Keeping Track, Promoting Health...

CDC NATIONAL ENVIRONMENTAL PUBLIC HEALTH TRACKING PROGRAM

Connecting the Dots
In 2000, the Pew Environmental Health Commission

detailed an “environmental health gap,” a lack of

basic information needed to document links 

between environmental hazards and chronic disease.

The most common environmental health hazards are

air and water pollution; asthma, cancer, and lead 

poisoning are the most frequent adverse health

effects that concern Americans.
Without a tracking program, environmental causes of chronic diseases are hard to identify. Systematically 

measuring amounts of hazardous substances in our environment, tracing their geographic spread, seeing how 

they show up in human tissues, and understanding how they may cause illness would seem a wise precaution.

The National Environmental Public Health Tracking Program, developed by the Centers for Disease Control and

Prevention (CDC), is the start of that system. 

Over the last four years, CDC has laid the foundation of a national system to track environmental hazards 

and the diseases they cause, updating traditional medical detective work with computers, satellites, and 

geographic information systems.

The building blocks of that foundation included grants to state and local health departments. Health departments 

are often best placed to monitor hazards because they understand special local conditions that modify general 

environmental health risks. In addition to its pilot grants, CDC has collaborated with a number of other federal 

agencies, professional organizations, and civic groups to mobilize support for the Tracking Program.

The pilot programs and collaborations are not mere exercises, though. They have already begun to pay off in faster

responses to environmental health questions and in action to prevent disease.

However, a full-fledged tracking program must do more than simply gather facts. It must connect data sources, 

provide the tools to make sense of them, and make that crucial information available to those who need it. To do 

just that, the CDC has been working intensely for the past several years to develop the National Environmental 

Public Health Tracking Network. 

The Network, which will promote information system standards to integrate local, state, and national databases of

environmental hazards, environmental exposures, and health effects, will be a crucial component of the National

Environmental Public Health Tracking Program. 

With the help of the National Environmental Public Health Tracking Network, scientists, communities, policymakers,

and the public soon will have access to the information they need to make good decisions about preventing disease,

keeping the American public healthy, and saving lives.
CONTENTS

2

Prologue

31

A Proven Concept, 

A New Reality 

5

On the Trail of 

Hazards to Health

41

Before and 

After Tracking 

44

Useful Resources

19

Pilot Projects 

Lead the Way

43

Acknowledgments
2

Daniel Kass was thinking about bug spray, not only what it does

to the bugs, but how too much of it can make people sick—

affecting their nervous systems, poisoning children, harming

fetuses, and causing other long-term effects. 

Kass and his colleagues at the New York City Department

of Health and Mental Hygiene wanted to know where and how

pesticides were used in the city. What risks did they represent

to city dwellers if wrongly used?

Fortunately, the health department had a new resource to

help them find the answers—a pilot grant from the U.S.

Centers for Disease Control and Prevention (CDC) to develop

a pesticide tracking system for the city.

“Poison control center calls and hospital admissions can

tell you about acute poisoning episodes, but there was no way

to evaluate how widespread use and exposure to pesticides

were,” says Kass.

The grant was part of CDC’s national effort to build an

environmental public health tracking program, one that 

would eventually help public health and environmental health

practitioners connect existing information and collect new

data on numerous environmental hazards, their presence in

humans, and their effects on health.

Using the CDC grant, Kass’s team pulled together 15

sources of hazard and health outcome data from city and 

state health, finance, planning, housing, and environmental

protection agencies. The sources ranged from pesticide sales

and housing reports to birth records and hospital emergency

room charts. They also drew from a city health survey that

measured pesticide levels in residents’ urine samples.

“We had to look at many different data, otherwise we

wouldn’t get a complete picture of the health impact of

pesticides,” Kass explained. “For instance, poison control data

came mostly from residents calling about children exposed to

rodenticide, while emergency room visits involved more 

serious exposures, and hospitalizations were overwhelmingly

due to improperly used insecticides. Pesticide use data helped

us make a connection with illness. Together, they gave us a 

better sense of what and where the problems were.”

By adding questions to an existing telephone survey, the

tracking program helped the health department warn vulnerable

neighborhoods about illegal use of certain pesticides, set up a

hotline for residents to report illegal sales, and learn more

about safer pest control. The results also provided the science

to back a city pesticide reduction ordinance.

“We wanted to rapidly apply our data to public health

needs, so we aimed for something practical,” says Kass. “We

were phenomenally successful in making a difference at the

local level, increasing awareness, reducing hazards, and

improving health.”

PROLOGUE
part one

5

Daniel Kass’s high-tech approach to pesticide poisoning illustrates how connecting health and hazard

information works to keep people healthy.

For the last four years, CDC has used similar programs to lay the foundations of a nationwide

Environmental Public Health Tracking Program.

When complete, the Tracking Program will pursue

environmental hazards and the diseases they cause,

complementing traditional medical detective work

with computers, satellites, and geographic information systems. Even now, with only pilot projects completed, CDC’s environmental public health tracking

strategy has already proved its worth in preventing illness and addressing community concerns.

