins the two and that represents a broader definition of health than the mere absence of death and disease. Despite extensive searches, site coordinators found little reliable data that are dedicated to explicating the human health impacts of environmental conditions.

 Participants have also found that their professional training in public health has not adequately prepared them for exposure to the findings of environmental health professionals. One coordinator described an assessment team meeting at which representatives from the local EPA office took an active role. She describes the ensuing discussion as one in which the two sides were "talking right past each other." She pointed out that the two fields of study tend to use similar terminology (such as "indicator" and "risk") but with very different associated meanings.

 Finally, participants have expressed the need for increased professional incentives to work toward bridging the ever-widening gap between public health and environmental health. One coordinator acknowledged that their department faces a reduced operating budget every year and must weigh the cost of taking on new projects against the necessity of acquiring secure funding through well-established channels. Needless to say, the desire for a health agency to take on an innovative project (e.g. land use planning or community-based assessment) during a time of forced cutbacks and careful spending will always be balanced with the need to maintain consistent cash flows, largely through more traditional programs (e.g. sanitation).

Overcoming the Obstacles

Despite these difficulties, the ten pilot sites utilized PACE EH and successfully integrated environmental with public health approaches in conducting a community-based environmental health assessment. Their success was not based necessarily on eliminating the obstacles but rather recognizing the limitations they impose and capitalizing on the opportunities they create. For example, they organized assessment teams with an eye toward including representatives of environmental protection agencies. One coordinator actively recruited local EPA members with letters, phone calls, and e-mail. In light of the lack of previous professional overlap, he believed that the extra effort to attract them was necessary. Not only did ensuring their participation provide for increased interagency coordination, it also went a long way toward educating each respective workforce in the ideology of the other.

The lack of data, problematic at every site, was impossible to rectify completely. The sites, however, approached it as an opportunity rather than a barrier. Where community interest resulted in a need to address issues for which data were unavailable, site coordinators found they had pinpointed a valuable reason for creating a means to begin collecting data. In short, working through PACE EH provided a methodology for recognizing a need to collect data relating human health and environmental status and a locally relevant way to begin.

 Finally, the issue of distinct funding streams driving public health activities was avoided by conducting assessment projects without project specific funds. The pilot site coordinators have found that undertaking a community-based environmental health assessment need not be expensive. If the coordinator can find a way to afford the cost in terms of staff assignments and work hours (no easy feat in and of itself), then the financial burden can be slight. In fact, it has always been the aim of the authors of PACE EH that the ability to conduct the assessment not be tethered to finances. The experiences of the pilot sites suggest they succeeded.

Value Added

Still, this recounting of the experiences of the pilot sites begs the question, "To what end?" Why should public health practitioners strive to address the gap between public health and environmental health activities? Is conducting a community-based environmental health assessment reason enough to focus so much energy, time and training on what amounts to an ideological distinction between two related professional fields?

The pilot initiative strongly suggests the answer is "yes." In fact, possibly the most positive finding from the field-testing of PACE EH is the strength of the linkages it has formed. Our pilot site coordinators report that the single greatest asset of becoming a test site has been the coalition building it has inspired. Health agencies that had never before worked with local environmental protection interests are undertaking long-term mutually beneficial initiatives. For instance, one coordinator is co-developing a joint project seeking to explicate and protect the interrelationship between local waterways and bordering communities. Another is facilitating possible training opportunities for health agency staff, and interested community members, at a local school of environmental health. A third is assisting in organizing an environmental health seminar and hopes to pave the way for his home state to enter into a confederation of states united in pursuing improved environmental health for their communities.

Many other similar examples exist. The common finding is that the value of reconnecting environmental and public health is in the long-term benefits that will accrue. Proponents in both professions recognize that public health and environmental health are flip sides of the same coin. In truth, they are not separate fields at all. Environmental health is public health.

 Jonathan Schwartz is a Senior Research Associate in the Research and Development Division of NACCHO. NACCHO is publishing PACE EH in November, 1999 and plans to launch Broadening the Practice of Environmental Health, a program designed to address the issues identified in this article in the coming year. If you have any questions or comments related to these projects, please contact Jonathan Schwartz at NACCHO, 1100 17th Street, NW, 2nd Floor, Washington, DC 20036, 202/783-5550 (phone), 202/783-1583 (fax), or via e-mail, jschwartz@naccho.org.