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Family & Environment

The Environment And Health: A Conversation With CDC Chief Jeffrey Koplan

Jeffrey Koplan: In the modern world of public health, with agencies having mixed responsibilities, the need for collaboration and partnership is not unique to the environmental or occupational areas. Certainly, even something as traditional and long-standing as infectious diseases involves overlap with the National Institute of Allergy and Infectious Diseases and FDA, and for international issues, with the State Department. As we can see with the anthrax bioterrorism event, it was vital that health agencies collaborate with the Department of Justice, the Postal Service, and others involved.

Certainly for the environment, it’s just as you say. There are a variety of agencies with roles to play, some of which emphasize very different things than we do. The way I look at it, EPA takes largely a regulatory function in the panoply of organizations, with an enforcement role as well, as do FDA and HUD (Housing and Urban Development). They establish regulations and seek enforcement of them. But the National Institute of Environmental Health Science (NIEHS) is much more at the basic research end of the spectrum. The various parts of CDC that play a role in the environment fit in the middle, with an emphasis on, obviously, epidemiologic study, ascertaining environmental hazards in human populations, doing exposure studies, and then focusing on certain specific diseases, such as lead poisoning, asthma, and others.

Goldstein: There’s a wonderful example of collaboration between CDC, EPA, and NIEHS on child environmental health centers. Are you planning any others of that nature?

Koplan: That is a good collaboration. In fact, we’ve got a meeting coming up that links our pediatric network from ATSDR (Agency for Toxic Substances and Disease Registry) with the clinicians who work in pediatric environmental health specialty units and do a lot of training and education with NIEHS researchers. Each needs to be informative to the other. Another example is the Action Against Asthma plan, which came out about a year and a half ago and does a good job of delineating a role for EPA, a role for NIEHS, and a role for CDC’s unit. Similarly, a president’s task force document on eliminating childhood lead poisoning pointed out the roles that each of the players can take—from HUD to CDC to a variety of others—doing what they do well but collaborating or working together to achieve some important goals.

Changing Focuses In Environmental Health

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Goldstein: It’s fascinating for someone like me who’s been in the field for so long to see these changes. You’ve been talking about asthma, child health, lead poisoning. (Well, lead’s an older issue.) Twenty years ago, inevitably, the first thing we would have talked about was cancer. By now we’ve moved away from considering just the effects of environment on cancer toward considering its effects on a much broader range of acute and chronic diseases. Do you see any further movement in that direction?

Koplan: "Environment" is such an all-encompassing term, it’s not hard to see it growing even broader. We must work hard not to lose focus on key specific challenges and interventions regarding more traditional environmental issues, such as toxins, chemicals, heavy metals, or other substances in soil, water, or air. Having said that, though, I do enjoy looking at "environment" from a broader perspective, in terms of what it brings to a wide number of fields. Take, for example, the anthrax bioterrorism outbreak following 11 September 2001. The key players in our response to bioterrorism have been environmental health scientists. We’ve had folks from ATSDR, the National Center for Environmental Health, and NIOSH (the National Institute for Occupational Safety and Health) involved on every piece of this response. To say they’re invaluable is an understatement. They have been an integral part of this effort, working side by side with the infectious disease experts.

I’ve seen this repeatedly over the past few years. Issues that in the past you wouldn’t have thought of as having an environmental element suddenly take on one. An example would be the issue related to thimerosal and mercury-containing compounds in vaccines. Suddenly, we had close collaboration and scientific meshing of our staff with, again, the environmental side, ATSDR, and immunization experts. We have created lots of new bedfellows in public health, and I think that’s terrific. One of the best things you can see in public health is the breaking down of compartments, or silos, whether it’s within an academic institution, HHS, an agency, or a CDC center. A level of excitement occurs when folks working in what they thought were very different areas suddenly realize how much they offer each other.

