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Bar Journal - December 1, 2001

Resurrecting the Link Between Environmental Health & Public Health in the 21st Century in NH

By:
I. INTRODUCTION

The World Health Organization has defined health as "…a complete state of physical, mental, and social well-being and not merely the absence of disease or infirmity." The successful achievement of health is a balancing act between services for the diagnosis and treatment of illness with services that promote health and prevent disease. Public health may be defined as "…one of the efforts organized by society to protect, promote, and restore the people’s health. It is a combination of sciences, skills, and beliefs that are directed to the maintenance and improvement of the health of all the people through collective or social actions. The programs, services, and institutions involved emphasize the prevention of disease and the health needs of the population as a whole….Public health is thus a social institution, a discipline, and a practice."

What then is environmental health? Environmental health encompasses the health consequences of the interaction between human populations and the whole range of factors in both the physical and social environments. Environmental health is perhaps the main determinant of the health of populations, i.e., public health. Thus, the disciplines of public health and environmental health are interconnected.1,2

Years ago, city planners, architects, and landscapers practiced the idea that a clean, hospitable, recreational environment would enhance public health by offering people a place to walk and engage in physical activity. This concept was intuitive to many professionals prior to the establishment of the scientific connection between public health and environmental health. For example, Frederick Law Olmstead practiced this notion back in 1857 with the design of New York City’s Central Park. Such a simple concept of creating a recreational environment poses an insurmountable hurdle to the benefit of the public’s health in many communities today.3

Unfortunately, as the disciplines of public health, city planning, land development, and environmental protection have become increasingly specialized, the connection between public health and environmental health has been severed. The national public health agenda has all but removed environmental health in favor of an increased emphasis on access to health care. Conversely, environmental health agencies have organized themselves to only address the three basic media of the environment: land, air, and water.

This fact may not serve us well in light of the recent tragedy at the World Trade Center in New York City. This incident is by far the worst destruction on American soil in our lifetime. This act of terrorism presents itself with not only unacceptable casualties and injuries, but it also presents public health and environmental health issues regarding air quality (dust, soot, jet fuel smoke and fumes, and airborne asbestos fibers), potable water, sewage disposal, and diseases, such as asthma, to name a few. At this time in our nation’s history, the fields of public health and environmental health need to rejoin their knowledge and expertise to address real, life-threatening public health and environmental health emergencies.

II. DEMOGRAPHIC PROFILE OF MANCHESTER, NH

In Manchester, New Hampshire, public health and environmental health are housed within the same organizational structure at the Manchester Health Department. This is important since the Manchester Health Department operates on the principle that public health and environmental health are complementary fields necessary to protect the health of the largest city in the State of New Hampshire, and they should not operate in isolation of one another. It is also important to understand the demographics of Manchester, in order to fully appreciate the factors involved when attempting to work in the public health and environmental health disciplines in an urban environment.

With a population of 107,006, Manchester is the largest city in the three northern New England states (United States Census, 2000). Although communities surrounding Manchester have enjoyed prosperity in the last few years, creating an eighth in per capita income and first in proportion of residents employed in technology industries, many neighborhoods in Manchester have not benefited from this prosperity. Nearly 23% of Manchester residents live within 200% of poverty level with some neighborhoods reaching poverty levels up to 70% (U.S. Census, 1990). As of 1995, 28.4% of Manchester’s families were receiving Medicaid with costs of public assistance programs (AFDC, Medicaid, and Food Stamps) surpassing $35,000,000, or 17% of the State’s total costs for these programs. The community welcomes over 1500 births every year and nearly 18,000 children fill the Manchester’s public and parochial schools. In 1998, a total of 4,663 children aged 18 or younger were receiving Medicaid health benefits or food stamps (New Hampshire Primary Care Access Data Report, 1999).