Public health workers have long been charged

with looking for patterns of infectious diseases—who

got sick, when, where, and how. When epidemics

broke out, they traced diseases from infected patients

back to where bacteria or viruses lurked. They identified the insects, the polluted water, or other sources of

infection that caused or carried such infectious diseases as cholera, yellow fever, tuberculosis, and polio.

These dedicated public health workers also

pushed for water purification, food inspection, and

immunization to prevent illness. Antibiotics and

other drugs kept people alive and reduced the risk of

On the Trail of Hazards to Health
6

epidemics. This combined attack was one of the great

health triumphs of the last century, saving lives by the

millions. 

While that success has allowed us to live longer,

healthier lives, it also brings new challenges to those

who protect the health of our communities. Today,

chronic illnesses—like birth defects, developmental

disabilities, asthma, cancers, heart disease, and neurological diseases—are responsible for 70 percent of

deaths in the United States and affect over 100 million

men, women, and children, says Shelley Hearne,

Dr.P.H., founding executive director of Trust for

America’s Health. These diseases cost our country

more than $325 billion a year in health care and lost

productivity and account for 60 percent of personal

health care costs.

Harvard researchers estimate that 50,000 to

100,000 people die prematurely each year as a result

of air pollution alone. Illnesses stemming from air

pollution cost about $100 billion annually in the

United States, according to the American Lung

Association. The Environmental Protection Agency

(EPA) estimates that reducing air pollution to levels

required by the 1990 Clean Air Act Amendments will

prevent more than 1.7 million asthma attacks.

Research shows a connection between our envi-
7

ronment and our health, but we still have a long way to

go in understanding what links the two. We need better information and more sophisticated tools to

understand the causes of these diseases if we are to

prevent them.

NEW TIMES, NEW HAZARDS

The World Health Organization estimates that poor

environmental quality may be responsible for one

fourth of all preventable illness in the world. Every day

we encounter chemicals, physical agents, and other

substances in the air, water, and soil around us, as well

as in the food we eat.

However, making the connection between environmental threats and chronic diseases is not easy.

Environmental hazards have subtle effects on human

health. They rarely cause immediate illness the way

epidemic disease germs do. Their effect on the human

body can go unnoticed, and years or decades may pass

before symptoms appear. A single exposure or a single

chemical may not trigger an illness, but an accumulation of exposures over time can take its toll. Effects are

complicated. Many hazards may influence the appearance of one disease, while a single hazard may influ-
8

ence many outcomes. Genes and behavior may also

affect how environmental pollutants cause disease in

individuals.

A tracking program can provide information to

help us understand how the environment influences

the development of disease. Only by systematically

measuring environmental insults, tracing their geographic distribution, documenting their residues in

human tissues, and understanding their connection

with illness can that information help prevent suffering and disease. Integrating all of these elements sets

environmental public health tracking apart from traditional disease surveillance.

Tracking programs serve another function, too.

Sometimes long-term data actually shows that disease

rates are not exceptional in communities worried

about clusters of illness. Tracking improves access to

that information and permits faster analysis. Lack of

ready access to usable data delays a health department’s ability to serve the public and address its concerns. Without a swift, accurate response, the public

may misinterpret delays as “foot dragging” or a “government cover-up.” 

Unfortunately, tracking programs are still in their

infancy.

“We can track flu, West Nile virus, and mad cow

“We can track flu, West Nile virus, and mad cow disease but not enough 

of the chronic illnesses that are the biggest killers of Americans, because 

we just don’t have enough of that basic information.”

TOM BURKE, Ph.D., PROFESSOR, CO-DIRECTOR, RISK SERVICES AND PUBLIC POLICY INSTITUTE, JOHNS HOPKINS UNIVERSITY
9

disease but not enough of the chronic illnesses that

are the biggest killers of Americans, because we just

don’t have enough of that basic information,” says

Johns Hopkins University’s Tom Burke, Ph.D.

FROM AIR TO BLOOD TO BRAIN

Exceptions exist, of course. Decades ago, scientists

documented concentrations of toxic lead from auto

exhaust and measured lead residues in the blood of

children who breathed polluted air or inhaled paint

dust. Doctors knew lead poisoning caused developmental problems, convulsions, coma, and even death.

Integrating that information persuaded Congress to

CASE STUDY:

Utah

Sam LeFevre of the Utah Department of Health received a

call from a citizen in west Salt Lake City who was concerned about cases of cancer in his neighborhood. In the

past, a similar call would have prompted a study that

would have taken a year to complete, with most of that

time spent waiting for data.

On a flight to Atlanta for a meeting, LeFevre pulled out his

laptop computer and began analyzing the cancer data.

Using the systems he’d helped develop with a CDC grant,

LeFevre mapped the location of the caller’s house, tied in

cancer data, and compared the percentage of cancer cases

in the neighborhood to the percentage in the entire state of

Utah. 

Before the flight landed, LeFevre knew he could assure the

resident that there was no greater likelihood of cancer in

his vicinity than in the state as a whole. Most important,

with the support of Utah’s pilot tracking program, he was

able to complete his analysis in a few hours instead of the

year it would have ordinarily taken.
10

ban lead compounds from gasoline and paints. In

time, lead levels in the atmosphere and in children’s

blood declined, and today lead poisoning rates in

children have declined and deaths are rare.

