The workshop discussion was organized around the topic of information needs including: availability, accessibility, and quality of information; gaps in information; and barriers to overcoming gaps. The actual workshop findings are more easily summarized, however, under two headings: information needs and barriers.
Workshop participants were asked to identify information needed by state and local public health practitioners to provide essential environmental health services to their respective populations. Three categories of needs were identified:
1) Raw data, and what is missing from current collection efforts
2) Conversion of raw data into useful information for decision making
3) Mechanisms for accessing and disseminating information
There is a need to broaden the categories of data examined in environmental public health analyses. This will enhance the public health perspective, reduce the gulf between surveillance and information systems, and result in better models for analyzing data, planning, and evaluating the application of subsequent information. There is a continuum from data, to information, to knowledge. New ways of collecting, looking at, and analyzing data are important. The need exists for more and better health indicators and new classes of information to enhance understanding of relationships.
While a wealth of data exists, asking the right questions, identifying processes and linkages, or placing the data in a more appropriate context would make the data more meaningful. For example, public health practitioners need to identify the different types of water pollution; water systems that can be affected (e.g., lakes, rivers, swimming pools, and drinking water); the sources of the contaminants; the appropriate indicator organisms, trace elements, and chemicals; the manner in which humans are exposed to the contaminants; and the implications of the contaminants on human health over time. Another example is the life cycle of chemicals. It is not enough to merely know the hazardous nature of chemicals. Health officials should know where the chemicals are used and stored after manufacture and how the public is being exposed to the chemicals. One final example involves raw data on indoor air quality in public schools, and questions that should be asked. How can these data be best interpreted? How should the air breathed by students outside of school be factored in? Are new models needed to convert these data into relevant health information?
In addition to the need to capture more complete exposure and outcome data, many of the other high-priority information needs relate to accessing broader ranges of existing data and integrating such data into public health status analyses. Workshop participants identified the following as priority environmental health information needs:
1. Health status indicators are needed, especially morbidity and primary care accessibility data. Additional indicators identified were patient outcome data, hospital discharge data, and clinical and environmental.
2. Laboratory data (e.g., biomarker data which aids in understanding exposure patterns). Also of importance, are improved methodologies for translating environmental monitoring data into human exposure estimates.
3. Comparison population information included in health policy analysis is essential to placing environmental health data in a useful context. A critical need is comparisons of exposures and other risk data with demographic characteristics-specifically racial, age distribution, economics, and poverty—especially for urban populations. More precise census data that indicates such additional details as inner-city, migrant, and linguistic status would be useful.
4. Economic data such as the economic impact of a foodborne outbreak or the cost of an intervention strategy (e.g., boil water notices) are also needed. Related to economic data is the need for cost-benefit and cost-effectiveness analyses.
5. Acute and chronic cumulative impact data that enable health practitioners to analyze the effects of human exposure to numerous combinations of hazards over time are needed. Such data could support a better, expanded understanding of the links between environmental hazards and health outcomes (e.g., data on cumulative exposures of chronic low doses of carbon monoxide and pesticides). Also, there is a need to be able to identify susceptible populations and/or individuals, and to better understand the impact of aggregate exposures on these individuals and communities. This would entail inclusion of demographic and health status data and related information in impact analysis.
6. Enhanced analysis models are required to identify hidden relationships. Exposure to one health hazard that results in one well-defined health outcome is not reality. This approach is too simplistic and results in poor information, poor protection, and an unnecessary waste of resources. In order to enhance public health programs, officials must develop analysis models that incorporate more extensive data such as including the effect of multiple hazards or single hazards on populations with different susceptibilities. These data will help determine key nuances that traditionally have been overlooked.