In addition, the federal government has recognized the city’s disenfranchised neighborhoods with nine census tracts in the center city designated as Health Professional Shortage Areas (United States Department of Health and Human Services); two census tracts in the center city designated as Medically Underserved Areas (USDHHS); and a total of twenty five census tracts designated as Dental Health Professional Shortage Areas (USDHHS). The entire city is under consideration for designation as a Mental Health Professional Shortage Area (USDHHS). The inner city has also been designated as a federal Enterprise Community (United States Housing and Urban Development) and a Weed and Seed area (United States Department of Justice), and seven of the city’s fourteen public elementary schools are recognized as Title One Schools (United States Department of Education). Although the overall economy has improved significantly throughout the State, the gap has widened between families who are able to function in the face of these changing circumstances and those who can not.

The face of the Manchester community is ever-changing, partially due to immigration and refugee resettlement patterns, as well as significant increases among racially, ethnically, culturally, and linguistically diverse populations already residing in the United States. Health care organizations and programs, along with federal, state, and local governments, must implement systemic change in order to meet the health needs of this diverse population. With limited resources available for prevention, it is imperative for public health agencies and communities to direct resources to those areas in greatest need, and to those issues most amenable to prevention efforts.

Nationally, racial and ethnic minorities are projected to grow from 28% of the United States population in 1998 to nearly 40% in 2030. The Children’s Defense Fund predicts that within the first decade following the year 2000, there will be 5.5 million more Latino children, 2.6 million more African-American children, 1.5 million more children of other races, and 6.2 million fewer white, non-Latino children in the United States than reported today.

Within the Manchester public school system, over 13% of children were reported to be American Indian/Alaskan Native, Asian/Pacific Islander, African American, or of Hispanic origin during the year 2000. Close to 1500 children at any given time are enrolled in English as a Second Language (ESL) classes due to limited English proficiency, with over 70 languages spoken as first languages in the Manchester public school system. It takes six years of ESL education to bring a child to a level of English proficiency. Since 1990, the community has been designated a preferred refugee resettlement site and has received over 3600 refugee families who have fled their countries of origin for fear of persecution. These "new" residents have traveled from all over the world, bringing with them cultures, languages, and interpretations of "health" and "environment" that are unfamiliar to many service providers and community agencies.

Demographers predict that by the year 2020, nearly 70% of the world’s population will live in cities. As the Manchester community continues to expand, the quality of the environment in which residents live, along with the provision of basic services and the utilization of health care, will continue to overwhelmingly contribute to the determinants of health disparities within urban neighborhoods. As the State’s largest city, the programs in Manchester today which are demonstrating measurable improvement in the health status of constituents and the quality of life in the community, will undoubtedly serve as a model for the growing number of urbanized New Hampshire cities and towns in the future. This inevitable reality will also call for the alliance of public health and environmental health leadership, to further articulate the relationship of human health, well-being, survival, within the context of the health and integrity of the environment in which residents will function and thrive.

Despite the reality of health disparity and the necessity of cultural competency that affects many urban communities, the improvement of the quality of one’s environmental health may address an important aspect of these issues. Children represent a segment of our population vulnerable to environmental threats. Children’s vulnerability stems from the fact that they are simply more exposed to contaminants present in the air, food, water, or physical environment. Pound for pound, children breathe more air, drink more water, and consume more food than do adults. In addition, children have greater physiological susceptibility to certain environmental exposures since their biochemical and physiological functions are relatively immature, and their developing organs are more susceptible to injury (National Research Defense Council, 1998). This field of children’s environmental health is relatively new and incorporates three vital components that encompass many disciplines: the child, environment, and health. However, the challenges that one encounters when attempting to reduce the environmental health threats posed to children residing in an urban, diverse community are not only scientific in nature, but also include sociological aspects of culture, language, tradition, education, and poverty, to name a few.

