#  Expanding Environmental Health Initiatives within the Local Community without Compromising Core Environmental Health Functions

# 2007 - 2008 

#  Environmental Public Health Leadership Institute Fellow:

# Susan G. King, M.S.

*Director, Division of Environmental Health;* Nassau County Department
of Health

*240 Old Country Road*

*Mineola, NY, 11501*

*516-571-3691*

*Susan.King@hhsnassaucountyny.us*

# Mentor(s):

### **Lisa Conti, DVM, MPH**

*Director, Division of Environmental Health;* Florida Department of
Health

# (Acknowledgements):

### **Abby J. Greenberg, M.D.**

*Acting Commissioner;* Nassau County Department of Health

### **Gerard Giuliano,**

*Attorney III, Health;* Nassau County Department of Health

### **Carolyn Ashe, BA**

*Management Analyst II;* Nassau County Department of Health

***Special thanks to my teammates:***

**Tracy Kolian, MPH and Sherlita Amler, M.D., M.S., F.A.A.P.**

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

# EXECUTIVE SUMMARY:

Public and environmental health agencies are experiencing budgetary cuts
or flat funding at a time of increased need for resources to incorporate
new and enhanced initiatives.

Apparent public health threats including emerging zoonotic diseases,
food-borne illness from agricultural products, lead in our children's
toys, terrorism and natural disasters have increased. Demands for
protection from unregulated facilities such as tanning salons and tattoo
parlors have increased. Regulatory standards for existing programs such
as drinking water have increased. Demands for the reduction of
environmental pollutants in natural resources and living space
environments have increased. These increased demands challenge
environmental health agencies which are today struggling to maintain
core environmental health functions while experiencing reduced staffing
and the loss of institutional knowledge.

Only an innovative and comprehensive response to this challenge by the
environmental health agencies will enable them to meet the continually
moving finish line that defines good public health. As public and
environmental health resources are cut back due to a reduction and
reallocation of funds within municipal budgets, the environmental health
agency must seek other means to maintain core environmental health
programs and incorporate new environmental health initiatives and
demands. The environmental health agency must also maintain the
confidence of the constituency which it serves in an ever-increasing
media driven public arena and continue to motivate and attract devoted
and talented staff.

Consequently, the focus of this project year has been a three-pronged
strategy which includes:

-   the development of an environmental health awareness campaign,

-   increasing the advisory capacity for the environmental health
    agency, and

-   improving the performance of the local health unit by employing
    "best practices" and developing the workforce.

> This strategy will lay the groundwork for the implementation of
> expanded public health initiatives while maintaining the integrity of
> core mandated functions.

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

This project sought to define the problem facing all environmental
health agencies that have suffered cutbacks in traditional resources of
how best to respond to demands for additional services and initiatives
caused by an increasing awareness from the media, public and political
communities, and to identify a means to resolution to wit: the
development of non-traditional resources.

####### ***Behavior Over Time Graph:***

####### ![](media/image2.wmf){width="6.125in" height="3.2881944444444446in"}

####### 

####### **Figure 1:** The *Behavior Over Time g*raph illustrates the trend over time of several variables. ***Resources*** or capacity of the local health unit remains flat or even decreases despite ***increased demands/mandates.*** These demands increase in response to ***Concerns/Public Perception*** which is often driven by the media or a special interest group. In reality, ***Public Health Risk***, despite emerging risks or trends, remains static or decreases due to the intervention of the local health unit. What is needed is a reduction in the gap between ***increased demands/mandates*** and ***resources*** which can be resolved with increasing local capacity and the gap between ***concerns/public perception*** and ***public health risk*** which can be reduced through an environmental health awareness campaign. 

####### ***Causal Loop Diagrams and applicable archetypes:***

![](media/image3.wmf){width="3.125in" height="2.25in"}

**Figure 2:**

This archetype is a variation of ***Success to the Successful**.* An
increase

in *Perceived Threats* increases *Demand* which in turn increases
*Mandates*.

An increase in *Demand* increases the *Gap Between Demand & Resources*.

As this gap increases, the *Ability to Perform* decreases which, in
turn,

increases *Criticism* as well as *Perceived Threats*. At this point,
*Resources*

are increased, but at a cost of reduced confidence in the local health
unit

(It's considered a bailout!). How can we break this cycle? We need key

stakeholders to want to partner with a "winning team". We need proactive

partners, not reactive adversaries.