To further expand on environmental considerations, I’m very much interested in how we design our communities. I have reflected on it in the past several months—about how we looked at communities in very different ways, even over the past hundred years. At one point, we would have cited big cities as the least healthy places and suburbia as the most healthy. At least that was the way our population migrated. Now in some ways it’s just the reverse. If we look at efforts to promote physical activity and some sense of community cohesion and social networking, which our society seems to want to emphasize, cities are much easier places to achieve these things than are some of the suburban developments that we’ve created. This direction for environmental study is fairly important, I think—it meshes what have traditionally just been environmental issues with issues such as urban design, behavioral health, nutrition, and a host of other subjects.

Leaving The Silos Behind

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Goldstein: You mentioned silos. One very difficult silo to penetrate has been the planning area. Certainly, in academia, there are almost no schools of public health, for instance, that have any cross-fertilization with the urban planning programs. We have very little of that at any level in our society. Do you see any way of breaking down those silos?

Koplan: We’re collaborating with bioengineering at Georgia Tech, looking for ways to do more together. Because Georgia Tech has a very active urban planning department, we’re beginning to explore possible interactions there also. We’re looking at some other models that would allow us to diffuse out and work with others. The schools of public health—where there is a school of architecture or urban studies nearby—could initiate some of those linkages. This is a very fertile growth area.

Goldstein: I certainly congratulate you on thinking that way and hope that you will help those of us that are involved in the field to have the incentives—the carrots—to get our faculties to work together, because as many silos as there are in government, I’m afraid we in academia are right along with you there. Many states, too, have environmental protection agencies separate from their departments of health. Is there any hope of breaking down that kind of barrier so that CDC can more effectively work with non–health departments in the states?

Koplan: That’s a very good point—clearly, many states, as you’re better aware than I am, separate their environmental health activities from their health departments. I don’t think that we at CDC are in the position to suggest structural changes, nor are we so presumptuous or arrogant as to do so. But it behooves us to seek partnerships and collaborations—not ignoring the state health departments, but seeking ways to bring in states’ environmental health branches, their EPA equivalents. Some of those linkages are taking place, but there’s a long way to go. One major problem is that state health departments are not well funded for environmental activity, so it’s hard to get the balance that is needed. Our environmental leaders are working with a group here called the Environmental Council of the States. It’s a group that’s equivalent to the state and territorial health officers.

Assessing The Risk Of Exposures

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Goldstein: You already mentioned the strength that NIOSH and ATSDR and CEH (Center for Environmental Health) have provided you in dealing with the anthrax issue. I suggest that a large part of their strength is in the area of exposure assessment, of understanding exposure pathways and dispersion of agents. At the state level, that expertise is often in the environmental protection agencies rather than in the health departments. And, that’s where I think it breaks down for health. Because, clearly, if you understand the exposure pathways, you can interdict them, and that’s where prevention is.

Koplan: Yes. You could say that we at CDC have a mix of the expertise you’d find in the states’ environmental and health agencies or departments. On the one hand, as you’d say, you need information on exposure pathways; certainly, our folks in ATSDR and NIOSH are very good at analyzing that. But we also have considerable interest and expertise in surveillance of environmental and occupational health issues, which may be found in other parts of state governments—in health departments or even in occupational entities.

Goldstein: All of us in environmental health are really beholden to the superb work that the Center for Environmental Health has done in conjunction with the NHANES survey (National Health and Nutrition Examination Survey) in developing superb analytical approaches to understand what the exposure levels are using biological markers to study lots of agents—everything from their classic work on lead to more recent work on benzene and tolulene and other compounds. An obvious question is, with the leadership that they have, whether or not they’re prepared to be able to move into the molecular biological era. I mean, our hope with molecular biology is to be able to do a better job of attribution—to be able to pick out which people with a certain disease have that disease because of loincloths as opposed to another cloth, to fingerprint the causes, if you will. Again, surveillance approaches like that of NHANES would be superb for that task, but it’s a different kind of skill set—molecular biology, not classic analytical chemistry. Do you think that your folks at CDC are prepared to take advantage of what molecular biology provides?

