Webinar: Intro to Public Health & Environmental Health
Thanks to everyone who attended our webinar this week with the Maine Public Health Association, "Promoting Health and Preventing Disease: How Public and Environmental Health Work Together."
Dr. Lani Graham, MD, MPH
Sarah Rines (Maine Public Health Association)
Patrick MacRoy, MS (Environmental Health Strategy Center)
In this introduction to environmental health and public health, our panelists discussed how public health and environmental health promote our overall health and well-being and prevent disease. They also discussed the importance of prevention and what that looks like, and how a strong public health system can save lives by preventing pandemics like COVID-19 as well as illnesses linked to toxic chemical exposure.
At the end of the webinar, our panelists had many more questions than we had time to answer on the webinar—we were grateful for so many thought-provoking questions!
Here are our panelists' answers to those outstanding questions:
What can be done to strengthen public health for the future?
Lani: At present the US spends about 3.5 trillion dollars a year for health care even though large portions of the population remain uninsured or underinsured. Public health’s portion of health expenditures has fallen steadily over the last decade and is likely now about 2.5% of the total. While health care is certainly important, in terms of making a difference in the overall health of the US population, it is not very cost effective compared to public health. We must assure solid funding (5% of the total would be a start) for public health on an on-going basis. There will have to be a national commitment to public health.
Patrick: We need to make investments in our public health infrastructure on all levels. The recognition that we need to invest in contact tracing for COVID-19 could be a starting point to beefing up our public health workforce, but ultimately we need to invest in the public health functions at the many other agencies that support protecting our health. Many have suggested policy frameworks that integrate health considerations into all major policy decisions. Moving towards a version of this would also help us avoid implanting policies that we will later regret or carry heavy health costs.
What environmental health policies would you say we need here in Maine? You mentioned the well water issue. Should we be requiring testing? What about radon, etc.?
Lani: Possibly I should leave this to the Strategy Center to answer, but I do have thoughts. In the case of all public health policies, environmental or other, we have to be very careful that the financial burdens do not fall on those least likely to be able to manage them. Therefore “policies” (the policy development function) have to be seen in tandem with the Assurance function. As you know about 50% of Maine people depend on private well water. I am a private well water user, and much better equipped to deal with a requirement for my well water to be tested. However, I have discovered that testing can be expensive and mitigation even worse. In the case of PFAS chemical contamination (polyflouroalklysubstance), it takes hundreds of dollars to test for it and if found, mitigation can run into the thousands. And that is just one example. We have not been good stewards of our environment and now correcting things is complex. But this is another example of why it is important to adequately fund public health.
Patrick: Specifically, for drinking water and residential wells, I would suggest we need to implement policy that makes safe drinking water a basic right and ensures everyone has access to safe water. The specific actions could vary – for people with means, creating a system that makes sure water is tested may be enough – but to reach everyone we need to make sure there are subsidies available to test and treat wells for low-income rural families or to expand public water systems. Those of us in more urban areas already enjoy ready access to (mostly safe, with room for improvement in some cases) drinking water since we all pay into a public system. The societal costs – in terms of health care costs and especially impact to children – are felt by all of us when rural water users don’t also have access to a guarantee of safe drinking water.
I’m interested in making a career change into public health and particularly around health education and prevention. I have a Master’s degree in Intercultural Relations and a background in education. What are the steps you suggest in moving toward those types of positions?
Lani: I think this person would be a great addition to the public health workforce, but I do think that more familiarity with public health itself would be helpful. University of New England and University of Southern Maine both have public health programs. They could be queried. It would almost certainly be possible to earn a Master of Public Health degree while working in a public health field. I am hopeful that the Maine CDC may be expanding its workforce. It could be worthwhile to look at options there because some such positions would not require a public health degree.
Becca: I’m not sure which state you’re in, but I do suggest looking at your State Public Health Association – they serve a networking and professional development function. In Maine, for example, we are launching a Mentor program later this year, which will pair students/early career public health folks with seasoned professionals. Associations also host annual conferences, which can also help with networking. Also in Maine, Maine Access Immigrant Network is an excellent organization to look into – you may also want to check out training to become a Community Health Outreach Worker – that would allow you to use your training in intercultural relations and education, and interest in health education & prevention.
I understand primary prevention is ideal, but is it always possible? What would primary prevention look like for this pandemic, for example?
Lani: Actually, ironically, primary prevention is exactly what is being attempted for COVID-19. I am high risk myself and have been given extensive guidance for how to behave so that I will not become infected. And now there is intense effort to find a vaccine, which will be another form of primary prevention.
But this question is likely being more directed to stopping the pandemic before it became a pandemic. That has been done in the past with SARS for example. While some people did become infected, SARS did not become a pandemic because prevention action was taken earlier, also because it did not have the features this virus has of being more infectious. The best primary prevention for all infectious diseases is early identification (a very robust data collection system) so that novel viruses are seen earlier and rapid action is taken. Also I do think that this pandemic is going to bring down the hammer on a lot of our practices which are not hygienic. There will be more hand washing, more disinfection of surfaces, less touching of the face etc.. This will serve to decrease a whole list of illnesses from the common cold to Tuberculosis.
