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Profiles in Leadership, Part II: The 15 Faces of Environmental Health Leadership

Posted on: Friday, 26 January 2007, 12:00 CST

By Berg, Rebecca

The individuals who were most frequently mentioned in the JEH leadership survey are a diverse group. (For more on ther survey and its methods, see last month's column.) They have worked for federal agencies, for trade associations, for local health departments, and in the private sector. They are ethnically and geographically diverse. They are American born and foreign born, men and women, religious and secular, extroverted and introverted. They are even short and tall.

All of which reflects well on the profession. Environmental health practitioners are interested in substance. They do not traffic in stereotypes, and they are not led by superficial flash.

Despite the diversity, a recurring theme emerged from the interviews with the 15 leaders who are profiled below: environmental health departments need to get out of the inspection rut and work interactively with communities to study disease patterns and environmental threats. A corollary is that the profession needs to reassert its public health mission and learn to communicate that mission. Another corollary (just as important but perhaps less obvious) is the need to cultivate listening skills. In fact, the conversations returned to that second corollary-the power of listening-with striking regularity.

For the rest of this introduction, JEH will highlight one other thing that the 15 people interviewed for this article had in common. That commonality was not a theme but a character trait. It was a trait of the most tangible-and mundane- sort: Their thoughts came through clearly on a cassette tape.

Does this seem like a trivial matter? JEH would suggest that the ability to be intelligible over the hiss of a tape and the rumble of a keyboard as a busy reporter transcribes your comments at 70 words a minute or so is actually a fair test of verbal clarity. If you can be heard under those circumstances, chances are you're still more vivid in person.

So then: Does leadership come down to what mothers, fathers, and grade school teachers have been saying-"Speak up! Enunciate!"-for generations? Yes and no. It is good to speak up and enunciate. But intelligibility on a cassette tape is not only about volume and the pronunciation of consonants. In fact, some of the leaders JEH interviewed for this article were rather soft spoken. And there were plenty of dropped Gs that never interfered with intelligibility.

No, the reason the tape machine makes a good indicator is that in less-than-ideal acoustic circumstances, listeners use speech patterns and emphasis to construct meaning. Speakers who overcome interference and background noise do so by giving their sentences expressive shape. To some extent, that kind of expressive clarity can derive from conscious strategies (think, for instance, of the little pauses that effective speakers sometimes allow before words of special significance). But to a larger extent, expressiveness derives from passion and energy. The voice rises and falls naturally, giving enthusiastic emphasis to important points and key words. When fear, uncertainty, or self-consciousness blocks that energy, the result tends to be monotone speech.

It may be that groups of people look to their leaders to compensate for their characteristic weaknesses. At any rate, a disconcerting number of the practitioners who were interviewed for this series spoke about urgent issues (issues that JEH knows they care about) in a monotone or dropped their voices, as if in embarrassment, precisely as they approached a telling word.

One of the key points that came out of this project is that there is a quality of blocked energy in the environmental health profession (see last month's column for a more detailed discussion). Why has this happened to environmental health? It's important to acknowledge that the problem may have many causes. As NEHA Executive Director Nelson Fabian pointed out in the course of his interview for this article, the external conditions under which the profession often operates-lack of political support and its quite tangible corollaries (dreary office quarters, outdated computers, and inadequate equipment, for instance)-can send a dispiriting message.

But JEH wonders if certain internal factors might also be at work. In addition to giving good advice like "speak up" and "enunciate," our cultural authority figures have been known on occasion to send, often subliminally, some less constructive messages. Perhaps environmental health practitioners have a bit too conscientiously internalized these strictures:

* Don't be well spoken-people will think you think you're so great.

* Don't be emphatic-people will want to take you down a peg.

* Don't show off-nobody cares.

And there's some truth in the message: It's a dangerous world! If you choose your words well, some people may feel threatened. If you show excitement, some people may respond with malice and ridicule. It's a risk. That's why leadership does, ultimately, require courage.

So without further ado, JEH introduces 15 courageous environmental health leaders.

Rob Blake, M.P.H., R.E.H.S.

NEHA President Elect Rob Blake is living proof that it is possible to be an influential environmental health leader without being the loudest person in the room. Quiet environmental health professionals might do well to take his example to heart. Nor does he fit that other stereotype-the ruthless Type-A personality who has no personal life and neglects his family-that shy people sometimes conjure in order to persuade themselves that they were never going to be leaders anyway.

That is not to say that Blake does not work hard-and systematically-at everything he does, completing his master's in public health degree at the University of Michigan, for instance, while working full time. But at a couple of key junctures, he took a strategic step backwards in order to learn and grow, both professionally and personally.

His career began in London, England. At the time (the late 1970s), "they had a really super way of bringing people into the profession," Blake told JEH. "You applied for a student internship or student training position and became a trainee environmental health officer. The process was very competitive because the employing authority actually paid your way through college. In return, we had to give at least two years' service on the back end of the degree." Blake thinks, by the way, that if money could be found to finance something similar in this country, it would help with the workforce development issues now facing the profession. Even if a program sponsored just the last two years of a student's college education, "then you could have a selection process and maybe support folks who had shown a bent toward science and health for the last two years, and then get them out in the field."

Blake worked as a trainee in the London borough of Croydon during breaks in the school year, gaining increasing responsibility as time went on. By the time he finished his undergraduate degree in 1980, he and a fellow student were almost managing their own districts.

Instead of continuing on in London, however, Blake married an American and moved to Saginaw County, Michigan. There, he had a new world to learn. The vastness of the country was a shock, he said: "I remember on the train [crossing over from Toronto]. I just remember saying to Jo, 'Where are all the people?' In Saginaw, the flatness- and the winter was pretty bleak."

A different landscape meant Blake needed to develop new environmental health skills. He found work as an entry-level sanitarian with Saginaw County, and "I learned a lot of things on the rural side," he said. "I learned a lot about water wells and septic tanks and some of the rural health issues. Very good experience."