![](media/image4.wmf){width="3.0in" height="2.25in"}

**Figure 3:**

In this archetype, the key element is the local health unit's *Success/*

*Reputation. Perception of Needs* drives *Initiatives.* A change in

*Resources/Capacity* impacts *Quality of Implementation* which affects

continued *Success*. Ideally, as *Success/Reputation* stabilizes, so too

will *Perception of Needs* which will ultimately reduce the addition of

new initiatives driven by unwarranted public/media outcry.

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

![](media/image5.png){width="2.459722222222222in"
height="2.5006944444444446in"}

Figure 4: "The Linkage of Essential Services to Core Functions" from
Carl Osaki, RA, MSPH, Northwest Center for Public Health Practice,
*Essential Services of Environmental Health*.

An argument can be made that this project, which considers how to
enhance, expand and introduce local environmental health initiatives
while maintaining core environmental health functions, encompasses in
toto the spirit and goals of all ten Essential Environmental Health
Services. For the purpose of this report, however, the activities
determined by the three pronged strategy of development of an awareness
campaign, increasing advisory capacity, and improving the competency of
the local work force in order to expand health initiatives will
concentrate primarily on the following named services and core functions
described in the IOM report:

**Core Function: Policy Development** -- *developing policy around an
identified threat*

-   ***Essential Service #3*:** Inform, educate, and empower people
    about environmental health issues.

    a.  Develop environmental health informational brochure.

    b.  Distribute brochures and other items including annual report to
        key stakeholders and general public in electronic form.

-   ***Essential Service #4*:** Mobilize community partnerships to
    identify and solve environmental health problems.

    a.  Interact with local legislators.

    b.  Develop list of community liaisons and meet and greet.

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-   ***Essential Service #5:*** Develop policies and plans that support
    individual and community environmental health efforts.

a.  Create strategic plan with buy in from the policy makers that set
    programs and priorities.

b.  Consult with regulators on best practices for expanded health
    initiatives.

**Core Function: Assurance** -- *Carrying out policy initiatives*

-   ***Essential Service #8:*** Assure a competent environmental health
    workforce.

a.  Develop cost analysis and staff evaluation of implementing new
    initiatives.

b.  Provide best practices information to local community volunteers.

-   ***Essential Service #10:*** Conduct research for new insights and
    innovative solutions to environmental health problems and issues.

a.  Consider and develop alternate methodologies including Geographic
    Information Systems.

b.  Enhance web site to provide information on environmental health
    issues and access to environmental health programs.

####### 

####### ***National Goals Supported*** 

The National Goals of the Centers for Disease Control and Prevention and
the American Public Health Association are supported by this project
which speaks to fostering healthy environments in an era of diminishing
resources. In times of reduced staffing, the local environmental health
agency, in order to continue its mission to protect public health,
prioritizes its activities and stresses its regulatory and investigative
objectives. However, by revisiting its educational mission and
refocusing its efforts, the local environmental health agency will
enable itself to take a different approach from the traditional
philosophy of increasing staff, and will instead seek non-traditional
resources and partner with key stakeholders. This can be done, in part,
by marketing local environmental health programs to the local community.
With recognition and support, the local environmental health regulatory
agency will be energized and emerge as a leader of a sustainable
community system.

A.  **CDC Health Protection Goals:**

This project supports several objectives of the Healthy People in
Healthy Places theme, specifically, Healthy Communities:

-   #38. Promote safe and high-quality air, water, food, and waste
    disposal, and safety from toxic, infectious, and other hazards, in
    communities.

-   #40. Support a robust, sustainable capacity to provide access to and
    ensure receipt of essential public health, health promotion, health
    education, and medical services

B.  **National Strategy to Revitalize Environmental Public Health
    Services:**

The overarching goal of the National Strategy to Revitalize
Environmental Public Health Services is to "...enhance and revitalize
the system of environmental public health services...".

-   *Goal 1: Build Capacity*

    a.  Develop key stakeholder and community contact list.

    b.  Distribute information about new technologies that provide
        access to environmental health issues.

-   *Goal 2: Support Research*

    a.  Evaluate and develop "best practices" for environmental health
        programs.

    b.  Distribute public health research projects to key stakeholders.

-   *Goal 3: Foster Leadership*

    a.  Develop environmental health service documents for distribution.

    b.  Provide guidance to key stakeholders to develop community group
        capacity.