Koplan: I think that we completely agree that that is a direction to move in, the fruits of which we hope will yield a lot of both information and more successful intervention on environmental problems in the near term. We see this area as a growth area for our laboratories and clinics as well. We have already begun working with state health departments to give them planning grants, to try to incorporate biomonitoring into their overall environmental public health programs. At the same time, we here are trying to mix different kinds of scientific capabilities, as you say, from chemistry to molecular biology.

A real resource in this is the data that we collected from NHANES. One of the things we would like to do in the future is to use some of those data in a prospective cohort manner, particularly focusing on infants, and then following the subjects over time. The purpose of this kind of combination study of genetic markers, other biological markers, and environmental exposures would be to come up with some answers that we now don’t have.

Goldstein: Is that part of the proposed longitudinal study of the health of children?

Koplan: Yes.

Workplace Health And Environment

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Goldstein: That’s an exciting project, if it goes forward. Now, to switch subjects a bit, let’s be a little futuristic. One issue for workers’ health is that we keep getting new technologies in the workplace, and very often (as humans do) we focus on the last problem rather than on the future problem. NIOSH is, of course, a lean and mean organization, which, I think, is very successful, but it may not have the resources to look forward. Are you at all concerned about new technologies, giving us, in a sense, new causes for disease, and what can we do about making sure that NIOSH is prepared to deal with these beforehand, rather than after the fact?

Koplan: That’s a very good point. It is a challenge, in part, because the direction of industry and occupations in the U.S. requires some futuristic thinking in figuring out how to get ahead of that. By the same token, some of the things that have been growth areas for us in the occupational health world have been ones that aren’t high-tech derived. For example, we’ve had a real challenge with the issue of ergonomics and how people physically operate in the work-place, which is not so much about changes in technology as it is about how people spend their time and what postures and positions they’re in at work. Similarly, issues of stress in the workplace, which we are also working on, are not ones that might be mediated by technological elements. Nevertheless, exposure to chemicals, dangerous pieces of equipment, and repetitive tasks are all items we have to think about and pay attention to the direction industry is going.

Over the past couple of decades I have observed that much of the U.S. is moving toward a service economy and providing a range of different services in the world—including health care, information technology, and others. We tried to anticipate some of those. But we’ve got to be, as you say, very nimble to try to catch up with where things are going.

Goldstein: Right now NIOSH is evaluating a bronchiolitis problem among people whose job is to make popcorn.

Koplan: Yes, it was one of those outbreaks or health hazards that, from the beginning, captured one’s interest, in part just because of the nature of the work. It was an industry in which they produced, I think, these bags of instant popcorn that you throw in your microwave and they expand to ten times their original size and provide you with your caloric intake for the next ten days. These folks were having severe respiratory problems, and it was initially an odd mix. I believe that they found that the linkage was with the additives that were being placed with the kernels, which somehow were aerosolizing and leading to this bronchiolitis. As we have learned over the years, many times these isolated, seemingly small-scale problems or hazards can offer insights into much larger risks in a variety of workplaces.

Goldstein: And sometimes among the general population.

Koplan: Exactly.

Population Studies And The Human Genome Project

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Goldstein: We’re becoming much better at identifying susceptible population groups through a variety of mechanisms. Part of this, of course, is the human genome study. How is that going to affect the approach to prevention at CDC?

Koplan: If you were to ask me to be futuristic and look ahead, I could imagine that at some point we will have a better grip on genetic markers or risks for a variety of conditions This might not be limited to just diseases. We could find that it’s the interaction of a genetic predisposition with an environmental expo sure that leads your relative risk to go up. All of us have done studies in which we’ve looked at a given exposure and found nothing that we could seize out of it to suggest an increased risk in a given population. I hope that we’ll get new tools that permit us to say, yes, in the population as a whole, there’s no increased risk, but the risk for this subgroup, which has the following genetic characteristics, is such and such, either greater or lesser. That gives us a much finer tool with which to do these studies, and it may be applicable to environ mental and occupational issues, infectious diseases, and certainly chronic diseases, too So, I’m hopeful that the genome project will give us a real epidemiological breakthrough.