Later, he worked for Washtenaw County, first doing food safety work, then, in quick succession, coordinating a pollution prevention and community right-to-know program and becoming director of environmental services. And maybe that was too much too fast.

"I jumped from a technician level into a director level," Blake said, "overworked myself, tried to get too many things going at once. And"-he paused

I was starting to lose my family. I was young; I was naive. I was just over 30 at the time. And I didn't want to lose my family. I was good technically, but I hadn't made that leap into the managerial and leadership aspects, where you trust people to do their things and you can handle the political pressures-and not work 15-hour days. You know, take it all home and stress yourself out at home and not be part of your family.

So after a year as director in Washtenaw County, Blake took a position as an assistant director in DeKaIb County, Georgia. He worked in that position for three years. In 1999, he became director of environmental health for DeKalb County and has held that position ever since.

JEH asked if he had any advice for people who might be struggling with the issue of how fast to advance in their careers. He said, "If I were doing it again, I think I would talk to people ahead of time and try to get more mentoring around that transition from the technical side to the managerial side.... But," he added, "I'm glad I went through it [the position in Washtenaw County]. Because I learned \so much. With the next steps that I made, the next promotions that I went for, I was more prepared, and I was thinking different questions." He also learned that it was important to trust members of his staff and "give them tasks that make them reach and stretch and grow."

JEH noticed an interesting pattern in Blake's career: Although he took several deliberate steps backwards, he kept getting promoted. This pattern contradicts much of the conventional wisdom about unforgiving career ladders, about the need for relentless ambition and unyielding aggression. Some quality seems to shine through in Blake, some merit that without a lot of high-volume self-promotion is readily apparent to those around him.

"The interesting thing about Rob," said one of the people JEH interviewed for Part I of this series, "is that he doesn't give an opinion until pressed for it. He is too busy asking questions from all the experts he can find. He is a constant learner and therefore must be an expert by now."

Perhaps the key is curiosity. Rob Blake is always interested. Everywhere he goes, he takes notes. He is constantly listening to other people, constantly writing down what they say. "I'm just known," he told JEH, "for carrying my big old fat Franklin around.... I've been told by presenters that diey like to have me in their audience because I look at them, nod my head occasionally, smile, and take lots of notes. Consequently they look back at me more in their presentations and I feel like I'm getting individual tuition."

That practice of listening and culling ideas everywhere he goes has led directly to innovative work in DeKalb County. Blake has expanded the use of student interns; established flex time, telecommuting, and work-from-home days for staff; and implemented the Protocol for Assessing Community Excellence in Environmental Health (PACE-EH).

"Instead of the top-down governmental approach," he said, "we go out in the community and start asking: 'What are the issues that you think are most important to you?'"

As a result, his department has stepped outside its daily routine to take on some unexpected issues. Staff are looking at landfills in south DeKalb County, where the presence of five landfills has created some environmental-justice issues. They also dealt with issues that arose from a proposal to site a crematorium in south DeKalb; residents in a nearby apartment building were concerned about emissions from the bodies that were going to be burned, especially the mercury amalgams that would be emitted.

Was it a problem, JEH asked, for the health department to get involved in that kind of issue? A lot of issues that, philosophically speaking, are environmental health issues don't technically fall under health department jurisdiction. What did Blake's department do when it lacked a regulatory platform or the legal standing to get involved?

"We just had to listen," Blake said, "to the community. Because if it is a concern to them, it's a concern." Sometimes serving the community meant connecting people with other agencies. He gave another example:

We had a couple of churches that were complaining about fuel dumps. They could smell fuel in the air. And they thought it was fuel being dumped from planes approaching the airport. So we found out who the people are who deal with that, where the fuel dumps have occurred, when they've occurred....

Over the years, Blake's department has increasingly come to be consulted on issues that fall outside its regulatory mandate: zoning and land use issues, for instance, "so now we're commenting on sidewalks, on school siting, on low-flying aircraft," Blake said. "We're accepted as making valid comments."

He sees himself primarily as an implementer. "I tend to tweak what other people have done. And then I'm fairly strong on the activation end. Once I've got an idea where we're going, then it's 'Okay, move. Action. How do we make that happen.'"

The emphasis on listening does not mean there is anything fuzzy about the way Blake works. He breaks down his goals into component parts and keeps track of them with detailed lists-tasks to be undertaken and tasks accomplished. Perhaps his effectiveness ultimately resides in that simple act of note taking-which allows him to be both open minded and systematic-and the fact that he is always at it:

Frequently I'm stuck in traffic on the way home, and I'm jotting down ideas for the next day. Don't let them slip. I carry a little notebook around in my top pocket. Frequently, I'm out with the family at a ballgame or something, and I just get an idea; I'll jot it down.

Pat Bohan, M.S.E.H., M.S., R.S.

An examination of Pat Bohan's achievements reveals something about environmental health leaders that should perhaps be more widely known than it is: Leadership (which Bohan defines as "taking people where they haven't been before") often involves blood, sweat, and tears.

Bohan is perhaps best known for his work in establishing the Environmental Health Services Branch (EHSB) at the Centers for Disease Control and Prevention (CDC) and for initiating EHSB's Environmental Public Health Leadership Institute (EPHLI). The work was undertaken because Dick Jackson, then director of CDCs National Center for Environmental Health (NCEH), had noticed an absence of sanitarians at the agency.

In the beginning, he said, "Dr. Joe Hollowell and I worked on that in '97, just the two of us, no budget, no nothing." By the time Bohan left in 2002, EHSB had a budget of $7 or $8 million.

Wait. He got a new federal program funded? How did he do that?

"Just putting in extra time and effort. We just made the case. Joe and I went around the country, learned as much as we could about the needs of local departments. During the Clinton Administration," he added, "there was emerging-infectious-disease money. So we got some money through that for food safety-related issues. And then the NCEH director gets some discretionary money for environmental health activities." He paused. "There were probably one or two other ways."

One kind of funding that EHSB did not get was a budgetary allocation from Congress. "Line-item funding," Bohan said, is a political problem that EHSB is still struggling with.

