# Developing a Respiratory Health and Indoor Environments Program for the City of Alexandria, Virginia

**2006 -- 2007**

**Environmental Public Health Leadership Institute Fellow(s):**

**Ms. Patricia Ferrao; B.Sc., M.Sc., M.S.**

***Environmental Health Supervisor;*** Alexandria Health Department

***4480 King Street, Alexandria, Virginia***

***Phone: 703-838-4400 Ext. 327, <patricia.ferrao@vdh.virgnia.gov>***

**Ms. Holly Feltner; B.S.**

***Environmental Health Biologist;*** Alexandria Health Department

***4480 King Street, Alexandria, Virginia***

***Phone: 703-838-4400 Ext. 326, <holly.feltner@vdh.virginia.gov>***

**Mr. Richard Michelback; R.E.H.S, C.F.S.P**

**Alexandria Health Department**

***4480 King Street, Alexandria, Virginia***

***Phone: 703-838-4400 Ext. 312,
[richard.michelback@vdh.virginia.gov](mailto:holly.feltner@vdh.virginia.gov)***

# 

**Mentor:**

**Capt. Craig A. Sheperd; M.P.H, R.S., D.A.A.S**

*Senior Environmental Health Officer;* Centers for Disease Control and
Prevention

**Acknowledgements:**

**Mr. David P. Stroh; M.A.**

*Principal,* Bridgeway Partners

**City of Alexandria Agencies**

Information Technology Services/EPO

Transportation and Environmental Services - Department of Environmental
Quality

Bureau of Code Enforcement

City of Alexandria Public Schools

**Mr. Kenneth S. Schoultz**

*Industrial Hygienist**; ***Virginia Department of Health

**Ms. Angela Crawford; B.S., M.S.**

*Epidemiologist;* Alexandria Health Department

**Ms. Gail Hollenbeck**

*Finance Manager*, Inova Alexandria Hospital

**Ms. Christina Sloan; B.S., M.P.H (candidate)**

George Mason University

**Mr. Robert Custard; R.E.H.S**

*Environmental Health Program Manager;* Alexandria Health Department

![](media/image1.jpeg){width="1.3756944444444446in"
height="0.6368055555555555in"}

# EXECUTIVE SUMMARY:

Healthy People 2010, developed by the US Department of Health and Human
Services, is a comprehensive nationwide health promotion and disease
prevention framework. Challenged by the content put forward in this
publication, the Alexandria Health Department, Environmental Health
Division facilitated the development of the first Alexandria Community
Environmental Health Assessment. The assessment outlines environmental
indicators that impact health in several broad categories, including
respiratory health and infectious diseases. The team involved in the
assessment ranked Indoor Air Quality (IAQ) as the most important
environmental component that impacts respiratory health of residents
within the City of Alexandria. Currently, several City Agencies, have
key roles in ensuring good IAQ in homes, schools and businesses.
However, the existing effort, by all involved stakeholders, to help
promote good indoor environmental quality and associated respiratory
health benefits is a disjointed venture. This article describes the
process of developing a *Respiratory Health and Indoor Environmental
Quality Program*, within the Alexandria Health Department, using the
methodology of Systems Thinking. The approach utilizes a set of
\"thinking tools\" that deals with interrelations between phenomena (in
a system) rather than singular aspects of reality. The analysis helped
highlight critical flaws that exist within the current system, and
showcased important leverage points that could be utilized to develop
effective program outcomes in the new system. Logic models were then
used to help in the process of program planning and to incorporate
established outcomes. The resulting program, that utilizes the ten
essential environmental health services as a guide, will aim to engage
all key stakeholders and ensure the development of resources that serves
to assess and implement interventions to promote good indoor
environments and associated health benefits, within the City of
Alexandria.

