Rachel's Democracy & Health News #852, 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 exploring.]

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 health."]

[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 mandate.]

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 assessments.

** 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.