At its best, that is how environmental public

health tracking works: helping connect the dots

between environmental hazards and illness. Parts of

that system are already in place. Many federal and

state agencies collect data on chemicals introduced

into the air or water. The EPA routinely monitors air

quality. The U.S. Geological Survey (USGS) tests water

in rivers and in wells. National Aeronautics and Space

Administration (NASA) satellites record information

on vegetation cover, forests and forest fires, flooding,

ultraviolet radiation, and surface temperatures. CDC

regularly measures levels of 148 chemicals found in

our blood. States or localities may record particular

substances depending on local geology, industry, or

weather patterns. Hospitals, doctors, and health

departments report cases of disease and injury. 

A nationwide environmental public health tracking program can rise from that foundation of existing

local, state, and federal systems. But such a program

will need more than a patchwork assortment of data. A

workable system will not only collect information

from disparate sources, but also analyze it and make it

“We need to get tracking results in front of people in a very 

usable way, not only on a national level, but by state and locality as well.”

HOWARD FRUMKIN, M.D., Dr.P.H., DIRECTOR, NATIONAL CENTER FOR ENVIRONMENTAL HEALTH AND THE AGENCY FOR TOXIC SUBSTANCES AND DISEASE REGISTRY, CDC
11

available to those who can act to prevent or control

disease.

“We need to get tracking results in front of people

in a very usable way, not only on a national level, but

by state and locality as well,” says Howard Frumkin,

M.D., Dr.P.H., director of CDC’s National Center for

Environmental Health and the Agency for Toxic

Substances and Disease Registry, which oversees the

Tracking Program. “People care deeply about local

health issues.”

A LITTLE HISTORY

Connecting hazardous substances in the air or water

CASE STUDY:

Wisconsin

Wisconsin’s tracking program collaborated with the state’s

Department of Natural Resources to implement a new

environmental public health tool, the Regional Air Impact

Modeling Initiative. Developed by the Environmental

Protection Agency, the Initiative provides geographically

focused estimates of toxic air pollutant concentrations and

then estimates community cancer risk. 

Public health officials soon provided the system with a

real-world test. A community in southeastern Wisconsin

asked about factory emissions of the solvent trichloroethylene. Drinking or breathing high levels of trichloroethylene

may harm the nervous system and cause liver and lung

damage, abnormal heartbeat, coma, and even death.

Regional Air Impact Modeling and other monitoring techniques confirmed high levels of the chemical.

With that information in hand, the Wisconsin Department

of Health and Family Services recommended that the

industrial plant reduce its emissions. Presented with modeling, monitoring, and consultation results, the factory

owner—who was in compliance with all applicable permit

requirements—agreed to change the manufacturing

process in the plant to eliminate trichloroethylene emissions. 

This intervention resulted in reduced community

trichloroethylene exposure, and showed how use of air pollutant modeling to identify high-risk communities can

prompt action to decrease toxic air pollutants. 
12

to illness might seem an obvious step, but its application has been spotty. Environmental and public health

units at all levels of governments were once united.

After creation of the EPA in the 1970s, however,

health and the environment often became separate

realms with separate administrative structures, separate funding, and separate legal authorities for action.

Doubts about that division emerged in 1988,

when the Institute of Medicine reported on the generally poor state of the public health infrastructure in

the United States. The Institute specifically said that

separating environmental health and public health

had fragmented responsibility for environmental

health.

Over the years, health and environmental data

systems functioned without broader integration. Data

collected by environmental agencies for regulatory

purposes was often unusable for environmental public health tracking. Information covered large geographic areas, like states, regions, or the entire

nation, but rarely zip codes, census tracts, or city

blocks, which might have been more helpful in targeting prevention efforts. On the health side, surveys of

individual health took too long to compile, and

reports from doctors or hospitals were delayed or

lacked crucial details. 
13

The idea of a nationwide tracking program moved

into the public policy arena with a 2000 report from

the Pew Environmental Health Commission, backed

by research from the Johns Hopkins School of

Hygiene and Public Health. The report detailed an

“environmental health gap,” a lack of basic information needed to document links between environmental hazards and chronic disease—even though surveys

found most people thought that tracking environmental health was a good idea.

“When the Pew Commission report came out,

everyone—the press, the public, Congress—couldn’t

believe that a tracking program didn’t already exist,”

says Hearne.

“While overt poisoning from environmental toxins has long been recognized, the environmental links

to a broad array of chronic diseases of uncertain cause

are unknown,” concluded the report. To forge those

links, the Pew report called for integrating tracking

systems for environmental hazards, bodily exposures,

and diseases; linking data to allow swift analysis; and

using the results to prevent disease and save lives.

FIRST STEPS TOWARD TRACKING

The Pew report stimulated new thinking and specific

proposals to overcome the split between environment

“When the Pew Commission report came out, everyone—the press, 

the public, Congress—couldn’t believe that a tracking program didn’t already exist.”

