- Background Paper
- Evaluating Environmental Equity in Allegheny County – Theodore S. Glickman
- Comparing Apples and Supercomputers: Evaluating Environmental Risk in Silicon Valley – Lenny Siegel
- List of Participants
Addressing Environmental Quality and Public Health at the Community Level: A Problem Statement
IDDO K. WERNICK
The Rockefeller University, New York, NY
As the size and diversity of the U.S. population grow, public institutions must accommodate a widening array of communities. To contend with rising obligations in all sectors, the government tends to compartmentalize research and provision of services on issues of public concern. Rigid categorization impedes integrative initiatives and often translates into a practical indiff erence to problems arising at the community level. Environmental quality and public health now suffer from the inflexibility of organizational, legislative, regulatory, and research structures. Environmental quality and health care may also offer grounds for innovative approaches that consider the breadth of public concerns and diversity of circumstance in the population. To examine the prospects for implementing change, we identify three areas for study. They are deliberative methods for risk assessment at the community level, systems for integrating and disseminating information and providing services at the community level, and policy levers that facilitate greater flexibility to community service providers. Treating the “community as the pa-
tient” in contrast to the nation or the average national citizen is a promising avenue for countering the fragmentation of knowledge and services that come with large scale and thus for improving the public welfare.
Communities form the molecules of the matter that we call society. Although families and ultimately individuals comprise the atoms, communities provide the smallest political unit in society responsible for defusing political conflicts and capable of meting out solutions to local problems. They also provide a reference point for defining the needs of individuals included within them and determining the best use of resources to meet those needs.
Defining communities is not a trivial exercise and constitutes an important step in meeting their needs. Simple geographical definitions are useful but may hide other factors that distinguish communities. Economic status, language, and proximity to industrial sites are other characteristics that may be used for definition. Table 1 lists a sample of five North American communities defined using these types of flexible criteria.
As the number of communities included within larger political entities grows, the responsibility of the general public for their welfare becomes greater. In their efforts to serve communities as well as attend to other areas of national concern, society in general and government in particular inclines to categorize concerns. The divisions have been achieved using taxonomies that isolate areas conducive to conventional analytic approaches, ease of data collection, accountability, identification of research areas, use of existing professional specializations, and policy development and implementation. Some divisions are the artifacts of inadvertent historical happenstance.
The need for large public, as well as private, institutions to divide and arrange their activities into separate categories has been inescapable. Sheer scale has made it a management imperative for large organizations to delegate authority and organize distinct departmental responsibilities to operate e ffectively. The National Institutes of Health, for instance, is divided into more than 20 separate institutes, mostly focused on a particular organ or disease. The same tendency is apparent on a smaller scale as evidenced by the proliferation of specialties and subspecialties in medicine, the natural sciences, and other disciplines.
The rigidity of classification schemes can diminish the public’s ability to address adequately the complex problems that affect communities and the nation as a whole. Evidence of this deficiency can be seen in the costly implementation of the major pieces of environmental legislation passed in recent decades that treat separately the public’s desire for clean air, clean water, and reduced waste. Use of this segmented approach to environmental quality fails to counter important environmental hazards not covered by media-specific regulations and discourages the search for systematic improvement.
Contrastingly, a joint experimental effort, involving the U.S. Environmental Protection Agency (EPA) and Amoco Oil Company, using a systematic multimedia approach to limiting benzene emissions at an oil refinery in Yorktown, VA met with success largely due to the breadth and flexibility of the approach taken. Officials at the EPA have, however, been frustrated in attempts to codify this approach to regulation through functional legislation aimed at treating pollution generating sites in a comprehensive manner, for example, with the use of a single environmental permit for entire complexes.
In the area of health services, unfunded local immunization programs, as well as other overlooked preventive measures, eventually lead to enormous health care expenses, often borne by the public, for disease treatment. Requiring providers of services to adhere to health budgets that discourage or disallow the local redistribution of funds to best serve individual communities provides a further example of the unintended results of inflexible approaches.
The reductionist approach also overlooks the interaction between closely related aspects of environment and health. Neglected is the possibility of finding solutions that deal effectively with problems common to both areas. Although the discipline of “environmental health” attempts to address both areas simultaneously, in practice it has focused quite narrowly on the toxic effects of hazardous chemicals. Promising avenues for improving public health by enhancing local environmental quality such as employing innovative waste treatment technologies and instituting pollution prevention measures in local industry have been overlooked. In short, the broader implications of combining the pursuit of improved environmental quality and public health have not been properly explored.