To illustrate the hard work involved in making new things happen, Bohan cited some of the trainees whom he has mentored through EPHLI.

"To a person, they had to work outside of regular hours-extra hours-to get this done. There was a lot of training, and there were setbacks.... It took a lot of blood, sweat, and tears. It was"- quite simply-"hard."

Blood, sweat, and tears are left surprisingly inexplicit in many discussions of leadership. (That is true not just within the field of environmental health, but in American culture at large.) There is a tendency to gloss over the grubby slog and grind and to perhaps hold up a miraculous result and sing the praises of an amazing hero.

And what's wrong with that? What's wrong with having a few shiny heroes to admire?

The problem is that when the next potential leader comes along and wants to "take people where they haven't been before," the wheel has to be reinvented. He or she has to discover all over again what effort means.

"I wonder, too," Bohan said, "if some people don't feel that, well, maybe I'm in this alone. Maybe there's nobody else."

Ah, self-doubt: Am I crazy to try this?

Or, as Bohan put it, "Am I just wasting my time?"

He thinks members of the profession would benefit from a compendium of stories that illustrated the extraordinary efforts that went into other peoples achievements. Paradoxically, he thinks such stories would serve to encourage future leaders; if more people knew how hard it is to make something new happen, they would be less likely to be discouraged by obstacles.

"A lot of it doesn't just come," he said.

Bohan cites his mother, who was a public health physician, as a formative influence for his work ethic and his interest in public health. Gunar Bohan, originally from Syria, was the first Muslim woman to graduate from the American University of Beirut with an M.D. degree. She met Bohan's father, who was in U.S. Navy intelligence in Beirut during World War II.

"They met-a Christian and a Muslim-" Bohan said, "and they ended up eloping and came to Boston."

She was so good at what she did. She was very in touch with people-spoke four languages-and she was one of those personalities, one of those people who come into a room and brighten it up, very friendly, always remembered people's names. Caring and well read.... So I used to hear about public health a lot when I was growing up. I would hear about everything from health issues to personnel issues.

Although Bohan is now retired from a 26-year career with the U.S. Public Health Service, he is deep into a second career, holding a position as assistant professor of environmental health science at East Central University (ECU) in Oklahoma, doing work under contract with CDC, serving as a mentor for EPHLI, working with the U.S. Environmental Protection Agency (U.S. EPA) on a summer enrichment program for Native American children, and winning a grant to form the Training Center for Native American Healthy Housing at ECU, where he serves as director.

He is also working on his doctorate, a project that has included drafting a set of performance standards for the practice of environmental health at the local level. How does he do it all? Not by magic.

The Centers for Disease Control and Prevention

The name that came most often to people's lips when JEH asked about environmental health leaders was not the name of any one person. It was the Centers for Disease Control and Prevention (CDC). One respondent referred to CDC as "the epicenter of public health leadership." Another sees the agency as one of the few places where people are thinking and working on a national level to promote environmental health. Respondents looked to CDC not just for broadnes\s of perspective, but also for expert research into particular subject areas. And many people mentioned the agency's work on the Environmental Public Health Leadership institute (EPHLI), which is addressing the leadership crisis in the profession by providing course work and mentoring for practicing environmental health professionals from around the country. (For more information on EPHLI, visit the program's Web site at http://www. heartlandcenters.slu.edu/ephli/.)

Respondents also mentioned the names of a number of individuals who work at CDC. Below, JEH profiles three of those mentioned as examples of the kind of hardworking people who make up the agency.

Sharunda Buchanan, Ph.D., M.S.

Dr. Buchanan traces her interest in public health to something that happened when she was a teenager. One night when her family was finishing dinner, her father suddenly appeared on television. As president of his community civic club, he was carrying a picket sign and talking about the public health consequences of a proposed landfill.

"And I thought," she recalls, "What is this about public health?"

Buchanan also had a deep love of science (here, too, she sees the influence of her father, a junior high principal who also taught math and science). And she wanted to find a way to combine that passion with an interest in helping people. After getting bachelor's and master's degrees in chemistry and a doctorate in biochemistry and toxicology, she began working as an environmental health scientist at the Agency for Toxic Substances and Disease Registry (ATSDR).

"That became my goal-bridging the gap between environmental science and human health. So that's the reason I was so interested in environmental epidemiology."

One of her ambitions was to be accepted into CDC's epidemic intelligence service (EIS), an extremely competitive, epidemiology- based training program. Doctors and Ph.D. scientists from all over the world compete to get into the program, Buchanan told JEH.

"To get accepted into EIS really is a feat," she said.

Buchanan entered EIS in 1993. She is particularly proud of the work she did as an EIS officer on heat-wave mortality. "In 1993, I and a couple of other scientists were the first to look at this as an epidemic," she said. "We believe we helped pave the way to looking at heat wave mortality and getting the public to recognize the issue." The work was written up in an article titled "Cardiovascular Mortality: The Hidden Peril of Heat Waves" (Wainright, Buchanan, Mainzer, Parrish, & Sinks, 1999).

She got the assignment in part, she believes, because before getting her degrees in chemistry and toxicology, she had also obtained a license and an associate's degree in mortuary science. "They looked around at CDC for somebody who was able to read death certificates and knew how to talk to medical examiners-and there weren't a whole lot of us. My name came up."

The project was perhaps a perfect example of how public health education can work. Before Buchanan and her colleagues undertook the project, it was not uncommon to hear of morbidity and mortality from children getting left in cars in the heat "and people innocently not knowing that this was not a good thing," she said. Such stories occasionally still crop up, but not nearly as often as they did a decade ago. The improvement in health outcomes is not because the world on the whole is getting any cooler; it's purely a function of public awareness.

From 2001 to 2006, Buchanan served as chief of CDC's Environmental Health Services (EHSB), where she led the development of a major document, A National Strategy to Revitalise Environmental Public Health Services in the United States (2003). Environmental health directors all over the country now use this document in shaping their programs. The goals and objectives of the strategy, Buchanan said, "focus on the need to revitalize the entire environmental public health system and the need to do so in a concerted fashion. We need to build capacity, foster research and leadership, develop the workforce, communicate and market, and develop strategic partnerships."