-   *Goal 4: Communicate and Market*

    a.  Participate in local conferences on environmental health issues.

    b.  Market environmental health services to key stakeholders

-   *Goal 5: Develop the Workforce*

    a.  Evaluate performance standards for core programs.

    b.  Cross train staff in multiple environmental health specialties.

    c.  Develop middle managers and program leaders.

-   *Goal 6: Create Strategic Partnerships*

    a.  Identify key stakeholders.

    b.  Develop communication mechanisms with key stakeholders on
        environmental health issues

> **C. APHA Environmental Health Competency Project**

The Environmental Health Competency Project provides guidelines and
recommendations to local public health leaders on the core non-technical
competencies needed to strengthen capacities to manage environmental
health challenges. The competencies supported by this project include:

-   *Management:*

    a.  Problem Solving: The capacity to understand and solve
        problems*.*

    b.  Partnering: The capacity to form partnerships and alliances with
        other individuals and organizations in order to enhance
        performance on the job.

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-   *Communication:*

    a.  Education: The capacity to use the environmental health
        practitioner's front-line role to effectively educate the public
        on environmental health issues.

    b.  Communication: The capacity to effectively communicate risk and
        exchange information.

    c.  Marketing Environmental/Public Health as a Service: The ability
        to articulate basic concepts of environmental health and public
        health and convey an understanding of their value and importance
        to clients and the public.

####### ***Project Logic Model:***

**PROBLEM STATEMENT: An increasing awareness from the scientific
community and community activists of health threats from sources
including feral cat populations, transfats, tattoo and body piercing,
underage tobacco smoking and summer day camps have caused an increased
demand/mandates by local regulatory officials for environmental health
services beyond basic environmental health core programs without
providing additional resources.**

**PROGRAM GOAL: To implement expanded environmental health initiatives
within the local community without compromising core environmental
health functions**

+-----------------------------------------------------------------------+
| **Resources**                                                         |
|                                                                       |
| ***What resources do we have to work with?***                         |
|                                                                       |
| ***Have: Need:***                                                     |
|                                                                       |
| **Current staff of local environmental health unit Additional local   |
| environmental health unit staff**                                     |
|                                                                       |
| **General fund budget (includes fees) Increase in general fund budget |
| (includes fees)**                                                     |
|                                                                       |
| **or**                                                                |
|                                                                       |
| **Non-traditional alternatives**                                      |
+-----------------------------------------------------------------------+

