Meeting report: development of environmental health indicators in Brazil and other countries in the americas.

This report summarizes the Brazilian experience on the design and implementation of environmental health, with contributions from Argentina, Canada, and Cuba, presented at the International Symposium on the Development of Indicators for Environmental Health Integrated Management, held in Recife, Pernambuco, Brazil, on 17-18 June 2004. The methodology for the development of environmental health indicators has been used as a reference in the implementation of environmental health surveillance in Brazil. This methodology has provided tools and processes to facilitate the understanding and to measure the determinants of risks to environmental health, to help decision makers control those risks. Key words: environmental health indicators, environmental health surveillance, integrated management.

From 1998 to the present, the Ministry of Health of Brazil has implemented environmental health surveillance (EHS) within the National Public Health System. The methodology for the development of environmental health indicators became one of the key issues for the implementation of EHS. The driving force, pressure, state/situation, exposure, effects, action (DPSEEA) model approach was applied to develop appropriate indicators (Corvalan et al. 1999). This matrix model takes into consideration the relationship cycle process among economic and social dynamics, environmental response, and human health. Thus, the driving forces consist of the economic and social processes, resulting in pressures such as the intensive use of particular natural resources. Both driving forces and pressures contribute to the situation/state scenarios where the environment is often contaminated or deteriorated, facilitating human exposure to environmental risk factors that might produce effects on health. For each of these categories, indicators and action proposals are developed to gain a more complete understanding of the problem as well as to visualize measures to be taken in each level of complexity of the cycle (Figure 1). The main objectives of the symposium were to assess the use of the indicators for the environmental health integrated management in the countries of the Americas, to present the Brazilian experience in the development of indicators regarding the integrated management of environmental health, and to contribute, through the development of environmental health indicators, to the strengthening of the following initiatives: a) the Health and Environment Ministers of the Americas meeting, b) the Pan American Health Organization Environmental Health Collaborating Centers Network, and c) methodologies for the integrated assessment of environmental health in the Americas.

The Regional Experience
The experiences in developing indicators in some countries in the American continents were evaluated, with particular attention to their usefulness in the decision-making processes. A summary of the indicators developed and evaluated are shown in Table 1, and national and international examples of the application of indicators are described in Table 2.

Conclusions and Recommendations
The symposium, in addition to presenting the experiences in Brazil and other countries, assessed ways of adopting the proposed indicators should also respect and incorporate community-based knowledge, the interdisciplinary and intersectorial approach toward integrated management. • The participation of government decision makers in the identification and development of indicators is highly valuable because it results in an improved future management of the problems identified. The environmental health indicators matrix (DPSEEA) also proved useful for the analysis of complex problems and for the analysis of emerging issues, such as the products of nanotechnology, genetic manipulation, and nonionizing radiation among others.
DPSEEA, which is a framework that organizes information from economic and social dynamics, environmental response, and human health, addresses all the complex levels of a given problem, and it is more efficient in the analysis of such problems compared with other cause-and-effect models. It promotes a holistic view of the issues and is therefore effective in the identification of relevant indicators. It is also a valuable tool for learning, training, and deeper discussions on complex exposure-effect process relationships in environmental health.
Workshop participants commented that DPSEEA would have some limitations if understood only in a linear and vertical form without considering the complex socioenvironmental contexts and their relation with underlying health problems, environment, and quality of life. Uses the DPSEEA framework to organize the environmental health indicators Currently collaborating with Environment Canada on the development of an air-health indicator (AHI) The potential AHI builds on ongoing work on improved air quality index to develop a multipollutant trend indicator that directly links potential health impacts to exposure to pollution, as recommended by NRTEE Such an indicator has also helped to assess the effectiveness of pollution mitigation strategies and public health interventions