What sorts of challenges does revitalization entail? The biggest task, Buchanan thinks, is to systematically increase the capacity of environmental health infrastructure. All other challenges are simply aspects of that imperative: new environmental threats such as SARS, hanta virus, and West Nile virus, for instance, not to mention emergency response.

We need a system that will help enhance an ill-prepared and shrinking workforce, and we need the country to think about adopting a strategic way of doing so, something we can all buy into. We had over 150 partner organizations provide input into this document, and approximately 25 to 30 of them came to the table-came to CDC in Atlanta. This was right after September 11, 2001.

Other issues that should be considered part of the future of environmental health are land use planning-with all its implications for issues like obesity and heart disease-and global warming.

Ah, global warming, JEH said. Everybody is worried about it; everybody considers it a quintessential environmental health issue. Nobody seems to know what environmental health practitioners can actually do about it.

"We all have a role," Buchanan said.

It is important, she believes, to consider global warming under the rubric of preparedness. In light of severe weather patterns in recent years, she thinks it is particularly urgent to be prepared for heat waves, hurricanes, and natural disasters in general:

Emergency preparedness also feeds into land use planning, you know. What happens if you don't design a particular city right? We can all talk about what might happen. We can learn from Katrina; we can learn from other hurricanes and disasters.

Another project Buchanan has in mind is recruiting retirees to help on the local level. EHSB has been working with retired military professionals to build up a corps of professionals who could perhaps take a few courses to "beef up their training" and then go out and share their expertise with local departments. She would like to see a kind of "environmental health service corps" develop into something along the lines of EIS: "What we got from EIS," she pointed out, "is common problem-solving methodology."

EIS has "epidemic intelligence officers."-EIOs. An environmental health service corps would have environmental health officersEHOs.

It's an idea that goes to the heart of the localnational divide in environmental health. Buchanan told JEH that she thinks environmental health is local.

But you can make sure that from a national perspective, the word gets out and trickles down to that local entities, so that they see themselves as a part of a larger effort.... Each one is different, with its own nuances, with its own issues, and we need to be able to recognize that. There are some common trainings, there's some common vernacular and some common tools that we as a national program can put out there, but hopefully these state and local entities will take those and customize them for their own issues.... It's like a mirror. We want to work with them to make a difference in their communities. But we also want them to give us feedback as to how we might do that better.

She added that EHSB is working on an "environmental health capacity-building program." The program is still very small, but the hope is to garner larger support, and its method would be to speak with state and local departments and say "What do you need? How can we support you to build capacity."

The term "capacity," she pointed out, is a broad one. Capacity building might mean building infrastructure. It might mean establishing connections between counties or states or between a health department and a local hospital. "Capacity building is a really, really big word," she said, "and we want to help them to help us define it for their particular jurisdiction."

All these projects were on Buchanan's plate in April when she spoke with JEH. Since then she has been appointed director of the Division of Emergency Environmental Health Services at NCEH (see the biographical notice that appears on page 82 of this month's Journal).

JEH wondered how Buchanan does it all. In the first article in this series, lack of time emerged as a major theme among environmental health practitioners at all levels. People were saying, essentially, "I'd like to take on all these important new issues like land use planning and global warming, but I'm in quicksand. I don't have the staff to do even our most routine mandated tasks."

Did Buchanan, JEH wanted to know, have any advice for them?

"Well I do, she said, "but it might not go over so well! You know, you make time for it-you make time and room for things that you believe are important. Do we not? And that's just human nature. If we really believe that it's important, we make time for it."

For instance, I know how important it is to publish some of the new and innovative methodologies. What I suggest to staff is "Okay, take half a day in the library, at home-do what is necessary to get a particular publication out." It's important to get the word out- to disseminate best practices and successful demonstrations. I know there are going to be tradeoffs. So yes, we'll all gather together and rally around you and take up whatever you needed to complete today and have you complete this-it's just a matter of rescheduling, reshuffling, and just doing a little bit every day.

Mark D. Miller, M.P.H., R.S.

Mark Miller, who got his bachelor's degree in environmental health from East Central University in Oklahoma, attributes the direction his career has taken to an intervention by one of his professors. Dr. Mickey Rowe had been encouraging his former students to consider careers in the Commissioned Corps of the U.S. Public Health Service (U.S. PHS). So Miller, who was working at the time for a private wastew\ater treatment operator, looked into it.

U.S. PHS did prove to be a place of opportunity. The corps emphasizes professional growth and sends its officers around the country to work with a variety of agencies and institutions (such as CDC). The officers are expected to advance on a regular basis and to carry the insights they gain from one institution to the next. In Miller's case, U.S. PHS also furthered his career by sending him in 1992 to the University of Texas to get his master's degree in public health. (For a history of the Commissioned Corps, as well as information on jobs and applications, visit http://www.usphs.gov/ html/history.html.)

But in 1988, Miller's first assignment for the corps was to work with the Indian Health Services in Gallup, New Mexico. "I absolutely loved it," he told JEH-and he worked with the Indian Health Service on various projects in a variety of locations until 2000, when he was sent to the Agency for Toxic Substances and Disease Registry (ATSDR) for two years.

At ATSDR, his assignment was to work with communities in which Superfund sites were located. He explained risk to community members, explained what was known about a particular hazard or chemical, explained how to avoid exposure, and in general bridged the divide between scientific language and the everyday language of the affected communities.

That must have been an interesting and challenging process.

"Yeah, it was," Miller said. "Sometimes people are upset at what's occurred. Sometimes they see the government as a whole, and they're not receptive. You have to work through a lot of issues. You have a lot of issues to overcome."

JEH asked if he had any words of advice for other environmental health practitioners facing challenges of that sort. His answer was heartfelt:

I think you have to-although it's impossible-you have to try to put yourself in other people's shoes. How would you feel if it happened in your community? Be understanding. And realize that sometimes when people say things about a particular event or whatever, you can't take it personally. You have to let them express their feelings and work with them to get to the real issues and understand how you can help them.