So how is one’s environmental health and sociodemographic profile related? The World Health Organization (1992) acknowledged this connection between the external environment and human health by stating that "…human health ultimately depends on society’s capacity to manage the interactions between human activities and the physical and biological environment." Again, the relationships among one’s race, ethnicity, cultural practices, language, access to health care, education level, exposure status, indoor and outdoor environment, etc. to the community’s ability to provide accessible, adequate, and affordable health care and safe home and school services needs to be considered. Their importance cannot be underestimated if we are to be successful in reducing public health and environmental health threats to a racially and culturally diverse population of children residing in Manchester. Children constitute 30% of the world’s population but they are 100% of our future (United Nations World Population, 1998). Therefore, every effort should be made to improve the quality of the environment for ourselves, as the families, care givers, and educators of these children.

III. MANCHESTER HEALTH INITIATIVES

How is the Manchester Health Department working to reduce environmental health risks to children residing in a diverse, urban community? The Department is currently engaged in conducting research to address the ambient and indoor air quality at an inner city elementary school in an effort to reduce the incidence of a chronic disease, asthma, among these children. Also, the Department is currently conducting an asthma surveillance project in the city’s public elementary schools, in order to obtain baseline information on the prevalence of this disease in elementary school aged children.

The air is only one environmental media that can pose a health threat to our children. There are many more environmental media that possess the potential for adverse health risks to our children and that warrant further study. Future studies should include an assessment of nutritional and clinical measures associated with risk factors for another chronic disease, cardiovascular disease, in a diverse, urban, elementary school population. We have only just begun our journey to address and improve the quality of the health of the environment and the public residing in Manchester.

Only at a population level is it possible to look at the impact of a broad range of health determinants. This perspective is necessary to see whether health improvement efforts are meeting the needs of all segments of the community. Performance indicators should balance population-based measures of risk factors and health outcomes and health systems-based measures of services performed. It is important to recognize that the populations served by accountable community entities do not stop solely at geographic boundaries; therefore, data collection systems and performance measures must reflect the diverse needs of constituents and yet be flexible enough so that organizations can define their role in improving the community’s health and environment. Thus, in order to plan programs and projects that address public health and environmental health issues, such as children’s health, environmental protection, health disparities, chronic disease morbidity and mortality, adolescent pregnancy, asthma, obesity, etc., it is imperative that the local health department (serving 107,006 people) for the largest city in the State have access to the public health and environmental health data and resources that will enable it to conduct the basic principles of public health in our community to be addressed: assessment, policy development, assurance, and communication.

IV. HISTORY OF THE MANCHESTER HEALTH DEPARTMENT

The Manchester Health Department is a local health department serving the city of Manchester since 1885. The Department’s mission is to "improve the health of individuals, families, and the community through disease prevention, health promotion and protection from environmental threats." Our community purpose can be described within the context of the core functions of public health, as defined by the Institute of Medicine:

  1. Assessment of community health status and available resources. Assessment includes monitoring the incidence and prevalence of diseases, causes of death, and social and demographic trends that relate to public health. This function also includes communicable disease reporting and identifying disease early so that the public can be protected and the medical community can be alerted. Assessing the sanitary conditions of a community, such as food establishment inspections, or air and water monitoring, are also components of the assessment function of public health.
  2. Policy development resulting in recommendations to support and encourage better health. Policy development includes activities that assimilate and disseminate data collected through the assessment function to help shape local policies and give direction for local services. This function is very much a community activity and includes a close working relationship with area health providers, public and private agencies, elected and appointed officials, and the public. This function is often referred to as the community health improvement process by the Manchester Health Department, which has been instrumental in the operation of this public health principle.
  3. Assurance that needed services are available. Assurance means making sure that necessary health services and functions are available. Related activities include maintaining organizational capabilities to complete food recall functions, the enforcement of laws and standards, and providing services necessary for the protection of the public health, particularly when these services are not available to the public from some other source. The provision of population-based health promotion and health education programs are essential components of public health that local health departments need to assure are occurring in the community. Lastly, the assurance function also encompasses the need to review health program activities to assure that they are effective, non-duplicative, and tailored to current issues. The Manchester Health Department has remained, and continues to remain, fairly close to this traditional approach to public health and environmental health.4