Patrick: It may not always be possible and is certainly not always practical. We still need the other tools in our toolbox to respond and fall back on secondary and tertiary prevention, but primary prevention is usually the first and best choice when feasible.
While I’m not sure if all the science is in on the origins of this pandemic, some have suggested it likely had made the jump from a wild animal to humans. The specifics of this virus aside, there is strong evidence that the more we encroach on wilderness around the world and as climate change displaces people and animals driving more interaction between people and wild animals, the more risk there is for infections to make that jump. On a broad level, there is primary prevention to be had in addressing how we treat wilderness and encourage more sustainable development around the world.
I’m interested in how feminism could play a role in public health as well. This can be applied to things such as women’s health and general reproductive health.
Lani: Interestingly, there has been some indication that countries led by women have done better in this pandemic than those led by men, but that is just anecdotal. And If by “feminism” you mean a willingness to take a leadership role, I think there is a very significant place for women. Because their on-going role in chid rearing and home maintenance, as well as their appreciation for science, women have a keen sense of the value of prevention. If you want to read about women taking charge and getting something done, try reading The Woman’s Hour by Elaine Weiss. This tells the story of the seven-decade fight for the right to vote. Sadly that was only 100 years ago and women have still not won equal pay for equal work. But the women who led the fight for the vote shows how it can be done.
Patrick: I don’t think there is an example of anything that hasn’t been improved by recognizing women as equal humans and assuring the protection of their rights.
COVID19: the reaction to it seems to be focused primarily on physical health and well-being. What sort of considerations are being given to the emotional health impact of the pandemic, feelings isolation, depression, etc. Thank you.
Lani: This is an excellent question/comment. I currently serve on a cadre of about 100 professionals who are volunteering their time to serve Maine front line workers with PFA (psychological first aid). The line is called "Maine Responds”. However, the call line is not well patronized at this time. In addition, it does not serve the sick or isolated, who are not front line. I think this is a huge problem and is only going to get bigger. A lot of thought is going to be needed, because mental health was not adequately addressed BEFORE the pandemic. We will probably need to design a whole new approach. I have some ideas.
Just a comment: One impact COVID seems to be making is that the public seems to be embracing the role of science and evidence in decision making. I'd like to see Maine establish more policies that explicitly include language related to evidence and continue to use our Maine assets like MCDC, MPHA, and our universities as resource expertise. What advocacy should we explore to ask for this?
Lani: This is another good comment and a huge problem. The internet is a big source of mis-information and outright lies. I think Maine Governor Janet Mills has done a good job of taking her own “marching orders” from science. But we likely need her and other leaders to make that point often and loudly. Science is one of the greatest advances in human history. We should not be electing people who have contempt for science.
Patrick: This is a great and interesting question, and many folks smarter than I have spent a lot of effort thinking about both the actual and ideal role of science in public policy. I’m not sure there is a single best solution and its critical to acknowledge that policy will always reflect beliefs and values – science can, perhaps, inform us how many people will die from COVID-19 if we take certain actions or not, but a value decision will ultimately determine the number of deaths we will accept and in exchange for what, for example. Bringing science to the table is critical and making sure decision makers understand the facts is necessary but perhaps not sufficient (to use some Epi speak) to guarantee an outcome that most folks agree with.
There are procedures and rules that could be put in place to help ensure consideration of science in public policy, but even those are open to manipulation. That’s certainly what we have seen with the current Federal administration and in particular its actions at the US EPA where time and time again they are trying to use the rules established to require sound scientific decision making to actually ensure only the science that supports industry-requested outcomes are considered. On the positive side, they are so distorting the rules in place there is an opportunity to sue and often win. But none-the-less, they are still making significant progress in both dismantling important protections and establishing misguided processes for the future that will distort agency actions after this administration is gone. The damage done will take a lot of time to undo.
So, I think I would go back to the cornerstones of advocacy on any topic: Get involved and elect good people. We need scientists and the scientifically minded being active participants in decision making. Showing up is often half the battle, especially in state and local decision-making processes. Write comments on rules and regulations. Testify on legislation. Write letters to the editor. Talk to your elected officials. And, of course, support organizations like MPHA and the Strategy Center that are involved in doing all that too.
I advocate that people, teens especially, spend time outdoors for their physical and mental health. A healthy environment is a large part of this, but also access to the outdoors through school programs as well as town planning to ensure that open space is protected and assessable to all. How can we get better access to the outdoors and acknowledge that learning happens outside and inside the classroom?
Patrick: This is another area where there are huge disparities in the United States. Too often, access to natural areas, especially in the context of formal educational programs, is expensive and inaccessible to lower-income and especially lower-income urban communities. Accounting for the value of park access in land-use planning is certainly a key, but more advocacy will be needed to push for other programs – such as school based outdoor education or even providing public transit connections to parks.
Lani: If this something you advocate for, you likely know that there is plenty of research supporting your position that being outside is healthy. Right now, is likely an excellent time to make the point that learning occurs outside the classroom as well inside. This pandemic is going to change how students are taught. [If you are in Maine,] I wonder if you might contact Hannah Pingree who is Governor Mills’ Futurist with your ideas of where and how good learning might take place.
Thanks for all the great questions and participation!