# INTRODUCTION/BACKGROUND:

Man's origin is documented in the tropical and near-tropical regions of
the world. Human's arrived in Southern Europe and China a million years
ago. In America, Northern Europe and Japan man's arrival can be
attributed to only 10,000-40,000 years (a period too short for major
genetic change within the body in relation to the outside environment).
The spread of man into regions with colder climates was possible only
because of interventions such as clothing, housing and the use of fire.
Therefore, as humans we are still accustomed to life outdoors. As we
spend most of our life indoors (in many regions more than 90%), it is
easy to understand that the most important environment in relation to
our health is the indoor environment (Sundell, 1999).

More than half of the body's intake during a lifetime is air inhaled in
the home. Thus, most illness related to environmental exposures stem
from indoor air exposure. Indoor air quality (IAQ) is a main cause for
allergies, other hypersensitivity reactions, air way infections and
cancers. Improper building operations and deferred maintenance
contribute to poor indoor environmental conditions, affecting the level
of mold, mildew, dust, animal dander, radon, secondhand smoke, asbestos
and formaldehyde in schools (U.S. General Accounting Office 1995). These
pollutants can affect the quality of indoor air and trigger various
health symptoms, from headaches to allergies and asthma attacks (Samet
and Spengler, 1991). The toll of these health conditions on education in
America is large. Asthma alone accounts for 14 million missed school
days each year (Centers for Disease Control and Prevention 2002). The
effective management of IAQ in schools can reduce a student's exposure
to the air pollutants that trigger allergies and asthma attacks,
potentially improving the students' ability to learn.

There is strong research relating certain IAQ management practices with
IAQ in buildings. A cursory glance at news reports in recent years on
buildings with poor IAQ suggests that the incidence of buildings with
air quality problems, and therefore, costs of insurance and litigation
to redress these problems, are significant and on the rise (Chen and
Vine, 1998). Recent media attention given to toxic mold and related
health effects and resulting litigation has led to new interest in, and
attention to, indoor air quality in homes, commercial buildings, schools
and hospitals. People are rediscovering research related to the health
of their indoor environments.

**[Variables that Impacting Respiratory Health Illness as it relates to
poor IAQ]{.underline}**

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####### ***Problem Statement:*** 

The Alexandria Community Environmental Health Assessment Team (ACEHAT)
recently ranked Indoor Air Quality as the most important environmental
health issue in the City. The mission of the Alexandria Health
Department - Environmental Health Division is to promote health and
quality of life, within the City, by preventing or controlling those
diseases or deaths that can result from interactions between people and
their environment. Given the above stated concern and the absence of a
program, that specifically addresses the issue of respiratory health and
the indoor environment, the Division feels the need to take on this
emerging problem. The onus of taking on this responsibility arises due
to the Division's innate sense of mission. In order to appease this
sense of mission and have the satisfaction of ownership in resolving the
emerging concern, the Division addresses any incoming call or query
relating to Indoor Air and Respiratory Health. It is important to note
that the Division has no formal accountability for this issue. The
ensuing efforts are,

-   Scattered with no outreach to sensitive groups (ex. those that do
    not have the resources to connect indoor air quality to respiratory
    health, sensitive groups that do show respiratory health illnesses,
    business and schools).

-   Address only those groups that may call in to inquire about indoor
    air quality and respiratory health.

-   Superficially help in addressing respiratory health illnesses
    associated with the indoor air environment.

-   No sharing of information with other Groups in the City that address
    similar issues.

**Mental Models explored in creating the behavior and archetypes:**

**Belief** Respiratory health related illness can occur due to indoor
air contaminants.

**Assumption** We assume that individuals will call the Health
Department on issues related to respiratory health illness and indoor
air. Addressing all incoming calls will help decrease the incidence of
respiratory health related illness associated with indoor air.

**Rationale** The current level of effort is enough to bring about
awareness between respiratory health and the quality of indoor air.

What thinking lets the system persists as it is?

-   No regulations and limited scientific information on the levels of
    indoor air contaminants and related respiratory health illnesses.
    This in turn makes enforcement non-existent.

-   Lack of resources and time to address the above issues in a thorough
    manner.

-   The notion that by addressing all incoming complaint-driven
    responses will help bring about awareness between the benefits of
    good indoor air and respiratory health.