The Manchester Health Department does not provide personal health care, but rather, it provides population-based services to protect and improve the health of the entire community. Population-based public health and environmental health measures, such as improved food-handling, water chlorination, sewage disposal, and immunizations have significantly improved the quality and length of human life. For example, the life expectancy for Americans has increased by over 30 years since the beginning of the last century, mostly as a result of public health and environmental health measures. Yet, we ended the twentieth century with new concerns in public health. There are newly discovered, as well as re-emerging communicable diseases. Twenty years ago, the public health community discussed the "end of the communicable disease era." Since then, the AIDS epidemic struck, new disease causing agents have been discovered in the United States, such as West Nile Virus, E. coli 0157, Hepatitis C, and, largely related to global migration and the AIDS outbreak, tuberculosis has reemerged as a threat to our health.

The cause of these threats are most likely due to lifestyle and nutritional habits that people practice. For example, an increasingly overweight and sedentary population will lead to increased chronic illnesses in the future, such as obesity and cardiovascular disease. Personal health behavior becomes more difficult to modify as one ages, so it is imperative that the community works with its families and youth to develop healthy lifestyles for the future.4

There are four distinct divisions in the Manchester Health Department: Divisions of Community Health, Environmental Health, School Health, and Public Health Assessment and Improvement. Each of these divisions provide public health and environmental health services that are determined by identified health needs within the community. They are necessary for continued assurance of the public’s health and environmental health (Figure 1).

FIGURE 1: GENERAL OVERVIEW OF THE MANCHESTER HEALTH DEPARTMENT’S PROGRAMS AND ACTIVITIES.

Community Health Environmental Health School Health Public Health Assessment and Improvement
Communicable Disease Food Protection Health Screening Community Health Assessment Control
Dental Health Immunizations Public Health Investigations EnvironmentalPlanning and Pollution Control Injury and Illness Care Chronic Illness Management Public Health Program Development Grants Management
Refugee Health Water Quality Health Education and Prevention Epidemiology
Tuberculosis Control Institutional Inspections   Community Interaction
Lead Poisoning Prevention Environmental Health Education   Health Education
SexuallyTransmitted Disease Control      
HIV Prevention      
Health Education      

For example, while certain childhood communicable diseases, such as mumps or measles, are rarely seen, the Division of Community Health continues to remain vigilant by administering over 5000 vaccines annually. In addition, the School Health Division is the only school health program in the state that is organizationally administered by a public health department, yet it enjoys a complete partnership with the school district. The Manchester Health Department staffs a registered nurse in each school in the district and has a full time nursing supervisor. Examples of school nurse commitment to public health have been their involvement on community tobacco prevention coalitions, asthma surveillance initiatives, and nutrition education initiatives. Furthermore, the Environmental Health Division continues to protect the public from epidemics, safeguard the food and water supplies, and extend and improve the quality of life for Manchester residents on a daily basis. Examples of these activities include food handler education, food service establishment special investigations, lead hazard education, public health complaints and investigations, institutional inspections, and environmental planning and pollution control, to name a few.

Lastly, the newest component of the Manchester Health Department is represented by the Public Health Assessment and Improvement Division. The mission of this program represents the foundation from which all other public health and environmental health activities are based and from which success is measured. Assessment is the core public health function that is responsible for measuring the health status of the community, identifying community health needs, and conducting studies of health problems facing the community. The ultimate goal is to assist policy makers and planners to meet these identified needs and evaluate outcomes of interventions designed to address these problems.4

As previously mentioned, one of the core functions of a local public health department is the ongoing health assessment of its community. In this regard, the Department routinely collects and analyzes local health data from several sources. The Healthy People 2010 Objectives, which are national goals for health, are utilized to examine, by comparison, the health status of Manchester residents. Once the data has been collected, a second goal of the program is the sharing of the information with the community. By doing so, a better understanding of community needs is formed.