7. Exposure and disease data lost through underreporting or threshold-reporting must be captured. Many incidents of disease related to environmental problems remain largely unreported. Even when the symptoms are treated by a medical system, there is often no data or insufficient data collection. Hospital discharge data and other data (e.g., job risk, childhood home location, and medical history) usually cannot be correlated back to environmental data because not enough data are gathered. If all cases of blood lead level readings (and other toxins) are made available, instead of only those surpassing arbitrary thresholds, more realistic exposure patterns can be realized. With respect for their need for job security, workers should be made more aware of discreet or non-threatening methods of reporting their injuries and exposures. Establishing reporting requirements for asthma, an escalating problem that is especially affecting children, would help in determining trends for this disease.
8. Linkages of regulatory, economic, exposure, and geographic data systems is needed to provide a clearer path to solutions. Little is known about the relationships of regulatory processes (i.e., retail food inspections), economic trends (e.g., decreased access to health care), and changing exposure scenarios (e.g., through changes in residential location or job responsibilities). For example, zoning decisions have significant public health implications, especially when hazardous facilities are placed near vulnerable populations. Linkages of data systems would provide information currently unavailable to zoning officials.
The remainder of items on the participants' priority list included: data on "saves" (e.g., how many lives are saved because smoke or carbon monoxide detectors are in place) and near misses (e.g., slips on glossy stairway that did not result in injury); baseline biological monitoring, baseline and sentinel monitoring of household pet well being (creatures exposed to many of the same household/community hazards as their owners), and background data (including such topics as air and water quality and the condition of various public infrastructures, like sewage systems, housing, gas pipes, and underground mining sites); exposure and health habits by race/ethnicity; exposure data at the time of environmental hazard release; more timely epidemiological data; foodborne illness surveillance related to influxes of people (e.g., tourists, migrant workers, and convention participants); relationship of such things as food consumption, diet supplements, and over-the-counter drugs to environmental hazard exposure; and community-wide symptoms which go unreported or are not considered as possible outcomes of environmental hazards exposure.
The fragmentation of environmental information systems has a direct impact on the ability to prevent illness and injury and to heal individuals and entire communities once they have been exposed to hazards. In many cases, there is an abundance of environmental health and related data that remains inaccessible, unlinked, or unusable. Data are generally collected and used for specific purposes, including regulatory compliance. Lack of networking and communication systems, lack of collaborating partnerships, inadequate training and personnel resources, and inconsistent quality often inhibit utilization of data. In general, barriers were grouped under four headings: managerial, administrative, technical, and socio-economic-political.
2.2.1 Managerial barriers primarily involve program direction, control, and the implementation of procedures. Difficulties stem from corporate cultures that resist collaborative efforts relevant to information collection and dissemination. More creative partnerships between the public and private sectors are essential. Efforts are needed to expand health programs, moving beyond collection of raw data, to more analyses of data, and to development of improved health indicators. Differences exist between needs at the national versus local levels, which affect collection, analysis, and use of data. Significant differences in the accessibility of various types of health data at the local level are partially responsible for the ineffectiveness of top-down approaches to surveillance. Problems arise in the inappropriate handling of confidential data, engagement in turf battles (including lack of role clarity among government agencies at the federal, state, and local levels), and the lack of agreement on the need for performance (management) data vs. outcome (health status) data.
The involvement of a broader range of disciplines and groups in public and environmental health activities is needed. Such groups include the lay community, medical personnel, private industry, and labor groups.
Conflicts between responsibility and accountability also result in data and information barriers. In many jurisdictions there remains a distinct dichotomy between health and environmental officials. Environmental agencies focusing on regulatory compliance need to prioritize public health considerations in their decision making. Public health agencies need to understand and help address the barriers that environmental agencies face in integrating public health measures. While much has been accomplished in bridging this divide, work remains to ensure that these two related professions proceed in partnership.
Many partnerships among federal, state, and local government agencies, and between government and the private sector are being developed in part because of scarce financial resources. However, in the long run, these partnerships could prove to be more fruitful financially as well as in the protection of public health, especially when common data can be agreed upon to meet common goals.
2.2.2 Administrative barriers pertain to program design, planning, and the development of procedures. They include relationships among concerned agencies and individuals; training that supports networking and collaboration; timeliness of data collection, analysis, and release; data collection as a budget priority; and reporting enforcement.