#######  The pattern of performance that seems to sum up the behavior of the Division is depicted in the following archetypes (Senge et al., 1994):

-   Shifting of Burden (Fig. 1): The reliance on the short-term fix
    ("quickfix") is strong and effort to fundamentally correct the real
    problem ("corrective action") is not actively sought. The "problem
    symptom", therefore, alternately improves and deteriorates with no
    shift in status.

-   Accidental Adversaries (Fig. 2): Lack of information exchange
    between City agencies lead to an intentional undermining of what
    could be a collaborative partnership to help achieve and strengthen
    each agencies success as it relates to indoor environments and
    respiratory health.

![](media/image2.wmf){width="9.000694444444445in"
height="5.750694444444444in"}

Figure 1 -- Archetype "Shifting the Burden"

####### ![](media/image3.wmf){width="8.247222222222222in" height="5.997916666666667in"}

Figure 2 -- Archetype "Accidental Adversaries"

####### ***10 Essential Environmental Health Services:***

The Respiratory Health and Indoor Environments Program aims to fulfill
the following Ten Essential Environmental Health Service objectives
(Osaki, 2004). This in turn will help clarify the Division's role in
enhancing respiratory health related to indoor environments as well as
work towards planning activities that maximize public health benefits.

![](media/image4.wmf){width="6.626388888888889in"
height="5.209027777777778in"}

Figure 3 -- The Ten Essential Environmental Service Objectives of the
*Respiratory Health and Indoor Environments Program*

***National Goals Supported***

The *Respiratory Health and Indoor Environments Program* aims to
integrate two goals outlined in the **Healthy People 2010** objectives:

1.  To promote respiratory health through prevention, detection,
    treatment and education efforts and,

2.  To promote health for all through a healthy environment.

> The objectives in the developed program will specifically focus on -

-   Increasing the proportion of persons with respiratory illness who
    receive formal patient education, including information about
    community and self-help resources in improving the quality of their
    indoor environments, as an essential part of the management of their
    condition.

-   Creating healthy homes, schools and work environments by
    disseminating and promoting information that relates to benefits of
    good indoor environments and respiratory health.

The program will also aim to fortify the Division's ability to perceive
and implement measures to combat new and re-emerging environmental
health issues. The creation of the *Respiratory Health and Indoor
Environments* program will require the Division to work on successfully
implementing some of the goals and objectives described in the
**National Strategy to Revitalize Environmental Public Health
Services**. This would include the ability to --

-   Build capacity by working with various City stakeholders (other City
    Departments -Transportation and Environmental Services (T&ES), City
    Public School Administration and Businesses) to anticipate,
    recognize and respond to issues involving Respiratory Health and
    Indoor Air.

-   Communicate and market strategies that promotes and makes available
    information on benefits of good respiratory health as it relates to
    indoor environments. This will help garner individual participation
    and support to establish good public health practices in homes,
    schools and work environments.

-   Foster leadership, within the Division, to enhance the Alexandria
    Health Department's ability to specifically build capabilities that
    address issues relating to Respiratory Health and Indoor
    Environments. The developed program can serve to act as a role model
    that other Local and State Health Departments can adopt.

# 

# 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

***Program Goal*:** To establish a *Respiratory Health and Indoor
Environments* Program within the Alexandria Health Department,
Environmental Health Division (EHD).

The **mission** of this program is to promote practices, by forming a
collaborative partnership with key stakeholders, to prevent or reduce
the contamination of indoor air thereby contributing to a safe, healthy
and productive environment for building occupants in homes, schools and
other areas, within the City of Alexandria.

***Health Problem*:** Typical pollutants, that have been documented to
cause a wide array of health problems, include:

1.  Environmental Tobacco Smoke

2.  Biologicals: Mold and mildew, bacteria, viruses, animal dander,
    pollen, dust mites. These are more likely to be a problem in
    buildings with high humidity, or water-damage.

3.  Carbon Monoxide: From un-vented gas heaters; leaking chimneys or
    furnaces; gas stoves; automobile exhaust. Low levels can cause
    headaches, flu-like symptoms. High levels can be fatal.