A unique aspect of this dissemination has been the development of Public Health Report Cards which serve as benchmarks to assist in shaping local policies and local services. Graphically presented, local health information quickly provides a clear picture on the status of key public health and environmental health issues within a community. Public and non-profit agencies often use this information to evaluate service needs, to target resources appropriately, and to support funding requests. In addition, local health data has been utilized in the production of a monthly cable television show called Our Public Health which covers a variety of health related topics. Finally, key data points are highlighted in the publication of the Manchester Health Department’s newsletter, Our Public Health, which is distributed to health and social service professionals within the Manchester community.4

The Public Health Report Cards are utilized to encourage and establish a collaborative community health improvement process. This process involves leaders from health care, community health and social service agencies, education, local government, and the community at large. In Manchester, this community health improvement process has led to significant policy and service changes on issues such as oral health and adolescent pregnancy prevention. Through its health assessment initiatives, the Department will identify key public health and environmental health issues and encourage community measures to improve the overall health of our community.

Below is an example of one of the Manchester Health Department’s Public Health Report Cards (Figure 2).5

The leading causes of death for the period 1993 – 1997 for the City of Manchester are similar to the State of New Hampshire. Heart disease and cancer are the two leading causes of death for this time period. The dramatic gains in life expectancy for Americans over the course of this century is primarily attributed to better sanitation, the use of immunizations, antibiotics, and other public health measures.

The major modifiable risk factors for cardiovascular disease are high blood pressure, high blood cholesterol, and cigarette smoking. In addition, more than 30% of cancer deaths are also due to cigarette smoking. A recent Manchester inner city survey revealed that 58% of the residents reported either they or someone in their house currently smoked. With 24% of the people in Hillsborough County as current smokers, deaths due to heart disease and cancer will continue to pose a problem well into the future. As the economic costs of treating these conditions are examined, society must choose between high cost medical procedures or less costly preventative measures.

Crude Mortality Rates per 100,000 Population¹, Manchester versus New Hampshire, 1993-1997

Location Heart Disease Cancer Stroke/CVD COPD Unintentional Injuries
Manchester, NH 329.3 239.5 67.9 49.5 19.6
New Hampshire (Without Manchester) 241.1 201.3 55.0 41.3 24.4
Source: Primary Care Access Plan, 1993-1997, NHDHHS
¹Rates are based on 1995 Population Estimates, NH Office of State Planning

 

V. BRIEF HISTORY OF PUBLIC HEALTH AND ENVIRONMENTAL HEALTH IN THE STATE OF NEW HAMPSHIRE

In 1961, the New Hampshire Department of Public Health became a small Division of Public Health Services in a larger Department of Health and Welfare. During this period, various program separations were performed which further exhausted New Hampshire’s public health strength and influence. For example, in 1962, the Water Supply Protection Bureau was removed; in 1972, the Air Pollution Branch was severed; and, finally, in 1987 Waste Management was excised and placed in the newly formed Department of Environmental Services (DES). Ultimately, the DES was formed to consolidate four separate state agencies: Air Resources Agency, Office of Waste Management, Water Supply and Pollution Control Commission, and the Water Resources Board. It was thought that the creation of DES as a consolidated environmental agency would allow for greater coordination of environmental programs and policymaking activities, but this action resulted in creating a potential organizational disconnect between most environmental and public health programs and health policy. It is interesting to note that important environmental health programs remain under the auspices of the New Hampshire Department of Health and Human Services (DHHS), e.g., radiological health. Additionally, important public health programs remain under the direction of the DES, e.g., summer camp inspections. In 1995, recognizing the need for communication between the state public health agency and its environmental agency, the Legislature enacted a statute that promotes communication and interaction between the Department of Health and Human Services (DHHS) and the Department of Environmental Services (DES) in matters of common interest.