SHELLEY HEARNE, Dr.P.H, FOUNDING EXECUTIVE DIRECTOR, TRUST FOR AMERICA’S HEALTH
14

and health. In response, Congress provided CDC with

funds in 2002 to develop the National Environmental

Public Health Tracking Program.

CDC in turn asked scientists, managers, and policy specialists from two dozen state health and environmental departments, medical societies, nongovernmental organizations, universities, and federal

agencies to serve on workgroups addressing tracking

issues. The four workgroups covered organization

issues, information technology and tracking methods,

tracking systems needs assessment, and how to provide tracking data to health agencies, elected officials,

and the public to prevent disease. 

CDC then selected pilot programs around the

country to build tracking capacity and demonstrate

just what a tracking program could do. The knowledge

gained would open new avenues of discovery, new

paths of prevention, and new hope for long-term

health for all Americans.

A quick look at those pilot projects gives clear

insight into the benefits of environmental public

health tracking.
EXPOSURE TRACKING NETWORK DISSEMINATION IMPROVED PUBLIC HEALTH

HAZARD

HEALTH EFFECT

DATA STAKEHOLDERS PREVENTION

Federal Agencies

State & Local

Governments

Academia

Health Care System

Business & Industry

Nongovernmental

Organizations

Policymakers

Media

Public

Stakeholders Include:

Environmental Public Health Tracking
16

1970

EPA is created—

environmental

health responsibility

moves from public

health authorities 

to EPA

1988

Institute of 

Medicine reveals 

a fragmented 

public health 

system with 

no link to

environmental

health

2000

Pew Environmental

Health Commission

issues America’s

Environmental

Health Gap: Why

the Country Needs 

a Nationwide

Tracking Network

2001

CDC and 

Agency for Toxic

Substances and

Disease Registry

develop a proposed

plan for environmental

public health tracking 

network

2002

Congress funds

$17.5 million to

CDC to develop a

tracking program

and network and

CDC convenes 

planning workgroups

2003

Congress funds

CDC’s Tracking

Program at 

$27.5 million

2004

Congress funds

CDC’s Tracking

Program at 

$27.4 million

2005

Congress funds

CDC’s Tracking

Program at 

$24.4 million

2006

Congress funds

CDC’s Tracking

Program at 

$24.2 million

The Beginning of Tracking
part two

19

LIKE POLITICS, ALL HEALTH IS LOCAL

People can be exposed to the hazards that cause

chronic illness at home, at school, at work, or at play,

so state and local health departments are often best

placed to monitor these hazards. They are aware of any

special local conditions that modify general environmental health risks, and they can take action to

improve conditions. Mercury levels in fish are a priority for Washington State, for example, while

Louisiana focuses on known hazardous waste sites,

and Maine is concerned about high arsenic levels in

well water. For that reason, individual states made

excellent testing grounds for the Tracking Program.

PHASE ONE

To put ideas into action, CDC issued three sets of pilot

grants. The first phase began in 2002 with about $7

million a year allocated for three years to health

departments in 10 states and three cities to build up

their ability to track hazards and diseases. Montana

linked hospital data on respiratory and cardiovascular

disease with air quality monitoring data and found an

association between asthma and increases in fine air

particle levels. New York State tackled a pilot project

that enabled the state’s environmental software to talk

to and exchange data with the health department. The

results led CDC and EPA to explore how similar sysPilot Projects Lead the Way
20

tems might exchange data between the two federal

agencies and among states.

Another seven states divided $5 million a year for

three years, beginning in 2002, for data linkage

demonstration projects. Illinois, for instance, used a

geographic information system and sophisticated

software to track chemical contamination in private

wells in two communities and their effects on rates of

cancer.

“Capacity building may not sound exciting, but it

has been one of the most rewarding aspects of this

program,” says Judith R. Qualters, Ph.D., chief of

CDC’s Tracking Branch. “When we started, capacity

CASE STUDY:

New Hampshire

Tracking programs often help focus the search for the

roots of illness by ruling out a suspected environmental

cause. In January 2006, a retired physician told the local

newspaper that he suspected a cancer cluster in

Claremont, a former mill town in the Upper Connecticut

River Valley. His comments came amidst an ongoing controversy over air pollution from a large solid waste incinerator operating nearby and sparked a call to look into the

health and environmental status of the town.

New Hampshire Governor John Lynch asked the state

health and environmental services departments to investigate. Thanks to a CDC-funded pilot tracking program, the

investigators had access to 14 years of health and environmental data showing that cancer incidence in Claremont

was actually less than expected for similar communities

and for the entire state. The tracking program team

explained the study’s results to community members in

town meetings and answered their questions about health

and the environment.
21

varied widely in the health departments. But in just

three short years, people were doing projects above

and beyond what we originally envisioned.” 