4.  Respirable Particles: From fireplaces, wood stoves, and smoke ash.

5.  Organic Gases: From household products including: paints, paint
    strippers, and other solvents; wood preservatives; aerosol sprays;
    cleansers and disinfectants; moth repellents and air fresheners;
    stored fuels and automotive products; hobby supplies; dry-cleaned
    clothing.

6.  Pesticides: Products used to kill household pests, and lawn and
    garden products that may drift or be tracked into the house.

7.  Lead

8.  Radon

9.  Formaldehyde, PVC and other chemicals: Usually from pressed wood
    products (hardwood plywood paneling, particle board, fiber-board)
    and furniture made with pressed wood products; or urea-formaldehyde
    foam insulation.

***Outcome Objective*:** By the year 2008 a *Respiratory Health and
Indoor Environments* Program will be established within the Alexandria
Health Department, EHD. The objective of this program is to help
educate, promote and identify problems relating to the quality of indoor
air and to promote practices that prevent or reduce the contamination of
indoor air.

***Determinant:*** Lack of awareness amongst private residents, schools,
small businesses, and collaborating government entities about the
probable source/cause of poor indoor air quality (IAQ), within their
institutions, and associated adverse health effects.

***Impact Objective*:** To increase awareness about IAQ issues (causes
and health effects) and to foster action on IAQ problems, in 10% of the
residents and other participating institutions (school and business
entities (restaurants)) in the City of Alexandria.

***Contributing Factors*:**

1.  Independent effort between various local government entities in
    promoting good IAQ.

2.  Lack of baseline data on the incidence of respiratory health (RH)
    related illness case rates among children and adults within the City
    of Alexandria.

3.  Lack of availability of a single informational site, within the
    City, that private residents, schools, small businesses and
    government entities can refer to on issues IAQ and RH.

4.  Lack of funding to initiate an IAQ public health education program
    that provides informational assistance, on-site IAQ investigations
    and training to schools, small business, public entities and
    residents on the benefits of good IAQ and its impact on RH.

####### ***Process Objectives***

1.  Dialogue and meet with stakeholders (Transportation and
    Environmental Services, City Public School Administration) and
    collate information (incoming calls, nature of information/services
    sought etc.) on what is currently being done to address IAQ issues
    within the City, by October 2006.

2.  Recruit a Master of Public Health (MPH) student to work with
    Schools, Hospitals, Daycare centers and Healthcare Providers to
    develop baseline data on the incidence rate of asthma and other
    respiratory illness among children and adults within the City, by
    September 2006.

3.  Create a "Resource Center" for RH information where residents,
    schools, small businesses and government entities can refer to on
    issues involving IAQ and RH, by November 2006.

4.  Develop relationships with Executive Sponsors, within or near the
    City of Alexandria, that have the ability to influence the creation
    of a *Respiratory Health and Indoor Environments* Program within the
    EHD, by October 2006.

5.  Implement a RH and IAQ pilot project in one school within the City,
    in collaboration with T&ES, effective 2007/2008 school year.

# METHODOLOGY:

# Event: Build coalitions among various stakeholders to accomplish program missions. Activity: To develop a funding strategy for a *Respiratory Health and Indoor Environments* program and formulate program goals with input, coordination and communication with all involved stakeholders (schools, homes, business entities) on the issue of IAQ and RH. Create goals that could specifically address IAQ issues within each unique setting (ex. schools, small business, homes etc.).

**Event:** Mine RH data on asthma, chronic obstructive pulmonary disease
(COPD), and lung cancer from schools, hospitals and daycare centers.

**Activity:** Develop baseline data on respiratory related illness
within the City to help conduct targeted outreach efforts in groups that
are most impacted by poor IAQ.

**Event:** Create an outlet within the current EHD web-site that
displays information on the benefits of good IAQ and resulting in
improved RH.

**Activity:** Develop website information that specifically relates to
IAQ issues in schools, homes, small businesses and other government
entities. Information that is to be developed would relate to strategies
that help promoting good IAQ practices.