A key administrative barrier, which inhibits creative ways of linking and using data, is the lack of a standard approach to data collection. A key provision of the recently enacted Health Insurance Portability and Accountability Act of 1996, referred to as the Kennedy-Kassebaum bill, will begin to address this issue. The administration simplification portion of the bill promotes a new integration of health data that could make bodies of data more useful to a wider audience. However, the bill focused mainly on clinical data, not population-based data.
The U.S. Environmental Protection Agency (EPA) is leading another innovative partnership approach. The environmental performance partnership agreement allows state governments to receive multiple grants in a single package, and facilitates a broader perspective by moving all involved parties away from single-minded "program think." Among its many features, the agreement permits fund expenditure in new ways (i.e., across areas rather than area-specific spending), differential oversight, and community outreach and involvement.
State and local public health agencies report an abundance of data on services and health care utilization to federal agencies, but little to no analysis of data reported is received in return. Birth and death information is collected by states, but it often takes as much as two years to get the data composites to local public health agencies.
State and local public health agencies can be needlessly burdened by performance-based reporting systems developed by government agencies or politicians that have not collaborated with the reporting agency during system development. Greater collaborative efforts would benefit all stakeholders, including the community as a primary stakeholder and participant.
The lack of a centralized source of environmental health and related data increases search time, builds costs, and discourages research efforts. A comprehensive, environmental health repository that includes regulatory, risk, hazard, exposure, disease/outcome, health status, demographic, socio-economic and geographic variables (including Census data) would serve many needs. In combination with cost figures, the repository would help health officials identify environmental causes and/or implications more quickly, while providing a broader picture of public health. Centralization would also facilitate access.
The lack of a list of available environmental health data sources is an obstacle that can be overcome without a substantial investment of resources. (See David Piposzar's paper entitled "Information Needs of Local Health Departments" at Appendix E.) There are many web site sources for public health information. A list of these sites and other available information sources could be compiled and distributed to state and local agencies to help them locate information.
Other administrative barriers noted were: downsizing and resource shortages and insufficient support for ongoing education and training in the use of existing data by public health practitioners and policymakers as well as the public.
2.2.3 Technical barriers cited included lack of a common architecture, analytical and technical staff, and computer resources. Due to financial resource shortages, some state and many local public health agencies are still without basic hardware and software and/or Internet access. This, of course, impedes their ability to access local and remote data. While participants agreed that a tremendous amount of data are available, usage is hampered by difficult access or an inability to access. Agencies and individuals with access to the Internet and e-mail would improve networking ability and responses to their own inquiries by being proactive in promoting their web sites, e-mail addresses, and other connectivity information.
A key technical barrier is the lack of transportable data systems (i.e., compatible, integrated data systems). A problem faced by resource-short local agencies is the lack of analytically skilled staff with expertise in manipulating data in order to produce useful information. The expertise to attach GIS data within datasets would improve usability, including enhancing the ability to map and link data. Lastly, the quality of data is uneven within and across agencies. A means must be devised to better gauge and ensure both quality and consistency.
| One workshop participant summed up the technical barriers this way: "No tools or the wrong tools, inadequate or improper hardware and/or software networking capability, weak science, inability to track critical issues, and no wired feedback loops." |
2.2.4 Socio-economic-political barriers dealt primarily with uncertainty about community knowledge, beliefs, and values; deficient or no outreach capability; insufficient stakeholder identification; lack of training for collaboration among agencies and between environmental health professionals and the public; and culturally insensitive survey instruments. Political and public ignorance of the meaning of environmental health, and of what is involved in protecting the public's health is another piece of the socio-economic-political puzzle.
In most cases, obtaining information on the immediate environment is complicated for the general public. Commercial muscle in many communities prevents access to data that may harm the image or even existence of a company that releases hazardous substances. An easy-to-use index on the "state of the environment" and its relationship to human health should be developed for use in public education programs. Additionally, it is important to evaluate the effectiveness of efforts to communicate environmental health data to the general public.
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