+------------------+-------------+-------------+----------+-----------+
| **Activities**   | **Outputs** | *           | **Inte   | **        |
|                  |             | *Short-term | rmediate | Long-term |
| ***What happens  | ***What are | Outcomes**  | Ou       | O         |
| in our           | the         |             | tcomes** | utcomes** |
| organization?*** | tangible    | ***What     |          |           |
|                  | products of | changes do  | ***What  | ***What   |
|                  | our         | we          | changes  | changes   |
|                  | act         | [expect]{   | do we    | do we     |
|                  | ivities?*** | .underline} | [w       | [hope]{.u |
|                  |             | to occur    | ant]{.un | nderline} |
|                  |             | within the  | derline} | to see    |
|                  |             | short       | to see   | over      |
|                  |             | term?***    | occur    | time?***  |
|                  |             |             | after    |           |
|                  |             |             | that?*** |           |
+==================+=============+=============+==========+===========+
| *Activity        | -   In      | -           | -        | -         |
| Category:*       | formational |   Awareness |   Public |    Public |
| **Awareness      |             |     of      |     will |     will  |
| Campaign**       |    brochure |     local   |          |     have  |
|                  |     of      |     en      |  contact |           |
| -   Develop      |     local   | vironmental |          |  restored |
|                  |     en      |     health  |    local |     c     |
|    informational | vironmental |     unit    |          | onfidence |
|     brochure of  |     health  |             |   health |     in    |
|     local        |     unit    |             |     unit |     the   |
|                  |             |             |     for  |     local |
|    environmental | -           |             |     re   |           |
|     health unit  |    Meetings |             | solution |    health |
|                  |     with    |             |     of   |     unit  |
| -   Interact     |     local   |             |     p    |           |
|     with         |             |             | erceived |           |
|     political    | legislators |             |          |           |
|     stakeholders |     and     |             |   health |           |
|                  |     local   |             |          |           |
| -   Promote      |     Board   |             |  threats |           |
|                  |     of      |             |          |           |
|  accomplishments |     Health  |             |          |           |
|     of local     |             |             |          |           |
|     health unit  | -   Monthly |             |          |           |
|     in monthly   |     reports |             |          |           |
|     and annual   |             |             |          |           |
|     reports      | -   Annual  |             |          |           |
|                  |     report  |             |          |           |
| -   Develop list |             |             |          |           |
|     of community | -           |             |          |           |
|     liaisons and |    Meetings |             |          |           |
|     meet and     |     with    |             |          |           |
|     greet        |     local   |             |          |           |
|                  |             |             |          |           |
|                  |   community |             |          |           |
|                  |             |             |          |           |
|                  |   activists |             |          |           |
+------------------+-------------+-------------+----------+-----------+
| *Activity        | -           | -           | -        | -   Feral |
| Category:*       |    Meetings |   Community |    Local |     cat   |
| **Develop        |     with    |             |          |     p     |
| advisory         |     Feral   |   activists |   health | opulation |
| capacity**       |     Cat     |     will    |     unit |     will  |
|                  |             |     take    |     will |     be    |
| -   Participate  |    Advisory |     res     |          |           |
|     on advisory  |             | ponsibility |  provide |   reduced |
|     committees   |   Committee |     for     |     best |     and   |
|                  |             |             |          |     the   |
| -   Consult with | -   C       |    remedial | practice |           |
|     regulators   | onsultation |     action  |          |    public |
|     on best      |     with    |             |   advice |     will  |
|     practices    |     local   | -   Local   |     to   |     be    |
|     for expanded |             |     en      |          |           |
|     public       |  regulatory | vironmental |  protect | protected |
|     health       |             |     health  |     vol  |           |
|     initiatives  |    counsels |     unit    | unteers. | -   New   |
|                  |             |     will be |          |           |
| -   Meet with    | -   C       |             | -        |    public |
|     local board  | onsultation |   consulted | Proposed |           |
|     of health    |     with    |     when    |          |    health |
|                  |     local   |     local   |    local |     in    |
| -   Meet with    |     board   |             |     laws | itiatives |
|     local        |     of      |  regulatory |     will |     will  |
|     community    |     health  |             |     be   |     be    |
|     activists    |             |   authority |          |     im    |
|                  | -   Use of  |             | modified | plemented |
| *Activity        |     non-    |    develops |     to   |           |
| category:*       | traditional |     new     |     best |   without |
| **Improve        |     titles  |     man     |          |     com   |
| competency of    |             | dates/local |  protect | promising |
| workforce and    | -           |     laws    |          |     basic |
| develop expanded |    Analysis |             |   public |     core  |
| public health    |     of      | -           |          |     envi  |
| initiatives**    |     staff   |    Improved |   health | ronmental |
|                  |     time    |     program |          |           |
| -   Cross train  |     needed  |     e       |    while |    health |
|     staff        |     to      | fficiencies |          |           |
|                  |             |             | limiting |  programs |
| -   Implement    |   implement | -   General |          |           |
|     "best        |             |     fund    |   direct | -         |
|     practices"   |   transfats |     budget  |          | Community |
|                  |     ban     |     will be |   impact |           |
| -   Create       |             |             |     to   |    health |
|     strategic    | -   Contact |   increased |          |           |
|     plan with    |     IT      |     to      | staffing |  improved |
|     buy in from  |             |     provide |          |           |
|     the policy   |  department |     for     | -        | -         |
|     makers that  |     to      |             |    Local |    Public |
|     set programs |     assist  |  additional |          |     will  |
|     and          |     in web  |             |   health |     be    |
|     priorities   |     based   |    staffing |     unit |           |
|                  |     program |             |     will | protected |
| -   Develop cost |             | -   IT will |     lead |     by    |
|     analysis of  |             |     assist  |     c    |     the   |
|     each new     |             |     in      | ommunity |           |
|     initiative   |             |             |          |   removal |
|                  |             | development | -   Ban  |     of    |
| -   Consider     |             |     of web  |     on   |           |
|     alternative  |             |     based   |     t    | transfats |
|     resources    |             |     day     | ransfats |     in    |
|     for each     |             |     camp    |     will |     food  |
|     initiative   |             |             |     be   |           |
|                  |             | information |          |   service |
| -   Consider     |             |     program | actively |     estab |
|     stopping     |             |             |          | lishments |
|     certain      |             |             | enforced |           |
|     mandated     |             |             |     by   | -         |
|     functions    |             |             |     ad   |    Public |
|                  |             |             | ditional |     will  |
|                  |             |             |          |     have  |
|                  |             |             | staffing |     in    |
|                  |             |             |          | formation |
|                  |             |             | -   Day  |     to    |
|                  |             |             |     camp |           |
|                  |             |             |     inf  |    select |
|                  |             |             | ormation |     best  |
|                  |             |             |     will |     day   |
|                  |             |             |     be   |     camp  |
|                  |             |             |     a    |     for   |
|                  |             |             | vailable |     their |
|                  |             |             |     on   |           |
|                  |             |             |     the  |  children |
|                  |             |             |     web  |           |
+------------------+-------------+-------------+----------+-----------+