PHASE TWO

In 2003, with additional funds from Congress, CDC

funded nine states and New York City with about $4

million each year for three years to explore how disparate sets of data already being collected could be

linked together. Along with some states from the original group of grantees, funding went to four new

states. Oklahoma’s health department tied data on

childhood lead poisoning, asthma, birth defects, and

CASE STUDY:

California

California’s agricultural industry applies 20 percent of all

the pesticides used in the United States. Pesticides contain

chemicals toxic to humans and can cause acute poisoning,

cancer, birth defects, and nervous system damage. These

pesticides are often applied where people live or work—

schools, homes, roadsides, and farms. With CDC funding,

California increased its tracking program capacity to provide reliable information to residents on pesticide use and

potential for exposure. The public now has free access to

that information through an online tool—AirPIC

(http://www.pesticideinfo.org/airpic)—developed by the

Pesticide Action Network. AirPIC shows that the technical

ins and outs of tracking programs often prove less important to communities than access to easily understood information.
22

cancer to environmental hazard data from the

Department of Environmental Quality. Louisiana

demonstrated ways to link existing state tumor registry data and human exposures to 32 creosote hazardous waste sites, groundwater contaminants, and

drinking water data. 

RESEARCH HELP FROM ACADEMIA

CDC also funded three schools of public health for

$2.1 million in 2002—Johns Hopkins University,

Tulane University, and the University of CaliforniaBerkeley—to explore how knowledge from the

research community can provide technical assistance

CASE STUDY:

Pennsylvania 

At present, the Allegheny County Health Department learns

of a chronic disease in an individual only when it is listed

on a death certificate. The department can’t relate asthma

cases to places of residence to see if they are near known

sources of air pollution. Now, under a CDC grant, Allegheny

County has begun working with the Pennsylvania

Department of Health, the University of Pittsburgh, and

Drexel University of Philadelphia to develop a standardized

asthma reporting system for schools. The two universities

will use their combined expertise in managing and linking

large databases to synchronize the flow of information.

This collaboration will enhance the surveillance of asthma,

clarify the role of environmental hazards and exposures,

and eventually reduce the burden of asthma among

Pennsylvania school children.
23

and training to state tracking programs and further

the science of environmental public health.

A new round of funding was awarded in 2005 to

academic partners including the University of

California-Berkeley, Tulane University, the

University of Pittsburgh, and the University of

Medicine and Dentistry of New Jersey. These university partners continue to research the relation

between health and the environment. They also provide technical advice on the best ways to conduct the

complex data analyses needed to describe and monitor the impact of environmental exposures on human

health.

CASE STUDY:

New Mexico

New Mexico compared levels of arsenic in wells with urine

biomonitoring samples and cancer incidence, evaluating all

the data by census tract. Arsenic in drinking water was

linked to bladder cancer, especially among white residents.

However, bladder cancer rates among Hispanics and Native

Americans were found to be lower, possibly as a result of

differences in how they metabolize arsenic. This pilot project answered some questions but also revealed new areas

for research.
24

FINDING COMMON GROUND

At CDC’s request, each state tracking program convened advisory groups to help identify leading environmental health problems. Most states said air and

water pollution were their prime concerns, while

asthma and cancer topped the list of adverse health

effects. State and city health personnel also wanted

more training opportunities to study tracking,

increased standardization of electronic data elements,

and better methods for disseminating information.

Priorities varied, but there were also common issues

that could be tackled collectively.

By September 2006, state and local tracking

CASE STUDY:

Florida

The Florida tracking program sought to explore how three

developmental disabilities—mental retardation, autism,

and behavioral disorders—might be connected to elevated

blood lead levels. Working with the University of Miami’s

Department of Psychology and Florida’s Department of

Education, the tracking program linked 2003–2004 school

records of 294,806 children with blood lead screening tests

taken over the previous decade. Results showed that children with lead levels above 10 μg/dL had a 30 percent

higher risk of developmental disabilities than children

below that cutoff point. The program found that several

socioeconomic factors were associated with higher levels

of these disabilities. The tracking program also mapped

results to the county level with a geographic information

system so that the health department could inform parents, health providers, and others about taking steps to

eliminate lead poisoning by 2010.
25

grantees had completed projects linking health and

environmental data. These projects looked at asthma,

cancer, birth defects, pesticide poisoning, and

autoimmune and neurodegenerative diseases among

other health outcomes. About half of the state and

local tracking programs examined children’s blood

lead levels, a well-known biological marker indicating

how much lead actually gets into the body. 

WORKING TOGETHER

These grants prompted discussions about tracking

between environmental monitoring agencies and traditional health organizations—both in and out of government. 

Those discussions proved to be at least as important as the grant programs.

“The primary value of the pilot programs has been

that they’ve brought various disciplines together—

especially at the state level—to talk and exchange

information and ideas,” says Henry Anderson, M.D.,

chief medical officer at Wisconsin’s Division of Public

Health.

In addition to its state, city, and academic grants,

CDC has collaborated with a number of other federal

agencies, professional associations, and nongovernmental organizations, including the EPA, USGS,

“The primary value of the pilot programs has been that 

they’ve brought various disciplines together—especially at the 

state level—to talk and exchange information and ideas.”

HENRY ANDERSON, M.D., CHIEF MEDICAL OFFICER, WISCONSIN DIVISION OF PUBLIC HEALTH
26

NASA, the Census Bureau, the Council of State

Governments, the National Council of State

Legislators, the American Public Health Association,

Physicians for Social Responsibility, the National

Environmental Health Association, and the Council of

State and Territorial Epidemiologists.