Goldstein: I think that we’re going to be able to cut down on the noise in terms of under standing risk by just selecting populations who are truly at risk. But that gets into the issue of risk assessment. Certainly, EPA has been taking the lead on a whole series of issues in the assessment of risk, trying to understand cumulative risk from multiple exposures, and risks that are attributable to simultaneous exposure to lots of different agents, which gets into the environmental justice area. CDC also has been very active in using risk assessment in its work with state agencies. But there doesn’t seem to be much emphasis on developing new risk assessment methodology. The risk assessment methodology coming out of EPA often has a regulatory, not a public health, viewpoint guiding it. Do you see any need for further methodological work in risk assessment that might come from CDC rather than EPA?

Koplan: Yes, I think that this is and should be a growth area for us. You’re quite right in pointing out that this has not been a strength of ours in the past. Our folks at ATSDR have taken this on as an increasing focus, and they’re trying to generate some more work in just the manner in which you say, to do a piece of it with an orientation and a slant that comes from an epidemiologic perspective, as opposed to a regulatory perspective. And, for better or worse, we epidemiologists, who love to think in terms of numerators and denominators, will bring a slightly different view to that and probably will be comfortable with a different range of probability.

Behavioral Health

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Goldstein: Another key area is the role of behavior in environmental health. CDC, of course, has done a superb job, at least in my estimation, of looking at behavioral factors in many types of public health issues. Behavioral issues are definitely related to environmental exposures. I was wondering to what extent the CDC’s expertise in behavioral factors and intervention strategies might also be applied to environmental health issues.

Koplan: This is a fascinating linkage. When I started here in 1972 there was one behavioral scientist at CDC, and he worked in the area of sexually transmitted diseases. Today, obviously, there are many hundreds at CDC, and this probably is true of schools of public health and state health departments and a range of places that we both work. The field has changed because of the contributions of social and behavioral scientists. But the interplay with the environment and occupation is huge. We’ve already mentioned several examples of this. For example, we’re trying to promote people to be more physically active. The environment is crucial in getting people to be physically active—whether it’s something simple like sidewalks or safe street crossings or, of course, safe playgrounds and green spaces for people to use.

Preparing For Chemical Threats

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Goldstein: I have one final question. One environmental issue that’s obviously at the forefront of our attention right now is the possibility that a future terrorist threat will come from the use of sarin or some other chemical rather than from an infectious agent. Are you comfortable with the extent to which you’re prepared, right now, for CDC to respond to a chemical attack?

Koplan: We’re very much concerned about that and have been for some time. In the past three and a half years or so, as we’ve been building up our bioterrorism capabilities. I consider the chemical side and, indeed, the nuclear side to be major threats for all of us in the public health world. But we have paid a lot of attention to the chemical side already. Some of our biologic toxic monitoring has focused on our ability to measure extremely minute amounts of these chemical agents in the human body, to make urgent detection a part of what we do. In addition, we have sought to place in our pharmaceutical stockpiles appropriate antidotes to some of the chemicals that might be used. As you’re aware, though, a wide range and number of lethal agents could be purposely introduced into an innocent population.

Goldstein: I was surprised that the attack came by way of a biological agent, because I was convinced that the terrorists would be too frightened of the anthrax and would use a chemical instead. It just shows how wrong I could be on these things.

Koplan: I think we all are on a steep learning curve when it comes to this, although I wish it would slow down.

Editor's Notes

 
At the time of this interview, Jeff Koplan was director of the Centers for Disease Control and Prevention in Atlanta. Bernie Goldstein is dean of the Graduate School of Public Health, University of Pittsburgh.

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