How can public institutions integrate their activities so that they consider cross-cutting relationships between problems and the relative importance of problems and thus better address the needs of individuals? Treating communities as the foundation for analysis and distribution of services, in contrast to managing categories of individual problems affecting communities, off ers a plausible way for integrating policy and services to reflect better the needs of the people. At first glance this set of propositions, better integrating policy considerations and organizing interest at the level of the community, seems contradictory. On the one hand, efforts to appreciate the full scope of a problem swells the range for policy analysis and development and could presumably lead to more bureaucracy and centralization and hence less sensitivity to the needs of individuals. Contrastingly, using the community as the focal point requires greater attention be paid to individual needs. Stated differently, how can we integrate many disparate factors into the policy process without growing more detached from the practical problems of individuals and communities?
The answer may lie in the greater appreciation for the scope of public concerns afforded by addressing problems at the level of the community. Viewing policy concerns from this perspective reveals the intricacy of issues facing communities and serves to demonstrate the limits inherent in strictly isolating problems. It also bares the need for additional flexibility in developing and implementing policy. As the relationships of problems in areas such as environment and health are better appreciated for their complexity, interconnectedness, and context, we improve our ability to accommodate a greater diversity of situations.
WHY ENVIRONMENT AND HEALTH?
Environmental quality and health care are two areas critical to long term national well-being and have received increased public attention in recent years. In both of these areas, government has assumed a leading role in identifying threats to public welfare, formulating policy solutions, and creating structures for implementing them. Each has seen a rapid escalation in costs. The EPA estimates that more than $130 billion were spent on environmental quality in the United States in 1992, up from approximately $80 billion in 1986, a growth rate of about 8 percent per year. Spending on health care in the United States passed $800 billion in 1992 and has been increasing at a rate of more than 10 percent per year.
Although a broad consensus exists as to the validity of these areas for government action, there is no shared vision regarding the best route for reaching desired objectives. In the face of rising costs and limited resources, it is urgent for the public to develop sound, responsive frameworks to improve and distribute appropriate services efficiently and equitably and to support relevant research.
Environmental problems affect individuals, communities, the nation, and the globe. To help develop a framework for examining and treating environmental hazards at all levels, the federal government has encouraged increasing the use of risk assessment to establish priorities. Risk assessment identifies, classifies, and evaluates environmental hazards that pose threats to human well-being and natural ecosystems. Several difficulties have troubled the successful use of risk assessment for making policy and the employment of risk reduction strategies to deal with environmental problems. One difficulty has been establishing a sound quantitative basis for risk assessment. Risk assessment must treat factors that may not be intrinsically amenable to measurement. Thus, the significance of many environmentally important factors remains fundamentally uncertain. Even if the level of risk posed to people or an ecosystem is confidently ascertained, a common framework for comparing the risks of a different nature (e.g., carcinogenic and noncarcinogenic) and across affected groups (e.g., marine and terrestrial biota) remains elusive.
The need for rigor that drives the analytic process towards a greater dissection of risk exacerbates a separate difficulty. In principle, the areas subject to risk assessment should be delineated in a manner that genuinely recognizes the holistic nature of natural and social systems. By limiting and effectively separating the areas subject to environmental measures and regulation the proliferation of risk categories confounds attempts to address environmental concerns comprehensively.
Adding to this list of difficulties, by no means comprehensive, is the issue of scale. Geographically speaking, some environmental problems are global in scope and, as such, require national and international attention, albeit still requiring individual contributions. Some problems have only regional or local dimensions and can be best appreciated by people intimately acquainted with local landscapes and populations. The difficulty in determining the proper scale arises in the analytical element of risk assessment as well as the operational component of risk management and reduction. Risk assessment is applied to issues that are often politically and emotionally charged. Parties with different vested interests battle to infl uence the agenda for public discourse, each with self-proclaimed high-minded principles. Further subjectivity is introduced by fundamental differences of approach by the parties engaged in the debate. Experts attempting to establish safety and welfare criteria for others can be oblivious to public anxiety about a particular problem and do little to calm their worries. A scientifically naive public tends to overemphasize issues that may be highly visible but pose a minimal environmental threat. Experts in turn hardly have an impeccable record of performance in assessing risk. To achieve acceptance the process of risk assessment must be both scientifically sound and socially sanctifi ed, and addressing each is a considerable challenge.