Miller acknowledged that the learning curve in all this can be fairly steep for someone with a science background. "We tend to talk in science terms," he said, "and we think that the whole world talks the same way-everything is all acronyms and levels of exposure and parts per million."

It's not a matter of "dumbing down" the material-and it's probably not constructive to think of the work in those terms, he said. It's a matter of translating the concepts into a language that is familiar to members of the community. And it's a matter sometimes of anticipating what people aren't going to know as a matter of course about things that might be a matter of course to the scientist. That work can require a significant effort of intellect and imagination.

After two years with ATSDR, Miller came to CDC. He had heard about an opportunity in the Environmental Health Services Branch to work in the field of preparedness, and he had read about EHSB's strategy to revitalize environmental health.

Those two areas of work are mutually reinforcing in Millers view: "I think there are more and more opportunities, certainly around preparedness, in environmental health."

The field is, he thinks, beginning to catch up with the preparedness trend. Yes, environmental health professionals could still do a better job of defining their role in emergency response,

but I think we are starting to see it now, finally taking root in the states, that the states are really defining what the role of their practitioners is. In Florida, for years, I think that was pretty well established because they got hit [with hurricanes] so regularly. They were going to have to go out and restore food operations, take care of shelters, and help with water and sanitation needs.... And now a lot of states are starting to see incorporation of environmental health roles into disaster response planning.... When environmental health ' isn't present, you start to get into real issues. You really, right off the bat, have to take care of peoples basic needs. If you don't, you're going to get disease outbreaks.

Miller is also working hard these days on workforce development. He has served as a mentor for EPHLI, for new officers in the Commissioned Corps, and for the U.S. PHS Junior Commissioned Officer Training and Extern Program (JRCOSTEP). The latter program is an opportunity for college students to intern with U.S. PHS during breaks in the school year (usually during summer vacation). It can give them an idea of what a career as an environmental health officer in U.S. PHS would be like. (For more information on JRCOSTEP, including application information, visit http:// www.usphs.gov/html/ jrcostep.html.)

Miller is particularly excited about another project: putting together some emergency response training courses and workshops specifically geared toward the role of environmental health practitioners during emergency response. (One of these workshops was given at NEHA Annual Educational Conference last June.) He believes this program will fill an important gap.

"You see a lot of workshops and curricula on preparedness," he said. "There's things like risk communication, which is good. But there's very little out there that speaks directly to what practitioners do in emergency response."

He'd like to create more incident command training specifically oriented to environmental health practitioners. During an emergency response, he said, "you've got a lot of data inputs that are coming into the emergency operations center. And it takes a talented and experienced practitioner to be able to sort it out and make a decision, weighing all the factors."

At the end of the interview, JEH asked Miller about sources of inspiration in his career. His response demonstrated the importance of listening skills to effective leadership:

I'm very blessed, because I was surrounded by people who wanted to see my career grow and flourish-who genuinely believed in me. So 1 want to pass that on to other people. It makes a world of difference. We need to keep that in mind in our daily work, too. A program will be that much stronger when you can facilitate growth within individuals. When I started in the field, I saw-well, that this could be improved, that could be improved. With younger officers, I think you encourage them to do that. I think what I call it is respectfully challenging the system. And I was lucky. I worked for a lot of people who would listen to your ideas and work with you on them.

Charles Otto, M.P.A., R.S.

When Charles Otto went to college, he was already interested in environmental issues. He was also interested in the field of medicine. So when the Auburn University environmental health program was formed in his junior year, he thought: "Boy! That's sort of interesting!" Here was an opportunity to combine his two interests.

He became the first graduate of the program and went on to work at the environmental health department in Mobile, Alabama, the second largest department in the state. While working in Mobile, he also obtained his master's degree, attending school at night.

That must have been a strenuous time.

He laughed. "You know, when you're young, you do things like that."

JEH asked if he had any advice for people who might be considering graduate school while working.

"I think it's well worth it," he said, "to go for higher education. And particularly after you've worked a little while.... If you have a little work experience, it helps to make that graduate education a little bit better."

After working for the state health department, Otto joined the Commissioned Corps of the U.S. Public Health Service in 1987. His first assignment sent him to Washington, D.C., to work in the retail food protection branch of the Food and Drug Administration (FDA). At that time, FDA had just begun work on rewriting the national retail food safety code. Otto said he learned a lot of history-"60 years' worth of history"-because the process involved going through a code that had been in place since the 1930s.

And what had happened in updating the code roughly every 5 to 10 years was they added a few more requirements. Now they were trying to revamp the entire process by going back and looking at every requirement in the code to see if it made sense at the end of the century. We were getting into a lot of research reviews, talking to scientists all over the world about what they were seeing as the challenges to food safety. We were working on applying principles. Maybe we were protecting against 10 different things by having the right principle in place rather than trying to incrementally create 10 different requirements that basically read the same way.

The result was FDA's Model Food Code, which was introduced in 1993 and contained a number of new approaches, including the hazard analysis critical control point (HACCP) system. In the 13 years since it first appeared, that code and its updates have increasingly been adopted across the country.

Another project Otto worked on was the FDA Electronic Inspection System, a database system that state and local departments could use to track inspection results. It was adopted by several hundred jurisdictions. The system, though no longer in use, was an early precursor of the many software packages that are now commercially available and that still apply many of the operational principles of the Electronic Inspection System.

Otto undertook one other major project at FDA:

When I got there, I found that they had in their files pretty much all the answers I'd ever needed at state and local about food safety. You know, they had an excellent file system. But that was information I'd really needed to have out there in the front lines when thesehard questions came up-and the why behind something.

Otto put together something called FDA Prime Connection, a service through which environmental health practitioners across the country-"and actually around the world," he said-could get answers from FDAs files. This was before the World Wide Web was available; Otto used dial-up bulletin board software.

"We kept user statistics and found that the primary users of this information system were the local environmental health programs in America-instead of the large metro health departments, which probably had more resources. And it was an amazing project," Otto added, "in that we built it for nothing."

