Rachel's Democracy & Health News #852  [Printer-friendly version]
April 27, 2006


[Rachel's introduction: Recently the National Association of County
and City Health Officials (NACCHO) published a definition of what a
local health department is supposed to do. If health departments did
these things, they'd be powerful allies in protecting the natural
environment and enhancing human health. This definitely seems worth

By Peter Montague

Last week I suggested that environmentalists and environmental justice
advocates might benefit by making alliances with public health
professionals and agencies.

The argument is simple:

(1) The core philosophy of public health calls for preventing harm 
before it occurs instead of managing harm after it occurs.
On the other hand, environmental professionals live under a regulatory
regime based on risk assessment. The difference is real. The public
health approach asks, "How much of this problem can we prevent?" but
environmental regulations require environmental officials to ask, "How
much of this problem can we declare acceptable?" -- in other words,
how much harm can we allow these polluters to get away with? The
"environmental" approach initiates a debate over a magic number that
represents "acceptable" risk. The public health approach initiates a
debate over the least-harmful alternative.

(2) Furthermore, public health agencies understand that there are
three environments -- the natural, the built, and the social, all of
which affect human health and quality of life. Public health officials
readily understand that gender discrimination or racial discrimination
can degrade people's health. They know that stress and poor nutrition
make people more susceptible to the effects of toxic chemicals. On the
other hand, it's a huge stretch for many environmental officials to
incorporate "the social environment" into their thinking. For a time
U.S. EPA seemed to be trying to incorporate environmental racism and
environmental justice into its programs, but it failed almost
completely. (Last summer EPA announced plans to eliminate race from
its definition of "environmental justice" -- quite an astonishing
denial of the available science, not to mention human experience.)

Anyway, last week I argued that community-based advocates for
environmental health and justice could fruitfully explore alliances
with public health professionals and agencies. Community activists
always need new allies, and the public health agencies always need
community support for their programs (and budgets) so they can
continue to do their job, which is to protect public health.

In response to last week's Rachel's, I received two letters from
community activists, both explaining that they had tried to work with
their local health departments but had run into a brick wall. In one
case, the health department seemed to resent sharing the spotlight
with a non-governmental organization, and in the other case the health
department was heavily influenced by corporate money sloshing around
in the local political system.

I can sympathize totally. In most disputes over environmental health,
many local health departments are simply absent. Worse, on more than
one occasion I have found myself opposed by a local health official
who denied that a toxic waste dump would have any effect on nearby
residents' health, or that a garbage incinerator would degrade the air
and tend to make people sick. In a society that has allowed corporate
money to infiltrate and corrupt all the institutions of democracy
(including elections, the media, law-making, the courts and even
public schools), we should not expect our health departments to have
an easy time opposing "development," even "development" that is
clearly toxic and unjust. Health departments will be embedded in a
political framework dominated by corporate money until we figure out
how to change that reality. Until then, we've still got public health
to worry about (and public health will no doubt be important in
eventually dethroning corporations, which are "the new kings, the new
tyrants," to use Gerry Spence's phrase).

Meanwhile, health departments are fundamentally important institutions
and they should be strengthened. Furthermore, they operate under
guidelines and principles that seem to demand that they speak out from
time to time on important environmental health issues. Their core
mission is nothing short of heroic. The question is how best to help
them do their job.

Some 3000 local health departments are represented by the National
Association of County and City Health Officials (NACCHO -- pronounced
Nay-Cho). Just last year NACCHO published a new "Operational
definition of a functional local health department." The NACCHO
definition was put together with the participation of more than 600
governmental public health professionals and local and state officials
representing 30 different states. The NACCHO definition describes the
duties, responsibilities and vision of a local health department.

NACCHO says the definition "will help citizens and residents
understand what they can reasonably expect from governmental public
health in their communities. The definition also will be useful to
elected officials, who need to understand what LHDs [local health
departments] do and how to hold them accountable. And, the definition
will aid LHDs in obtaining their fair share of resources."

Operational definition of a functional local health department

The opening sentence reads as follows: "Governmental public health
departments are responsible for creating and maintaining conditions
that keep people healthy." Get that? Creating conditions that
make people healthy. And then maintaining those conditions.
That's a pretty powerful mandate. In contrast, the mission of U.S.
Environmental Protection Agency is "to protect human health and the
environment." EPA's mission is reactive -- protect against threats.
The public health mandate is proactive: create conditions that
keep people healthy. Do you see the difference?