**Event:** Each EPHLI team member, as part of their Individual
Development Plan assignment, will identify an Executive Sponsor that has
the ability to lend a positive influence to the creation of a
***Respiratory Health and Indoor Environments*** program**.**

**Activity:** Create awareness within each individual Executive Sponsor
on issues relating to IAQ and individual RH and how they can assist
(politically, financially, working across departments, etc.) by lending
collaborative support to influence the development of a ***Respiratory
Health and Indoor Environments*** program within EHD.

# STATUS AND NEXT STEPS:

# Coalition Building with Stakeholders: As part of developing a funding strategy and understanding the concerns of residents, schools and businesses within the City of Alexandria on issues regarding RH and IAQ we met with the following stakeholders: 

Schools - City of Alexandria Public School Administration

Director- General Services, Building Operations and Safety Supervisor,
and Supervising Nurse Coordinator

-   Only certain aspects of IAQ - Tools for Schools are currently in
    use. This specifically related to proper operation and maintenance
    of school ventilation systems.

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-   It was agreed that given the increasing awareness of indoor air
    quality issues it would be good to actually initiate an effort to
    improve the quality of air in all schools.

-   The Supervising Nurse Coordinator invited all 17 school nurses from
    all the public schools in the City to discuss issues involving
    respiratory health in children and its relation to indoor air
    quality. The data on percentage of children enrolled in City schools
    with asthma is depicted below (Fig. 4).

-   A plan to buy in leadership from each school is currently being
    planned. A pilot project to work on all ten aspects of the IAQ --
    Tools for schools roadmap (
    <http://www.epa.gov/iaq/schools/roadmap.html> ), in one City Public
    School is currently underway.

> ![](media/image5.wmf){width="5.1090277777777775in" height="2.75in"}

Figure 4 -- Percentage of children enrolled in City Public Schools with
Asthma

City Agencies -- Transportation and Environmental Services (T&ES) and
Alexandria Code Enforcement Bureau/Fire Department (CE/FD)

Division Chief -- T&ES and Acting Division Chief -- Code Enforcement

-   T&ES -- Division of Environmental Quality (DEQ) currently has an
    Indoor Air Quality Program that is complaint driven. No long term
    monitoring or follow up is conducted on incoming calls. It was
    agreed that a concentrated effort needs to be implemented especially
    to target audiences (like those living in rental homes) that do not
    have access to resources involving RH and IAQ as well as what
    services may be available to them to address such situations. DEQ
    will work to provide technical guidance, in conjunction with our
    Division, during the implementation of the IAQ pilot project in a
    selected City public school.

-   CE/FD -- The bureau staff enforces the Virginia Uniform Statewide
    Building Code (USBC), to assure minimum standards in housing and
    construction are met. It currently does not coordinate and
    communicate with the Environmental Health Division on issues that
    relate to damp living spaces (related to buildings) and respiratory
    health. After our meeting with CE, they agreed to partner with
    Environmental Health to promote training materials, educational
    information, and innovative methods to address respiratory health
    problems associated with building structures (ventilation and
    pollutant pathways) and construction/building materials. The FD has
    provided information on carbon monoxide detector activations that
    take place in City residences and businesses (Fig. 5). The depicted
    information will be used to conduct targeted education efforts on
    the importance of regular inspection and maintenance of CO alarms in
    homes within the City.

![](media/image6.wmf){width="5.986111111111111in"
height="4.343055555555556in"}

Figure 5 -- Carbon Monoxide Detector Activations 2000 - 2006

Businesses -- Restaurants

-   The Alexandria Health Department's Proud to be Smoke Free Program
    encourages restaurants in the City to voluntarily adopt a 100%
    smoke-free policy for both outdoor and indoor seating.

-   To date, over 100 restaurants have voluntarily chosen to join the
    program, with 11 restaurants changing policies and eliminating areas
    that previously allowed smoking.