Many of the goals and responsibilities of DHHS and DES have a direct impact on the health of New Hampshire citizens. As a result, the DHHS and DES work closely on many long-term programs and special projects involving public health and environmental health. Some of these programs include hazardous waste site remediation whereby DHHS, in cooperation with DES, works routinely with the United States Agency for Toxic Substances and Disease Registry (ATSDR) to conduct health risk assessments at hazardous waste sites in New Hampshire. DHHS is a member of the DES Sludge Management Advisory Committee and provides advice to DES on health risk issues pertaining to the land application of sludge and biosolids. In the Cumulative Exposure Project, DHHS worked cooperatively with DES to evaluate the results of the US Environmental Protection Agency’s (EPA) Cumulative Exposure Project and National Air Toxics Assessment and provided public education and outreach materials regarding their implications to New Hampshire citizens.

Although DES and DHHS work effectively in many areas, there remains outstanding areas of cooperation, including indoor air quality, environmental justice issues, and environmental impacts on sensitive members of the population, e.g., children and the elderly. One may argue that these topics would already be addressed by these two agencies if they had remained as one because the joint agency would be operating from one agenda and strategic plan instead of two. Additionally, there are two financial budgets to consider with the separation of these organizations resulting in costly, duplicate administrative overhead. Under the current organization and administration of DHHS and DES, they view themselves as having independent functions as "risk assessors" and "risk managers", respectively. One may argue that these functions are complementary and not independent of one another. This topic is of great interest in the State of New Hampshire, so much so, that a bill has been passed to establish a commission to study the relationship between public health and the environment (HB 1390).

VI. JUSTIFICATION FOR THE REJOINING OF THE FIELDS OF PUBLIC HEALTH AND ENVIRONMENTAL HEALTH

Most historians attribute the creation of the field of public health to John Snow and early efforts to prevent the spread of disease and infection through basic sanitation (water purification, waste disposal, establishment of building codes, etc.). In fact, the organization and practice of environmental health activity as it is known today can be traced far back to the times of the Romans.

However, in the majority of states, public sector responsibility for most or all environmental activity is assigned to independent departments of environmental quality or protection, not to public health agencies. The gap among medicine, transportation, public health, environmental health, and environmental protection – as unique disciplines, each with their own culture, philosophy, language, methods of practice, professional requirements, and funding sources – can create an impenetrable barrier to achieving effective and sustainable prevention approaches. This fragmentation is compounded by the usual differences in practice between public and private sectors, as well as customary differences between state and community priorities.6

In the new century, continued growth in the United States will inevitably exacerbate the need to reintegrate public health activity with environmental protection and environmental conservation efforts to improve the health status of all communities. There is continued tension in this country among development, land use, and environmental preservation. This pressure, coupled with increased concern about neighborhood safety, responsible land use and planning approaches, urban sprawl, inequitable burdens of environmental impacts, increased asthma and cancer rates, global climate change, access to recreational areas, inadequate and costly public transportation, and emerging infectious social diseases such as road rage and school violence, suggest the need for new approaches to protect and improve human health. As communities strive to enhance the quality of life they afford their residents, it becomes paramount that those who are dedicated toward improving health and positive environmental outcome learn to work together to build lasting, collaborative, interdependence on the disciplines of public health and environmental health.6

The last two decades have seen a gradual widening in the gap 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 United States Environmental Protection Agency (EPA) and the United States Department of Health and Human Services (DHHS), 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 the following:

  • A lack of coordination among agencies working toward related goals;
  • A lack 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 sources for environmental health and public health programs.

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. This tool has undergone field testing at ten pilot sites across the country. Based on lessons learned through the pilot site coordinators, there exists numerous difficulties in integrating environmental health, environmental protection, and public health efforts in local health agencies facilitating community-based assessment activities. Nevertheless, the PACE EH pilot site experiences clearly demonstrate both the value and necessity of working through such difficulties.6

While both the public health and environmental health professions are dedicated to improving the health of communities, both are under the impression that the other is focused on the "wrong" elements in need of improvement. Often times, local environmental protection interests focus on how protecting the physical environment benefits community members, while public health workers focus on protecting human health as it relates to specified physical environments. In addition, 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 hospital and vital statistics data collection. The result is the lack of data that describes the human health impacts of environmental conditions.6