A brief recent chronology of risk assessment reports highlights the difficulties. In 1987 the EPA published a report Unfinished Business: A Comparative Assessment of Environmental Problems. The work was the product of an expert panel, convened by the EPA, that reviewed a list of 31 environmental problems. The problems were evaluated according to four different risk criteria: cancer-related effects, noncancer health effects, ecological e ffects, and welfare effects. Groups assigned to analyze the 31 problems from the four points of view ranked risk as high, medium, and low. Throughout the initial report, the difficulty of using uniform criteria was raised as well as the paucity of data for many areas. On the whole, the document is tentative due to these factors, hence the appropriateness of its title. Notable among the issues raised at the end of the report were
þ Expert evaluation contrasts with a parallel listing and ranking of environmental problems based on a public survey conducted by the Roper Organization. An example of the disparity between expert and public rankings of environmental hazards is the risk posed by hazardous chemical wastes. This top public concern–a finding associated with high media visibility–was regarded by the experts as being of fairly low priority. Air pollution, ranked highest according to the experts, placed fourth in the public poll where it was followed by oil spills, which were very low on the expert list.
þ “National rankings do not necessarily reflect local situations–local analyses are needed.” Acknowledged was the fact that local and regional analyses provided necessary information regarding local problems that differ from mainstream or average national concerns.
In accordance with the recommendations made in the report, the EPA began with assessing risk on the regional, then state level. In 1990, the Agency began a project funding local environmental risk assessments. The city of Seattle has completed its local risk assessment, and Cleveland, Columbus, Houston, Atlanta, and Jackson are currently conducting their own projects. The Seattle study instructively focuses attention on local concerns and the means for local governments to act in addressing those concerns. Dispensed with are areas identified as under federal jurisdiction and thus beyond the influence of local authority.
In addition to providing information on local problems, these assessments practically serve localities by questioning the wisdom of requiring them to conform with unfunded mandates, both federal and state, for environmental quality arising from other than local assessments.
Commissioned by the EPA administrator under the Bush administration, W.K. Reilly, Reducing Risks: Setting Priorities and Strategies for Environmental Protection, released in 1990, was a follow-up report to Unfinished Business. Subcommittees for health and ecology were established. The health subcommittee declined to rank risks due to the lack of sufficient data. The ecological risk committee encouraged EPA to reconceptualize its mission and base its approach on risk severity when possible. Again, the lack of data was noted. The Carnegie Commission on Science, and Technology, and Government in its report released in June of 1993, Risk and the Environment, found, after looking at EPA budget priorities, that Agency funds were allocated more on the basis of the public perception of risk than expert assessment. The Carnegie report recommended encouraging agencies to undertake comprehensive risk inventories, as much for the discipline of the process as for the utility or applicability of the outcome.
No direct analogue to environmental risk assessment exists in the area of health care. Health care delivery is a more particular activity because the recipients of health care services are normally diagnosed and treated individually. While biomedical research is largely financed with federal funds, an established system of private care providers and institutions is already in place and is not required to follow government guidelines directly for prioritizing clinical activities. Nonetheless, the scarcity of public funds coupled to uncertainty about a future expanded role of government in the health care system portends that the time for evaluating national health care priorities for the general population is approaching. To date, no attempt at a comprehensive national assessment of health care needs has been made, and the debate rages on as to the very desirability of such a national ranking.
A more local ranking of priorities has been attempted at the state level in Oregon. Under the Oregon plan, 709 medical procedures were ranked according to costs and benefits. Those items falling below item 587 would no longer be covered by Medicaid. Preventive treatments such as childhood vaccinations and prenatal care are examples of treatments that received high rankings. More exotic treatments such as strenuous AIDS therapies for patients with less than six months to live and liver transplants for unrepentant alcoholics received low rankings. Some treatments received low rankings not due to their relative contribution to quality of life but because of a history of clinical ineff ectiveness. The plan was rejected by the Bush administration because it was biased against certain population groups, most notably the disabled. Despite its current questionable status, the Oregon plan opened the Pandora’s box containing the issue of heath care rationing and has kindled questions of medical ethics and social justice that affects individuals, communities, and the nation.
The priority given to various health care measures in communities and their ability to incorporate those priorities into the distribution system is critical to providing adequate care to members of the community. Although measures at the national level have far-reaching effects, market forces have hitherto defined the community’s capacity for providing satisfactory health care services.