Professional organizations like the Association of

State and Territorial Health Officials share successful

models, best practices, lessons learned, and resources

developed by funded states with other states to help

them develop tracking capabilities. The National

Association of County and City Health Officials works

to ensure that the Tracking Network meets the needs

of local health professionals.

The pilot projects have now established a proof of

concept and can serve as models for the next round of

the nationwide effort. The challenges they have overcome are providing guidance for the implementation

phase of the Tracking Program.
PHASE I

Extended Funding

$10.2 MILLION

27

2002 2003 2004 2005 2006 2010

The Tracking Program and 

Network Development Through Grants

PHASE III

Implementation — Making It Happen

$14 MILLION (FOR YEAR 1)

BUILDING ACADEMIC PARTNERSHIPS

$8.2 MILLION

PHASE I

Building State and Local Capacity $21.4 MILLION

Enhancing Infrastructure/Data Linking $15.1 MILLION

PHASE I

States: California, Connecticut, Illinois, Maine, Maryland,

Massachusetts, Missouri, Montana, Nevada, New Hampshire, New

Mexico, New York, Oregon, Pennsylvania, Utah, Washington, Wisconsin

Cities: Houston, TX, New York City, Washington, DC

BUILDING ACADEMIC PARTNERSHIPS

Universities: Johns Hopkins University, Tulane University, 

University of California–Berkeley, University of Pittsburgh, 

University of Medicine and Dentistry of New Jersey

PHASE II

States: California, Florida, Louisiana, Massachusetts, New Jersey,

New Mexico, New York, Oklahoma, Wisconsin

Cities: New York City

PHASE III

States: California, Connecticut, Florida, Maine, Maryland,

Massachusetts, Missouri, New Hampshire, New Jersey, New Mexico,

New York, Oregon, Pennsylvania, Utah, Washington, Wisconsin

Cities: New York City

PHASE II

Demonstration — Linking Health and Environmental Data

$11.7 MILLION
28
part three

31

CDC, the states, and cities all learned important lessons from the pilot programs. Flexibility, collaboration, and integration replaced the isolated approach to

data and its uses. Furthermore, the pilot programs

and collaborations are not mere exercises. They have

already begun to pay off, says CDC’s Frumkin. “This is

real information that lets us know we’re on the right

track and helps alert us to problems we need to turn

to.”

Today, because of CDC’s Tracking Program,

Washington State can not only think about mercury

levels in fish, but also take action. Using tracking

resources, it has automated the process of compiling

information from many sources to warn citizens faster

and more accurately about fish hazards. Tracking

funds allowed Maine to examine high arsenic levels in

well water and their effects on reproductive outcomes

so that state public health officials can warn well users

about the hazards of exposure to arsenic during pregnancy. 

Massachusetts’s Center for Environmental

Health monitored the air in schools to measure temperature, humidity, carbon dioxide, carbon monoxide, and fine particulates. It linked these data to

school records and student health data and found

higher rates of asthma in schools with moisture or

A Proven Concept, A New Reality 
32

mold problems.

“The Tracking Program showed us the value of

having advance data on the environment and health

for making decisions,” explains Suzanne Condon,

Massachusetts associate health commissioner. “In

this case, if you have to make a decision with limited

resources, fixing the school with the leaky roof first

makes the best public health and economic sense.”

Since 2002, 21 states and three cities have used

CDC grants to expand tracking capacity and demonstrate to the public what tracking can do.

CDC has not been sitting on the sidelines. The

agency now has greater expertise and capacity to provide technical support to state and local programs.

Meetings and conferences allow people from around

the country to share experiences and lessons learned,

as well as to build collaborations. 

“So much has changed since the Pew Commission

report,” says Hearne. “It’s phenomenal to see the

rapid evolution from concept to implementation,

from gap to engagement.”

CHALLENGES

Yet with all the success of the pilot projects, challenges

still remain.

“Initially we thought we could quickly link envi-

“The Tracking Program showed us the value of having 

advance data on the environment and health for making decisions.”

SUZANNE CONDON, M.S.M., ASSOCIATE HEALTH COMMISSIONER, MASSACHUSETTS
33

ronmental and health data to investigate community

concerns,” says LuAnn E. White, Ph.D., professor and

director of the Tulane School of Public Health and

Tropical Medicine’s Center for Applied

Environmental Public Health. “However, we found

tracking is like peeling an onion—each layer reveals

more issues that require extensive work to find the

answers we seek.”

Among those layers rest questions of how data is

organized, how it can be linked for analysis, how privacy is protected, and how to ensure a broader understanding of the entire program.

The environmental and health communities have

traditionally looked at data in very different ways, says

Richard Jackson, M.D., M.P.H., of the University of

California-Berkeley. The two use different vocabularies and have different standards of accountability.

Environmental agencies accumulate immense

amounts of data, most of it publicly available. Health

data is subdivided, hard to access, stored in aging

databases, and constricted by a legal priority on privacy, all of which lead to its underutilization, says

Jackson. 

A workable system must bridge the gaps between

sources, but not by creating a single massive system,

says CDC computer scientist Patrick Wall. Hundreds
34

of data sources from an array of city, county, state, and

federal agencies must be made compatible and tied

together seamlessly to make a tracking network useful

in practice.