To set up FDA Prime Connection, Otto used an old computer, free software, and a telecommunications contract that FDA was not exploiting to its fullest extent.

For this work, Otto was awarded U.S. PHS's Outstanding Service Medal in 1993. FDA Prime Connection became the forerunner of FDA's current Web-based information system.

JEH wondered: Had Otto obtained some education in computer technology along the way?

"Uh, it was all pretty much self-taught," he said. "I think I've had two computer courses in my career."

Otto is particularly proud of these achievements because for him they embody a mission every federal environmental health program should have: To support the environmental health services that are delivered on the front line by local environmental health practitioners. "What we've got to do," he said, "is provide them with as much information and as many tools as possible so that they can do the best possible job."

In 1995, Otto got assigned to work with the National Park Service, to implement the Food Code throughout the national park system. From 1998 to 2002, he worked with CDC's cruise ship program, helping to apply the Food Code to food service at sea. In 2002, he came to his present position at EHSB.

JEH asked what sorts of challenges he sees in the future of environmental health and how they should be addressed. He had several projects and ideas in the works.

"The current budget crisis," he said, "limits the ability of individuals to get to educational opportunities like the NEHA annual conference-really sort of limiting their ability to get access to the information they need." He is working on bringing back, in new format, the old CDC home study courses. The project, which is still in its early stages, would involve a series of Web-, DVD-, or CD ROM- based modules, each of which would give users a particular competency.

"It would be something that you could sit down and do in the morning while you're waiting for calls to come in or drinking some coffee. You know," he added, "I've heard recently that sometimes agencies cannot even travel out to do inspections because of the cost of fuel and the budget situation. That would be a day you take for training."

EHSB has already funded a demonstration project. More than 30 Web- based courses are now available through Tulane University. (To check them out, visit http://www.sph.tulane. edu/CAEPH/epht/ training.htm.)

Otto also sees a need for the profession to move into nontraditional areas. He would like to see practitioners still using the classic prevention approaches, but applying them at the community level to issues like smart growth:

It's not something that we have a blueprint for the way we do for our more traditional programs. But there are ways to get involved in community planning, to make sure that the facilities we are involved with, such as school construction, are built with walking access- reducing the use of the car, improving the physical activity level.... We could get involved very early on in subdivision development-raise the question with the developers: What are you going to be doing about sidewalks here? Since it's not part of our normal mission, it's a matter of selling the idea.

And that last bit, Otto said, is key; environmental health practitioners need to think of themselves as salespeople in their communities. He added:

It's the same thing as with emergency preparedness. If you never go talk to the leadership in the emergency planning center within your community, environmental health will not be invited at the time of the emergency. So there's a lot of bridge building as part of promoting the message that healthy growth is good for the community.

Otto has his hand in many other projects. When JEH called, he was on a brief break from a 14-hour-a-day experiment that is looking at concentrations of trichloramines in air around indoor swimming pools. The work is being undertaken to provide insight into the increasing frequency with which people are getting sick around pools- sometimes without even going into the water.

JEH asked Otto what inspires the unflagging hard work he has engaged in throughout his career.

"I can see things being better than the way they are. Always there's something that can be improved," Otto said. He laughed. "So yeah, I work too much. But I think anybody at our level in environmental health does that. It's not unique to Charles."

Amer El-Ahraf, Dr.P.H., R.E.H.S.

For Amer El-Ahraf, thinking in terms of "the job" is never enough.

"I remember my first call," he told JEH. It was 1970, and he was working as a sanitarian for the Los Angeles County Department of Health Services. The call was a complaint about flies. When he went out to investigate, he found the man who had lodged the complaint sitting in a rocking chair on his front porch, a man of about 65- "about my age, now," El-Ahraf said, "but I was a young man at the time"-with the flies swarming all around.

"I said, 'Mr. Johnson, it looks like we have a problem here.' And I asked him: 'What do you think we should do?'"

Asking questions-and so building partnerships with members of the public, drawing on their knowledge-is important to El-Ahrafs philosophy of environmental health: "The fact that you have the book is not sufficient to solve the problem," he told JEH.

El-Ahraf noticed that the flies were small-not horseflies. He got to chatting and learned that Mr. Johnson was "a backyard ecologist" who was keeping cut grass in his yard, composting it and creating a haven for flies.

"We found the problem in his own backyard," El-Ahraf said. "And had I not spoken to him, we would have been chasing those flies all over the neighborhood."

El-Ahraf was about to obtain his Dr.P.H. degree at the University of California Los Angeles (UCLA). Why, then, was he working as an entry-level sanitarian?

"I had a philosophy," he said, "that things should be different in the way we practiced in the field, the way we framed the field." But as a teaching assistant at UCLA, he had students who were working in the field, and they often told him, "Dr. El-Ahraf, there is no way you can change anything in the field. Everything is set."

El-Ahraf refused to believe that. Nor did he want to be an armchair philosopher, "to sit in my university and have my feet off the floor and say the field should do this and that." Ultimately, his goal was to return to academia. But he had also noticed that among his professors, the most effective teachers were those who had both field experience and academic experience.

He had one more reason: He had come to UCLA as an international student (from Cairo) and having decided to stay in this country,

I thought: Now I understand American life at the university, ... but it behooves me, if I want to serve my new country well, to know it well.... So I have to walk the streets, I have to visit people in their homes, I have to go to the churches, I have to sit at the board of supervisors meetings.

He took complaints like Mr. Johnson's not as irritants but as an opening onto the community. Every time he got a complaint he went and met someone and said: Thank you for complaining.

"And of course, people looked at me and said really?" El-Ahraf laughed. "But I meant it. The fact that you complained meant that you were interested in public health."

El-Ahraf's assignment-to the Compton Health District-was considered a tough one, especially since he arrived only a few years after the Watts Riots of 1965, which took place in the area. His colleagues didn't understand why he was happy to receive this assignment. "But my approach," El-Ahraf said, "has been always: We deal with the issues where they are. And challenges are not bad for the profession." For two years, he worked collaboratively with block clubs and community centers, schools and churches, and other government entities to clean up the area and address residents' public health concerns.