Despite many difficulties, the ten pilot sites that utilized the PACE EH 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.6

The common finding during the PACE EH process was that the value of reconnecting environmental health and public health is in the long-term benefits that will develop. Proponents in both professions should recognize that public health and environmental health are not separate fields at all. Environmental health is public health. Public health is environmental health.6

The more one knows about public health and environmental health as practiced at the local level, the more impact one’s community will have on reducing illness and injury. Yet, it is important to realize that the ultimate responsibility for dealing with these issues rests at the local level. When working within these two disciplines, it is important to consider the breadth to which these sciences reach. For instance, an important single predictor of a person’s health is his or her socioeconomic status. The lower individuals are in the socioeconomic hierarchy, the shorter is their lifespan and the greater is the likelihood of their experiencing a wide range of diseases. Urban sprawl is creating additional problems throughout the United States that are having an effect on the environment, for example, ground-level ozone and the creation of heat islands. Understanding the importance of greenspace is also necessary. The physical environment has always had a link to health and chronic disease prevention. For example, exposure to sunlight and the addition of open, greenspace at the turn of the twentieth century led to a decrease in rickets, whereas today, we have a new epidemic of chronic diseases associated to obesity due to an increased sedentary lifestyle and poor nutrition choices.6

We do not need to travel to another country to find environmental conditions that put humans at risk. In Manchester, New Hampshire, children still get poisoned from lead in their homes every year. In fact, last year a two-year old refugee child died from lead poisoning that was associated to lead exposure from her Manchester, New Hampshire dwelling. Elevated blood lead levels can leave children with behavioral problems and intellectual deficits throughout their lives. Yet, even though we have known about the hazards of lead paint for years, we still have not found the means to eliminate this hazard from our children. As another example, the incidence of asthma has significantly risen in this country. Environmental "triggers" located in both the home and community environments are most likely a major contributor. Recent research has identified that the environment also influences other public health issues, such as heart disease. Individuals who live in congested center city neighborhoods are more likely to experience heart disease. While some studies have illustrated the health benefits of living in close proximity to parks and other greenspace for exercise.

Manchester’s environment is a common denominator for the health of all residents. We need to return to one of the bases for establishing public health in the first place, and to reconnect the important link between public health and the environment we live in. Like every other urban setting, we will be challenged in the coming years to develop healthy environments that are accessible to all. When we accomplish this, the health and quality of life of residents will improve and our public health will be assured. The responsibility for this task needs to begin at the local public health and environmental health level.

ENDNOTES

1. The Future of Public Health, Committee for the Study of the Future of Public Health, Division of Health Care Services, Institute of Medicine, National Academy Press, 1988.
2. Principles of Health Care Practice, F. Douglas Scutchfield and C. William Keck, Delmar Publishers, 1997.
3. Environmental and Public Health: Pulling the Pieces Together, Harvey Black, Environmental Health Perspectives, v.108, n.11, 2000
4. Turn of the Century Report, The Public Health of the City of Manchester, Manchester Health Department, 1999.
5. Public Health Report Cards, Manchester Public Health Assessment and Improvement, Manchester Health Department, 1997.
6. Transformations in Public Health, Turning Point: Collaborating for a New Century in Public Health, v.2, n.2, 1999.

ACKNOWLEDGEMENT

I would like to acknowledge the expertise and wide breadth of knowledge of my colleagues at the Manchester Health Department, Frederick Rusczek (Manchester Public Health Director), Richard DiPentima (Manchester Public Health Deputy Director), Anna Noetzel (Manchester Public Health Epidemiologist), and Timothy Soucy (Manchester Environmental Health Supervisor) who provided me with valuable insights and information through our discussions on how to resurrect the link between public health and environmental health in the State of New Hampshire.

The Author

Rosemary M. Caron, PhD, MPH is the Public Health Toxicologist in the Division of Public Health Assessment and Improvement, Manchester Health Department.

 

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