+---------------------------------+------------------------------------+
| **Rationale(s):**               | **Assumptions:**                   |
|                                 |                                    |
| ***The explanation of a set of  | ***Facts or conditions you assume  |
| beliefs, based on a body of     | to be true.***                     |
| knowledge, about how change     |                                    |
| occurs in your field and with   |                                    |
| your specific clients (or       |                                    |
| audience).***                   |                                    |
+---------------------------------+------------------------------------+
|                                 |                                    |
+---------------------------------+------------------------------------+
| **External Factors: Local       |                                    |
| politicians respond to the      |                                    |
| urgency of the need for         |                                    |
| intervention demanded by their  |                                    |
| constituency's perception of    |                                    |
| public health threats.**        |                                    |
+---------------------------------+------------------------------------+

# 

# PROJECT OBJECTIVES/DESCRIPTION/DELIVERABLES:

####### ***Program Goal***

To implement expanded environmental health initiatives in the local
community

####### ***Health Problem***

An increasing awareness from the scientific community and community
activists of health threats from sources including feral cat
populations, transfats, community planning, tattoo and body piercing,
underage tobacco smoking, and summer day camps, have caused an increased
demand by local regulatory officials for environmental health services
beyond basic environmental health core programs without providing
additional resources.

####### ***Outcome Objective***

To implement expanded environmental health initiatives without
compromising the ability of the local environmental health unit to
perform basic environmental health functions.

####### ***Determinant***

The number of new initiatives implemented which draw staff from and
potentially compromise basic environmental health core programs.

####### ***Impact Objective***

By January 2009, key stakeholders such as the local county legislature,
local Board of Health, and local coalitions will partner with the local
health unit to provide resources to implement expanded environmental
health initiatives.

####### ***Contributing Factors***

1.  Local constituents contact local legislators on matters of personal
    interest that are not addressed by regulatory mandate. Lack of a
    mandate implies that there is a public health risk to the local
    community if the matters are in fact validated as a public health
    issue. Local legislators create a county mandate for a
    responsibility which may belong to another municipal agency or that
    provide limited public health protection for the public health
    dollars being spent. Local legislators seek recognition as
    environmental health watchdogs.

2.  Executive and Legislative branches operate separately. Budgetary
    restraints set by Executive branch due to fiscal crisis restrict the
    local health unit from aggressively implementing latest,
    non-mandated public health initiatives. Due to a lack of
    understanding of basic environmental core functions, an impression
    of ineffectiveness and inefficiency is fostered. Executive Branch
    also has unique environmental health priorities. Board of Health is
    appointed by County Executive.

# METHODOLOGY:

####### ***Events and Activities***

1.  By January 1, 2009, key stakeholders will partner with the local
    environmental health unit on matters involving environmental health.

-   *Event:* Implement an awareness campaign and develop advisory
    capacity

-   *Activities:*

    i.  Develop informational document on the mission, goals, and
        objectives of the local health unit and provide to identified
        key stakeholders.

    ii. Interact with staff assigned to local legislators.

    iii. Advise local legislators of budget and staffing capacity.

    iv. Advise key stakeholders of local regulatory agencies whenever
        appropriate.

    v.  Identify and meet local community activists.

    vi. Discuss alternative methodologies to resolve environmental
        issues such as inclusion on advisory boards, resources available
        from other agencies, and/or modifications to proposed mandates.

2.  By January 1, 2009, the local environmental health unit will
    implement enhanced environmental health initiatives.