These days, the concept of partnership is established enough to receive almost constant lip service-and sometimes to be put into practice to very good effect. At the time, however, El-Ahraf was anticipating the profession by something like a quarter of a century.

After two years, he returned to academia. Here, too, he was at the forefront of new trends. He received a federal grant, for instance, to develop a generic model for a health administration/ planning degree. "At the time," he pointed out, "people trained on the graduate level either as health administrators or health planners." There was not a lot of understanding between the two groups. The planners tended to underestimate administrative difficulties, and the administrators tended to say of the planners: "These guys are dreamers. These are nice plans, but I can't implement them'-and dismiss them out of hand." El-Ahraf's solution was to "develop a professional who is an administrator and a planner."

The program was implemented at three California State University campuses: San Bernardino, Chico, and Northridge (Health Administration/Planning Program, 1982).

At San Bernardino, El-Ahraf navigated interdepartmental politics to set up a new academic program and design a curriculum in health sciences and human ecology. He has also taught at the University of California-Irvine and Californi\a State University-Dominguez Hills. Along the way he has served as NEHA president (1980-1981); has been recognized with awards, including the Mangold Award and the Snyder Award; and has published widely on environmental health issues. His most recent work has been on the health effects associated with global warming (El-Ahraf, 2006, 2004).

After becoming department chair at San Bernardino, he continued to return each summer to work in the county health department; throughout his career he has been committed to linking theory with practice.

El-Ahraf has something of an artist's intensity of engagement and curiosity about the world; every new encounter is grist for the mill. JEH was not surprised to learn that he is also a poet. When asked, he said he did think his interest in poetry helped him see things differently: "Poetry is part of a vision of human nature," he said. "It tends not to be limited by the regular boundaries. So you think on a bigger horizon, I guess."

Nelson Fabian, M.S.

"I've gone through periods when I thought Nelson Fabian was the devil," Joe Beck of Eastern Kentucky University told JEH, "and I'm at the point now where I think he's a saint."

Another way of saying this might be to say that Fabian is not only intensely technical in his approach to environmental health, but also surprisingly spiritual.

"When I thought he was the devil, it was his absolute focus on the bottom line, the financial survival of the organization [NEHA]," Beck said. "And in all honesty, I think he's done wonders consolidating the financial realities.... And I think that he's been strategic, I think he's been incredibly methodical about it, and I think he's gotten there." The result has been the transformation of NEHA into what Beck describes as "a maneuverable instrument." But the notion that Fabian cares only about "the bottom line," he said, "turns out to be a very, very poor analysis."

Fabian himself told JEH that he considers "being a part of the growth and development" of NEHA to be his greatest professional achievement. If people think of him as an environmental health leader, he told JEH, they do so primarily because he is identified with NEHA and NEHA "has achieved that standing." He, too, pointed out the distance that NEHA has come. "I mean, we were almost out of business in 1983. We were told we were going out of business. And look at us now."

For Fabian, the key to recognition is quality: I follow a very simple formula. And I indoctrinate the staff in this from the time I interview them to the time I do performance appraisals, and in hallway conversations. And it's nothing more than this: If you produce quality, you get credibility. Credibility draws people to you. If you draw people to you, you get growth and strength. And with growth and strength, you acquire an ability to wield influence.

Indeed, NEHA is being invited to give its opinions on issues as never before. Where are the requests coming from? From CDC, from U.S. EPA, from legislators and regulators. Even from members of the public.

"We used to bruise our knuckles knocking on doors trying to get people to open them so that we could talk to them," Fabian said. "Today, we have more requests for our opinions than we even have the capacity to respond to."

Fabian's vision for NEHA also involves an organization that is "always on the balls of its feet," ready to take advantage of any opportunity that arises. "We have thrown the book away on strategic planning," he said:

This world goes so fast, it's breathtaking. And with each passing day and year, it goes faster. It's preposterous to think that we can predict the future and then orient the organization to hit these five-year goals, these three-year goals. God, I hope no one's got a 10-year goal out there. In classical strategic planning, what you risk is hitting your target, as bizarre as that might sound, only to discover that it's now irrelevant.

Instead of setting targets, NEHA's approach is to make sure "we have the right people on the bus.... If you have the right people, who understand that the world changes really, really, fast, then they can adapt-day by day, if necessary. We're a very opportunistic organization, and I'm proud of that."

Now there is something counterintuitive in all this, not just because strategic planning has long been a sacred cow, but also because "opportunist" is so often used as a term of opprobrium. It is sometimes assumed that opportunists lack passion, principles, and interest in the big picture. Fabian embodies the refutation of that notion.

"He speaks with real passion," observed Mark McMillan of the Colorado Department of Public Health and Environment. "And he brings a philosophical bent to environmental health."

In fact, in addition to receiving two hard-science degrees (a bachelor's degree in systems engineering from Oakland University and a master's degree in management engineering from Wayne State University), Fabian has done extensive coursework in philosophy and comparative religion. He sees these apparently disparate interests as part of a larger whole: "an interest in the big picture." He also traces his interest in social issues to the times in which he attended college, when he was surrounded by students engaged with issues like the Vietnam War and the Great Society.

On the one hand, "I was in chemistry laboratories until 11 o'clock on Friday nights," Fabian said. "Boy, what a great social life, huh?" And on the other hand: "I didn't ever want to go into an isolated work environment where all I had was my slide ruler or my computer, and no opportunity to engage social issues." So he began to steer his academic work in directions that allowed him both to delve into technical fields and to be involved in social issues. That led to an interest in environmental issues, "a technological field that had huge social relevance."

When he graduated in the top 10 percent of his class, some dazzling job opportunities opened up: Fabian found himself being flown to Baltimore to interview with Westinghouse, being flown to Minneapolis to interview with Honeywell.

"But I just didn't want to use my know-how to design missile systems. That wasn't my idea of a fulfilling job, you know?"