Mining Respiratory Health Data on Asthma and Chronic Obstructive
Pulmonary Disease (COPD) from Inova Alexandria Hospital

-   We have established contact with the Finance Manager from Inova
    Alexandria Hospital. She in turn has provided data on in- and out-
    patient visits as well as total out-patient discharges from the
    hospital for the past five years.

-   A Master of Public Health student from George Washington University
    is currently working towards analyzing the supplied data and will
    provide a detailed report by March 2007.

Create an informational outlet on Respiratory Health and Indoor
Environments within the current EHD web-site

-   The City Information Technology Group and the Industrial Hygienist
    at the Virginia Department of Health have worked with us in
    developing a website that provides information on IAQ issues to
    schools, homes, small businesses. Information on this website
    specifically relates to strategies that help promote good IAQ
    practices.

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-   The developed web-site can be accessed at
    <http://www.alexhealth.org/rhie/>

![](media/image7.jpeg){width="6.000694444444444in" height="3.3125in"}

Figure 6 -- *Respiratory Health and Indoor Environments* website

EPHLI team member and identified Executive Sponsor

-   Executive Sponsors were identified by two EPHLI Team members. They
    included Program Director -Healthy Community Access Program and the
    City of Alexandria - Director of Communications.

-   They have directed us to take the information we have thus far put
    together to various advocacy groups to garner support for the
    program. Some of the mentioned groups include Consumer Advocacy -
    Spanish Speaking Residents, Inova Partnerships for Healthier Kids,
    Tenants and Workers United, as well as Churches and Businesses
    within the City of Alexandria.

-   We will be presenting data/reports mentioned above, that are
    currently in the pipeline, as well as emphasizing the importance of
    RH and IAQ issues within the City. Receiving support from such
    groups will be crucial in trying to generate funds to create an
    ongoing program that works on issues involving *Respiratory Health
    and Indoor Environments*.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Patricia Ferrao***

####### I would like to thank the Environmental Public Health Leadership Institute for the opportunity to participate and learn from the Institute activities in the past year. The Systems Approach Thinking Process and the Ten Essentials Services in a Public Health Program are very valuable tools. I have a feeling that I will be constantly referring back to them in all my adventures in public health from now on. The Institute has been monumental in providing an avenue to help create bridges and interact with other professionals (Fellows and Mentors) in the field of Environmetnal Health. I look forward to tapping this very knowlegeable (and fun) resource in the very near future.

####### ***Holly Feltner***

Upon completion of the Environmental Health Leadership Institute and
reflecting on the past year, I will try to summarize this once in a
lifetime experience. First, I was not aware of two critical tools,
Systems Thinking and the 10 Essential Services of Environmental Health
prior to attending the Institute. These are integral tools in the
Environmental Health Field, and I plan to use these extensively in the
years ahead. Second, I was part of a unique team, working with two
coworkers. Learning that I am an introverted thinker with intuition
(MBTI), and a slight originator (CSI), has given me a better perspective
on why I may preform the way I do, likewise, participating team members.
Finally, our project was completely different from the program I work
in, so time management and communication was critical for all parties.
When working so closely in a team, it is imperative to keep these things
in mind for both individual and team growth and development. My greatest
take away from the year has been the opportunity to network. This was
useful not only with faculty, fellows, and mentors but also city
officials whom I may have never had the opportunity to meet. As the year
ends, I plan to take the opportunity to focus on particular challenges
brought to light in my CSI, both professionally, and now personally.

####### ***Richard Michelback***

The Environmental Public Health Leadership Institute was an invaluable
learning experience for me. Looking back on the past year, I find that I
have learned more about myself in this short twelve months than I have
in last twelve or so years of my environmental health career. The
Institute opened my eyes to how important leadership will be in the
coming years and that if I am to be an effective leader, I need to make
some changes. I found that there are many things I have to learn to be
better prepared to assume leadership when the opportunity arises. I
learned and discovered the value of networking in the sense of seeing
how colleagues working in different parts of the country deal with some
of the same issues. I learned self study is difficult for me and that I
really need to set long and short term goals to complete tasks. I
learned that working in groups can be easier than working alone, but it
also can be more challenging. I learned how I tend to deal with change
and that it's important to try and understand how others deal with
change as well. I plan to take what I've learned about myself and work
to be a better leader.

