One of the positive aspects of the conversation that the PHAA has been having around the formation of a Centre for Disease Control (CDC) has been the recognition that a CDC needs to have a broader scope than solely that of communicable disease control. The purpose of this article is to explore the inclusion of an environmental health focus in the Centre.
These are my personal reflections and observations having spent many years in the field of environmental health at the state and national level, including as a state director of environmental health programs and chair of the Environmental Health Standing Committee of the Australian Health Protection Principal Committee.
Environmental health’s important role
So, what do I mean by ‘environmental health’? It is simply about identifying and managing risks to health from the physical environment. For those with an interest in the history of public health, it is probably one of the oldest parts of any health department. The 19th and early 20th century public health agendas were focussed on sanitation, hygiene, safe food and medicines, poisons control, and the control of noxious industries.
These challenges were thought to have been solved, and certainly the increases in life expectancy due to the provision of safe food, water, human waste, and environmental pollutants through town planning and emissions controls are there to see. Further, over the 20th century, this environmental health agenda was taken up across government with many non-health agencies tasked with managing these risks, including town planning, water management, and occupational health to name just a few.
So why is environmental health still so important and what does a CDC need to focus on? The old problems were never ‘solved’. Rather, the problems have re-emerged in a different context. Take ‘noxious fumes’ as a case in point. The most significant environmental problem of the 21st century is climate change arising from the combustion of fossil fuels producing carbon dioxide and other sources of greenhouse gasses. The challenge of safe water is still not solved, particularly in rural communities.
When one looks at good national public health leadership models in other countries, environmental health (both science and workforce) is integrated within their national public health agency model. The US and UK both have a broader remit and include issues such as response to climate change risks, chemicals, and radiation safety.
Air pollution and PFAS
In recent years, Australia’s public health system was caught out by two significant environmental health issues and the lack of investment in environmental health science, namely, the health effects of air pollution and PFAS (Perfluoroalkyl and Polyfluoroalkyl Substances). The widespread bushfires across eastern Australia in 2019-20 saw differing health advice across jurisdictions being provided to the public. This included advice on whether face masks were useful, and whether outdoor activity needed to cease and at what pollution levels.
The emergence of the PFAS, mainly from use of certain firefighting foams, has been a costly challenge for industry, health, environment, agriculture, defence, and other agencies. It caused significant mental health and financial impacts on local communities who were faced with contamination of their land and water sources.
While these issues are perhaps not as major as the COVID-19 pandemic, they were certainly more significant and more costly issues than a typical run-of-the-mill disease control incident.
Workforce and innovation
The toxicology workforce is small and aging. The issues of air pollution and PFAS have exposed the desperate need for centralised scientific capacity and leadership in toxicology and environmental health.
Environmental health epidemiology is also in need of national leadership. It is a poorly understood and underutilised aspect of environmental health, requiring different approaches to traditional disease control epidemiology. Recent developments in toxicology call for greater incorporation of epidemiology evidence.
Disease control is not just the province of epidemiologists, doctors, and nurses. On the ground, disease control work is often undertaken by environmental health officers at the local and state government levels. In an outbreak (and more broadly), they are best placed to effectively manage hygiene and sanitation, or broader issues such as waste management, food safety, or water quality.
And conversely, issues like food safety and water quality are not solely disease control matters. These issues span chemical and physical risks as well as biological risks. In my experience, communicable disease control specialists tend to take a narrower approach to managing these risks as their expertise lies in the disease control itself, not the systems that generate risk.
Innovation in the environmental health sector directly benefits disease control. The most recent example was the wastewater surveillance that grew out of chemicals and drugs testing of wastewater. And there is interesting research emerging regarding the relationship between chemicals and antibiotic resistance.
Legislation and leadership
CDC work also directly interacts with public health legislation and the environmental health workforce is trained and experienced in handling the implementation of legislation relating to disease outbreaks. Most jurisdictions relied on the environmental health workforce to handle the legislative part of their COVID-19 response.
Sometimes, legislation is viewed as both a punitive and limited (dare I say, unnecessary?) part of the disease control system. Yet, if well designed and implemented, it can be protective and enhancing. In my experience, the disease control field did not value the role of public health legislation until, as we saw in the COVID-19 response, it really needed it. And, generally, the skill set in diseases control does not lend itself particularly well to legislative development and implementation.
Nationally, the leadership of health agencies in promoting consistent legislative approaches to public health across Australia has been lacking. This contrasts with legislative systems in other agencies which have sought to align regulatory systems for the benefit of both those being regulated, and the community.
Finally, if the disease control component sits within a national centre which is deemed to be the primary public health leadership organisation, and health promotion sits elsewhere, then not only is the environmental health capacity isolated and further marginalised, but opportunities for synergy are lost. We need to follow the examples of national centres for disease control in other countries and integrate environmental health as a core role of the Australian CDC.