One method aimed at improving the responsiveness of health care professionals and institutions receiving federal funds is the pursuit of quality control in health care through improved monitoring and feedback. Improved information gathering on the effectiveness of various treatments dispensed by local providers, as well as the relative costs of those treatments, marks an important step towards identifying the health care services with the highest return on investment for treating the population. However, extended oversight of federally funded health care services may, in some cases, rob communities of the little autonomy they have left for dispensing funds appropriately according to local needs. As in the case of environment, greater federal infl uence on local budgets burdens the local health care distribution system with conforming to mandates of outside import. Perhaps more importantly, dealing with 587 rather than 709 categories may not bring much relief if the fine categorization and not just priorities are the essential problem.
The intricacies of the health care bureaucracy are legendary. Adding to this complex array is a litany of other publicly administered social services that influence health and environment also. Community professionals must now contend with a multitude of separate streams of information and services provided by the public sector. Distribution of health care and other social services according to this rigidly divided framework frustrates efforts to accommodate individuals needing assistance by requiring them to deal with the artifacts of bureaucratic structures that hardly reflect their lives.
The plethora of agencies and departments that administer social programs provides no common information source to professionals at the community level. Access to a combined information source and better integration of public services would significantly enhance their ability to properly address community needs.
Public health provides an excellent venue for integrating environmental and health concerns in serving communities. Public health measures aimed at disease prevention and lifestyle changes may prove to be a very effi cient use of discretionary funds at several levels of the system. Individual communities may need a special menu of health services to serve them best. Historically, public health measures have improved the general health and mortality profile of populations largely without direct medical intervention. Environmental quality, particularly in urban areas, has contributed to improvements in public health in equal or greater measure. Many of the “wonder drugs” of the 20th century proved effective in diminishing mortality for infectious diseases after these diseases had been substantially eradicated due to prior nonmedical measures. Improvements in urban water quality, for instance, coincided with steep declines in the incidence of waterborne diseases such as cholera, diphtheria, and typhoid. Tuberculosis is another example. Over 80 percent of the drop in mortality attributable to this disease since the 19th century occurred prior to the introduction of multidrug therapy in the early 1950’s and is most likely attributable to behavioral changes and improvements in the indoor urban environment.
Interest is emerging in local evaluations of environmental quality and health care needs. This fact, coupled to the historical precedent of improving environmental quality positively impacting public health, argues for a new or revived paradigm. Viewing health and environment problems strategically and in combination, allowing for greater fungibility of resources allocated to them, and integrating services in these areas to better serve communities offers a most promising avenue for advancing the public welfare.
KEY AREAS TO EXPLORE
To narrow the discussion we have identified three key areas that we believe will provide for greater policy insight and more efficient public services at the community level.
Community Risk Assessment
What is the current status of deliberative processes for risk assessment at the level of the community? This examination draws on the recognition that at the local level the most satisfactory solutions to environmental problems often come from a combination of heightened public awareness, community activism, expert advice, and local government action.
Community-Oriented Information Systems
What is the current structure for accessing, integrating, and disseminating information about health and environment and related concerns at the local level? How can information technologies, geographical information systems (GIS), and other new capabilities be best used to serve local communities, and how can feedback from communities best be channeled back to inform higher level decision-making?
Policy Levers that can Assist Communities
What policy levers can be used by the government to insure that communities can better address remediating local environmental hazards and improve the efficacy of local health care delivery? One proposal, initiated by the National Governors Association and echoed in a recent list of suggested government actions issued by the Office of the Vice President, recommends that over four dozen categorical Federal grant programs be consolidated into six “flexible grants” that combine disparate goals in areas such as education, water quality, and defense conversion. The resulting grants would offer some degree of fungibility of funds distributed to different budgets to accommodate regional or local needs. This initiative, and ones like it, could be further explored to examine their feasibility and to search for the outcome of past ventures of this nature. The challenges and possibilities of functional environmental legislation that integrate pollution control and prevention measures would also fall under the purview of this study.
As well intended and apparently necessary as the strategy of itemizing policy concerns has been, and despite the many advantages that have been gained by its use, it may have reached and even exceeded the limits of its utility. The use of inflexible and labyrinthine organizational structures that correspond to compartmentalized legislation and regulation has led to neglect of synergistic relationships helpful in addressing public concerns. Communities and individuals are sometimes ill-served as a result of requirements to comply with standards and regulations that do not consider their particular set of circumstances. Neither our communities nor ecosystems appear to experience environmental and health problems in the neat categories our institutions now rely upon.
Properly executed, a community-oriented approach could help establish policies that better reflect the concerns of the communities they are supposed to serve and serve as a starting point for incorporating the amalgam of issues that individuals encounter in their daily lives into the policy process.
Would the quality of health and environmental research and the provision of public services in these areas differ greatly if we take the “community as the patient” as the basis for approach? We believe the answer is yes.