-   *Event:* Improve workforce competency and develop advisory capacity

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-   *Activities:*

i.  Routinely meet with local Board of Health and administration on
    capacity status of the local health unit and emerging environmental
    health issues.

ii. Promote accomplishments of local health unit in monthly and annual
    documents.

iii. Routinely meet with local community activists to discuss
     environmental health issues of concern.

iv. Develop new environmental health initiatives with cost analyses
    including staffing and revenues.

v.  Implement "best practices" to improve workforce effectiveness.

vi. Develop local health unit supervisors to improve individual
    programs.

# RESULTS:

-   The local health unit continues interactions with local legislators
    which have resulted in the restructuring of proposed mandates to the
    benefit of the local health unit.

-   The local health unit provides advice as a member of the Feral Cat
    Advisory Committee.

-   Workforce has been supplemented by non-traditional environmental
    health titles such as management analyst.

-   Local health unit supervisors are encouraged to think as leaders not
    just managers.

-   An environmental health educational brochure is in development.

-   More advice on key environmental health issues has been sought of
    the local health unit by both local and state government
    stakeholders.

# EXPECTED OUTCOMES:

This project's three-pronged strategy has made key stakeholders aware of
the critical role of the local environmental health agency in
maintaining good public health including expertise and dedication, as
well as the critical staff shortage and extent of the number of programs
it regulates, investigates, and enforces on a daily basis. With this
recognition, our key stakeholders are joining us at the table and taking
the first steps in truly becoming partners in the protection of public
health.

# LEADERSHIP DEVELOPMENT OPPORTUNITIES:

####### ***Susan G. King***

Besides the obvious benefit of being able to share the work of my
agency, EPHLI has enabled me to come in close contact with other
environmental health professionals whose efforts to overcome real world
problems and challenges have become an inspiration to me. I believe I am
learning far more from EPHLI than I am contributing to it, and in doing
so I am firming up the foundation upon which I have built my career. In
working on my project, I have learned to extend my reach by partnering
with local key stakeholders to protect public health. Systems thinking
has put into context the processes used to define and resolve a conflict
and has clarified for me the need to be more open minded, look for the
long term solution and create paths to success (Don't say "No!", ask
"How?"). I have become acutely aware of the different roles played by
leaders and managers and encourage my subordinate staff to share and
develop new ideas. EPHLI has helped me to realize that while we are all
faced with similar obstacles, such as budget and personnel constraints,
bureaucratic red tape and political decision making, we all manage to
find creative and effective ways to deal with them. It is heartening to
know that we are truly "all in this together!"

# ABOUT THE EPHLI FELLOW

Susan G. King currently serves as Director of Environmental Health for
the County of Nassau, New York. She directs a staff of 135 environmental
health professionals who serve a suburban population on Long Island of
nearly 1.4 million people adjacent to New York City with a budget of
over eight million dollars. Sue has been with the Nassau County Health
Department since 1976, starting in the Marine Ecology Lab, supervising
in the Bureau of Land Resources Management and then assuming the
position of Assistant to the Director of Environmental Health and Deputy
Director prior to her current assignment.

Sue has been a member of the National Environmental Health Association
and is Vice Chair of the New York State Conference of Environmental
Health Directors. Besides her duties in environmental health, Sue serves
on the Executive Committee for Geographic Information Systems in the
County and is actively involved in the day-to-day planning of Emergency
Response.

Sue holds Bachelor's and Master's degrees in Earth Sciences from Adelphi
University. She lives in Wantagh, NY where she has been an active
participant in a number of community affairs.

# REFERENCES

1.  Goodman, Michael, David Stroh, and Sherry Immediato, "Introduction
    to Organizational Learning and Systems Thinking", Bridgeway Partners
    and Innovation Associates Organizational Learning, 2007 (Power Point
    Presentation).

2.  Senge, Peter, et al, [The Fifth Discipline Fieldbook,]{.underline}
    New York, Doubleday, 1994

3.  Osaki, Carl, RA, MSPH, Northwest Center for Public Health Practice,
    *Essential Services of Environmental Health*.

4.  CDC Health Protection Goals
    <http://www.cdc.gov/about/goals/default.htm>

5.  National Strategy to Revitalize Environmental Public Health Services
    <http://www.cdc.gov/nceh/ehs/Docs/nationalstrategy2003.pdf>

6.  Environmental Health Competency Project: Recommendation for Core
    Competencies for Local Environmental Health Practitioners
    [http://www.apha.org/programs/standards/healthcompproject/corenontechnicalcompetencies.htm]{.underline}