# ABOUT THE EPHLI FELLOW(s)

Ms. Patricia Ferrao is an Environmental Health Supervisor at the
Alexandria Health Department, Vector-borne Illness Prevention Program.
She currently manages all working aspects of the Vector-borne Illness
Prevention Program for the City of Alexandria. Her expertise is in the
field of Medical Entomology and has ten years of work experience in the
area of mosquito control and arboviral disease management.

Patricia has a dual Master's Degree in Science with specialization in
Neurophysiology and Chemical Ecology. Her Post-Graduate degrees are from
the University of Bombay, India and Simon Fraser University, British
Columbia.

Ms. Holly Feltner is an Environmental Health Biologist at the Alexandria
Health Department, Vector-borne Illness Prevention Program. She has been
in the Environmental Health field for two years, primarily operating in
the Rabies and Vector-Borne Illness Prevention Programs. A significant
amount of time is spent identifying mosquitoes and educating the public
on diseases transmitted by animals and insects. She also works with
Water Quality issues as they relate to drinking water and Indoor
Environmental issues as they relate to various contaminants such as
mold, chemicals, pets, and insects.

Holly left Kansas State University with a B.S. in Animal
Sciences/Pre-Veterinary Medicine, and a B.S. in Kinesiology. She has
spent two years in England studying Equine Respiratory Physiology, not
recognizing the analogy of COPD in horses would someday turn to the
equivalent of asthma in humans.

Mr. Richard Michelback is an Environmental Health Technical Specialist
at the Alexandria Health Department, Environmental Health Division. He
has been in the Environmental Health field for 14 years and his current
duties are primarily in the food program. He is the Certified Food
Program Inspection/Training Officer responsible for maintaining
standardization, and conducting training for field staff. He also works
in other areas such as indoor environmental issues, pool safety,
lead-based paint, food-borne illness investigation, and community and
industry relations.

Richard started his Environmental Health career while serving in the
Unites States Marine Corps for 6 years. Afterward, he attended George
Mason University in Fairfax, Virginia on an athletic scholarship, and
received a B.A. degree in biology.

# REFERENCES

1.  Chen, Alan and Vine, Edward. 1998. A Scoping Study on the Costs of
    Indoor Air Quality Illness: An Insurance Loss Reduction Perspective.
    Environmental Energy Technologies Division, Ernest Orlando Lawrence
    Berkeley National Laboratory, Berkeley, California.

2.  Centers for Disease Control and Prevention. 2002. Surveillance
    summaries: surveillance for asthma 1980-1999. *MMWR Morb Mortal Wkly
    Rep* 51:5-9.

3.  Centers for Disease Control and Prevention. 2003. *National Strategy
    to Revitalize Environmental Public Health Services*, Atlanta,
    Georgia. Department of Health and Human Services.
    <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>

4.  Centers for Disease Control and Prevention. 2005. Healthy People
    2010 Objectives. Department of Health and Human Services.
    <http://www.cdc.gov/nchs/about/otheract/hpdata2010/abouthp.htm>

5.  Osaki, C., eds. 2004. *Essential Services of Environmental Health*.
    Northwest Center for Public Health Practice, University of
    Washington school of Public Health and Community Medicine, Seattle.

6.  Samet JM, Spengler JD, eds. 1991. Indoor Air Pollution, a Health
    Perspective. Baltimore, MD: John Hopkins University Press.

7.  Senge PM, Kleiner A, Roberts C, Ross RB, Smith BJ, eds. 1994. *The
    Fifth Discipline Fieldbook.* New York, NY: Doubleday.

8.  Sundell J. 1999. On the history of indoor air quality and health.
    *Indoor Air* 2004; 14 (Suppl 7): 51-58.

9.  U.S. General Accounting Office. 1995. School Facilities: Condition
    of America's Schools. GAO/HEHS 95-61. Washington, DC: US General
    Accounting Office.