NACCHO goes on to describe what a "functional local health department"
does. The definition of "local health department" may include a
locally-governed health department, a branch of the state health
department, a state-created district or region, a department governed
by and serving a multi-county area, or any other arrangement that has
governmental authority and is responsible for public health functions
at the local level.

So what does a local health department do?

First a local health department "Understands the specific health
issues confronting the community, and how physical, behavioral,
environmental, social, and economic conditions affect them."

[So your health department has a mandate to concern itself with social
and economic conditions that affect health. Public health
professionals call these "the social determinants of health," and
they include inequalities, social exclusion, social isolation,
pyramids of status, racism, sexism, low income, stress, job loss, lack
of control over one's circumstances, run-down housing, and so on.]

** Implements health promotion programs. [In other words, a public
health department doesn't just stop bad things from happening; it
takes steps to make good things happen.]

** Develops partnerships with public and private healthcare providers
and institutions, community-based organizations, and other government
agencies (e.g., housing authority, criminal justice, education)
engaged in services that affect health to collectively identify,
alleviate, and act on the sources of public health problems. [In other
words, NACCHO expects your health department to form alliances with
community-based citizen groups, among others.]

NACCHO says "All LHDs [local health departments] exist for the common
good and are responsible for demonstrating strong leadership in the
promotion of physical, behavioral, environmental, social, and economic
conditions that improve health and well-being; prevent illness,
disease, injury, and premature death; and eliminate health
disparities." [NACCHO defines "health disparities" as "differences in
populations' health status that are avoidable and can be changed.
These differences can result from social and/or economic conditions,
as well as public policy. Examples include situations whereby
hazardous waste sites are located in poor communities, there is a lack
of affordable housing, and there is limited or no access to
transportation. These and other factors adversely affect population

[So your local health department is supposed to exercise "strong
leadership" in the promotion of environmental, social and economic
conditions that improve health and well-being. Again, that's quite a

NACCHO goes on to say that a functional health department...

** Addresses health disparities. [In other words, asks why some people
are healthy and others are not. Probing this question gets you into
some really interesting territory.]

** Obtain and maintain data that provide information on the
community's health (e.g., immunization rates; hospital discharge data;
environmental health hazard, risk, and exposure data; community-
specific data; number of uninsured; and indicators of health
disparities such as high levels of poverty, lack of affordable
housing, limited or no access to transportation, etc.).

** Analyze data to identify trends, health problems, environmental
health hazards, and social and economic conditions that adversely
affect the public's health.

** Conduct or contribute expertise to periodic community health

** Engage the community to identify and solve health problems.

** Advocate for policies that lessen health disparities and improve
physical, behavioral, environmental, social, and economic conditions
in the community that affect the public's health.

** Inform the community, governing bodies, and elected officials about
governmental public health services that are being provided,
improvements being made in those services, and priority health issues
not yet being adequately addressed.


I am now wondering why President Nixon in 1970 created an entirely new
federal bureaucracy to deal with "the environment" when the public
health system had been in place for 120 years and it already
recognized the importance of maintaining clean air, water and soil.
Public health in the U.S. started with the idea of preventing health
problems by cleaning up the environment. So why did President Nixon
need to create the EPA?

In my most cynical moments I suspect that President Nixon created EPA
because it allowed him to

(a) not increase the budget of the public health agencies with their
powerful mandate to worry about all three environments (natural, built
and social);

(b) create a competing agency with a mandate to worry about only two
environments (natural and built), thus isolating "environmentalists"
from the potent source of political power inherent in the social
determinants of health.

Isn't it time we all adopted a "public health perspective" on
environmental problems, which entails:

** recognizing the importance of all three environments (natural,
built and social)

** exploring our local health department to see if they meet the
NACCHO definition and, if they do, explore alliances with them, and,
if they don't, then explore how they can be reformed and strengthened
to fall into line with the NACCHO definition.

Of course it's not a silver bullet but it seems like a huge
opportunity waiting to be seized. As I like to say, the environmental
movement definitely isn't dead, but it's lonely and needs more
friends. The public health community could be a new set of friends --
and good friendships benefit everyone.