Creating computer systems to exchange data easily requires experts knowledgeable in both computer

science and health. Those experts must unite many

types of environmental and health information, in

diverse data systems, and then devise systems for

complex analyses.

But even simple issues can cause complications.

One state adopts zip codes as its geographic unit, while

another uses street addresses. Men and women are

coded in one database as M or F and in another by

numerals. Information is still often confined by organizational boundaries, although barriers are coming

down, especially where pilot projects have led the way. 

Keeping the health data of individuals private

takes careful planning, too. Laws governing health

information vary from state to state and within each

state. Public health agencies may be authorized or

required to collect some data, yet they are barred from

access to other information. Still other laws regulate

who may use the data and for what purpose.

“The current legal structure is not conducive to

the development and implementation of a compre-

“The current legal structure is not conducive to the development 

and implementation of a comprehensive environmental tracking system.”

LANCE GABLE, J.D., M.P.H., PROFESSOR OF LAW, WAYNE STATE UNIVERSITY
35

hensive environmental tracking system,” says Wayne

State University law professor Lance Gable, J.D.,

M.P.H., “We don’t practice public health or medicine

with outdated science. We shouldn’t practice it with

antiquated legal authorities.”

Finally, the Tracking Program can also benefit

from broader knowledge among the public and policymakers about its purposes and value. The more they

know about this part of the health infrastructure, the

better they will understand how tracking can help

them and their families.

“Infrastructure is rarely at the top of the public’s

agenda, yet it is essential to improve health care in the

United States,” says Hopkins’s Tom Burke. “Unless

you can pull together environmental data and measures of population health, fundamental questions

won’t be asked and can’t be answered.”

THE FUTURE

Yet these are challenges, not obstacles. Today, CDC is

building on its existing partnerships and lessons

learned to implement the next big step: creation of the

National Environmental Public Health Tracking

Network. 

Secure and Web-based, the Network will unite

smaller networks, using standardized data systems to

“Infrastructure is rarely at the top of the public’s agenda, 

yet it is essential to improve health care in the United States.”

TOM BURKE, Ph.D., PROFESSOR, CO-DIRECTOR, RISK SERVICES AND PUBLIC POLICY INSTITUTE, JOHNS HOPKINS UNIVERSITY
36

bring together local, state, and national data sources

for environmental hazards, environmental exposures,

and health effects.

The vision is simple—but making it a reality is not.

Creating the Network will require developing and

using standards to protect sensitive information,

improving states’ computer capacity to exchange

information, and developing tools to consistently

analyze and report data.

The Network will allow cities and states to easily

and quickly access information needed to protect the

health of their citizens. It will help people to learn

about the health status of their communities, about

potential hazards, and about what they can do to keep

healthy. Researchers will access data through the

Network to further our understanding of the environment and health.

In 2006, CDC moved from the planning and

capacity building phase to the implementation phase

of the Network. In August 2006, CDC awarded $14

million to California, Connecticut, Florida, Maine,

Maryland, Massachusetts, Missouri, New Hampshire,

New Jersey, New Mexico, New York, New York City,

Oregon, Pennsylvania, Utah, Washington, and

Wisconsin to continue work on the Network. These

grants will improve information technology but will
37

also expand laboratory capacity, continue training

public health workers, and develop better ways to

communicate information on the Network to those

who need it to take action.

In 2007, with the continued support of Congress,

CDC will expand local and state health department

networks and contacts with other state, local, and federal partners.

In 2008, the Tracking Network will be ready for

launch. Once launched, development will continue as

more people use the Program and CDC expands its

capacity, updates research on the system, and evaluates its progress.

CASE STUDY:

Maine

After a killer winter storm hit Maine in 1998, knocking out

power around the state, Maine’s health department began

receiving reports about carbon monoxide poisonings as

people turned to gasoline-powered generators. Two people

died from the deadly gas and 285 fell ill. Without a tracking system, the department’s most powerful tool for

recording these incidents proved to be the telephone. The

state toxicologist called each of Maine’s hospital emergency departments every day to find out how many people

had been poisoned by carbon monoxide. 

The state’s CDC grant helped Maine begin to track carbon

monoxide poisoning. Maine and other states developing

carbon monoxide surveillance shared their knowledge with

a CDC response team after Hurricane Katrina in 2005. They

helped the New York State Department of Health launch an

emergency carbon monoxide surveillance system after

Buffalo lost power in an early winter storm in 2006.

Tracking provided the resources to collect the information

needed to protect people.
38

The story won’t end there.

“Longer term, tracking will be able to provide a

real service to the American people,” says Michael

McGeehin, Ph.D., director of the Division of

Environmental Hazards and Health Effects, National

Center for Environmental Health at the CDC. “I can

envision a day when people will be able to go to the

Tracking Web site and instantly find a wealth of easily

understood information about their community—on

the environment, possible human exposures, and the

overall health status of their neighborhood. They will

be able to make informed decisions on not only where

but also how they live. We still have plenty to do before

we get to that point, but that’s the tracking goal, and

we’re heading in the right direction.”

CONCLUSION

Since the Tracking Program’s inception in 2002, the

environmental health information gap has begun to

close. CDC and its partners have made great strides in

laying the foundation for an information network that

can guide health protection decisions. 

“Up until now, we have attempted to address

environmental threats to the health of our communities without the benefit of an integrated system of

health and environmental data,” says McGeehin. “A
39

successful tracking system will provide our citizens

with critical information on the threats to their health

posed by the environment and how well we, as a

nation, a state, or a community, are dealing with those

threats.”

Indeed, as this scientific dream becomes an

everyday reality, the National Environmental Public

Health Tracking Program will give state and local public health officials the ability to spot long-term trends

as hazards or diseases increase or decline. The

Tracking Program will help them warn the public and

elected officials of impending health dangers and plan

for changes in health services or infrastructure. When

citizens call with complaints or fears of disease outbreaks, the Tracking Program will provide the data

necessary for officials to respond with scientifically

valid information. The Tracking Program will help

governments at all levels better target scarce prevention dollars.

With the help of the National Environmental

Public Health Tracking Network, scientists, communities, policymakers, and the public will have access to

the information they need to make wise decisions to

prevent disease, keep the American public healthy,

and save lives.

“A successful tracking system will provide our citizens with critical 

information on the threats to their health posed by the environment and how well 

we, as a nation, a state, or a community, are dealing with those threats.”

MICHAEL MCGEEHIN, Ph.D., DIRECTOR, DIVISION OF ENVIRONMENTAL HAZARDS AND HEALTH EFFECTS, NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CDC
40

2006

> Disseminate lessons learned from

tracking program projects

> Disseminate Tracking Network

Implementation Plan 

> Fund state/local health departments

to construct tracking networks

> Begin construction of CDC national

Tracking Network

> Complete state/local pilot projects

> Identify nationally consistent data

and measures 

2007

> Disseminate standards for Tracking

Network structure and content

> Publish report on first four years 

of Tracking Program

2008

> Deploy national Tracking Network

> Deploy state and local networks

> Publish first CDC biennial report on

health and environment

2009

> Develope strategic plan for 2010–2015

> Expand and enhance the content and

usability of the Tracking Network

2010

> Develop additional Tracking Network

tools and services

> Publish second CDC biennial report

on health and environment

The Future of Tracking

“Longer term, tracking will be able to provide a real service to the American

people. I can envision a day when people will be able to go to the Tracking

Web site and instantly find a wealth of easily understood information about

their community—on the environment, possible human exposures, and the

overall health status of their neighborhood. They will be able to make

informed decisions on not only where but also how they live. We still have

plenty to do before we get to that point, but that’s the tracking goal, and 

we’re heading in the right direction.”

Michael McGeehin, Ph.D.

DIRECTOR, DIVISION OF ENVIRONMENTAL HAZARDS AND 

HEALTH EFFECTS, NATIONAL CENTER FOR ENVIRONMENTAL HEALTH, CDC
41

Before tracking, even simple questions about health

and the environment would take months to answer. 

With a tracking system in place, health officials

can respond quickly, often within hours, to locate hazard sources or allay citizen concerns.

Before tracking, collections of data were created

and held by many different government departments

in individual “silos.”

Tracking creates standards and tools to link these

disparate sources of information and then help ask

important questions about the public’s health.

Before tracking, the environmental and health

realms were often separated administratively and

philosophically.

The CDC tracking initiative brings these two

worlds together for the benefit of all.

Before tracking, health and environmental officials concentrated mainly on acute incidents like hazardous chemical releases or point-source pollution.

With tracking in place, they can follow amounts

and geographic spread of compounds over time,

allowing them to monitor long-term trends and place

those acute incidents in context.

Before tracking, CDC and state and local health

departments concentrated on infectious disease surveillance, their traditional area of concern.

With tracking, they can apply the same “disease

detective” skills to finding environmental causes of

illness and then taking preventive measures to protect

the public’s health.

Before and After Tracking

Acknowledgments

CDC would like to thank

the following people and

organizations for support

in developing this book:

FROM APHA:

Tracy Kolian, Policy Analyst, and Susan Polan, Ph.D., 

Associate Executive Director, Public Affairs and Advocacy

AUTHOR:

Aaron Levin

DESIGN:

Zeigler/Dacus, Richmond, Virginia

THIS BOOK WAS DEVELOPED UNDER CONTRACT NUMBER 200-2006-15969 WITH FUNDS FROM CDC.

43
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ASTHO [Internet]. Available at: http://www.astho.org/pubs/EPHTfactsheet.pdf. Accessed November 2006.

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Bell ML, McDermott A, Zeger SL, Samet JM, Dominici F. Ozone and short-term mortality in 95 US urban 

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Atlanta, GA, August 9-11, 2006. CDC [Internet]. Available at: http://www.cdc.gov/nceh/tracking/tracks06/presentations.htm. 

Accessed November 2006.

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45


Centers for Disease Control and Prevention

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Tel: (404) 639-3311

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For more information about the National

Environmental Public Health Tracking Program

please visit: www.cdc.gov/nceh/tracking.