And so, Fabian took his first job out of college-as a stock boy in a toy store. That job did not last long; he soon obtained a position with the Southeast Michigan Council of Governments. It was, he said, a "wonderful job," in which the focus was on analysis of environmental impacts of proposed plans: How would it affect the environment if transportation systems were built in a given direction? How would population growth then develop? What would be the implications of a wetlands area becoming populated? There was an environmental health component to this work, but the focus, Fabian said, was primarily ecological.

The health implications of environmental issues became clear to him in the wake of a couple of incidents that occurred in the early 1970s in Michigan, where he was living at the time. The first incident involved the poisoning of cattle with polybrominated biphenyls. The state health department was quoted on the front pages of newspapers saying that it was not a good idea to eat beef. The second incident was a warning to pregnant women to limit fish consumption because of contamination with DDT and pesticides.

You know, I'm going, "Holy smokes! For thousands of years, people have eaten beef! What in the world have we done?" Suddenly we were messing up our environment in such a way that we couldn't carry on with these fundamental ways of living. And so that led to a particular interest in the health side of ecology. I'd always been interested in systems and the big picture, but with those two headlines, I was not only captivated by the systems issues, but I was also beginning to understand how environmental imbalances were actually affecting human health.

Since then, Fabian has been passionate about environmental health. His dedication has been recognized with a number of awards, including the Snyder Award. Here, one might say, is a profession that perfectly meshes the technical and the spiritual, a perfect fit.

And yet-and yet. He also expressed some frustration. Like the other leaders interviewed for this article, Fabian sees a profession that is "quite frankly struggling."

Why does he think that is?

"The work we do is fascinating. We're not trying to figure out how to come up with a new polish to make a refrigerator shinier," he said. "This is really fascinating stuff that literally has life and death implications." But "somehow we don't excite others about this like we should. There's a disconnect between the importance of the work we do, the nature of the work we do, and the passion we show for it."

He thinks the profession should be in search of some new metaphors for itself. Environmental health is used to calling itself "the invisible profession," even describing its practitioners as "gray collar," he told JEH.

Gray collar! Talk about disheartening!

"If we continue to use those metaphors," he said, "we reinforce the very problem that we're complaining about."

Fabian has been trying out the term "chewing-gum profession."

We go out, we're trying to figure out a problem, and more often than not, we're pulling a stick of gum out of our mouth and plugging a hole and getting a problem fixed. Now, that's not particularly elegant in the way of a solution. But we get the job done. We get the job done with lean resources and not a lot of support, political support included. We figure out a way, as we're listening to five different sides of story, to get a job done.... And the problems we fix contribute significantly to environmental health and quality of life issues for the people we serve.

"I'm not sure," he admitted, "that I'm quite ready to rent out the marquis of the Paramount Theater and say, 'Environmental Health, the Chewing Gum Profession!\'" He's open to suggestions for other metaphors. But he does believe environmental health is at a crossroads. An increased national interest in emergency preparedness, arising out of terrorism concerns, the country's experience with Hurricane Katrina, and emerging disease threats like pandemic flu constitute "a phenomenal opportunity for our profession to become more involved and more visible."

He added, "I hate to sound manipulative or like I have lower motives, but you know, if this is the way the world is going, let's make the most of it. And take advantage of this opportunity to connect us better with other segments of our communities."

NEHA-that opportunistic organization-is currently on a mission "to guide our profession into a heightened state of readiness: preparedness for pandemic flu in particular and emergency response in general." Even if a flu pandemic does not occur, Fabian pointed out, environmental health will still be doing the country an enormous service by "ingraining the idea of preparedness into the American value system."

Larry Gordon, M.P.H., M.S.

The name Larry Gordon was often the first one on people's lips when JEH asked members of the profession whom they saw as leaders. Again and again, respondents cited the prestige of his accomplishments-a point that seemed especially important to members of a profession whose greatest strength generally is not self- promotion.

Gordon, one might say, is the celebrity personality of environmental health.

Here is an environmental health professional who has been president of the American Public Health Association (1980-1981); who testified before the Presidential Committee on Executive Reorganization about the creation of the U.S. Environmental Protection Agency; who has several times testified before Congress; who has won numerous awards, including the Snyder Award and the Mangold Award; and who has more than 240 publications to his name. He founded the New Mexico Scientific Laboratory System in 1973 and the New Mexico Environmental Improvement Agency (now the New Mexico Department of the Environment) in 1976, as well as the Albuquerque- Bernalillo County Environmental Health department in 1957-to name just a few highlights from a 56-year career.

Several respondents to the JEH survey cited Gordon as the only nationally recognized "public intellectual" the profession has.

And what is a public intellectual? For environmental health practitioners, the term seems to mean someone "who is thinking several years out," someone with "predictive abilities," and above all someone who is willing to challenge basic assumptions of the profession. Often respondents said that they disagreed with some of Gordon's positions but still found that, as one put it, "every time I read something he writes, it changes the way I look at the issue forever."

An example of the way he challenges assumptions might be Gordon's response to a question JEH asked of all the leaders interviewed for this article: "Where do you see the profession heading from here?":

The field of environmental health and protection is not a profession, and it is misleading to continue the pretense. It is an effort engaged in by a varied assortment of disciplines and professions within a broad array of organizations. The field of environmental health and protection is profoundly multidisciplinary as well as interdisciplinary. Environmental health and protection practitioners may be classified as either environmental health or protection professionals [i.e., if they have been educated in "environmental health" or "environmental protection" per se] or professionals in environmental health and protection [if they have been educated in some other discipline such as chemistry or biology]. Environmental health and protection is a field in which to practice one's profession.

He sees opportunities for people to practice in this field "not only at local health departments, but also at state environmental protection agencies, pollution control departments, the federal Department of Energy, the Department of Defense, and the Indian Health Service, as well as local planning agencies." The key is to embrace the whole field of practice regardless of "organizational and mental barriers" and be willing to move around among agencies.

A too-narrow focus has gotten environmental health in trouble before, he pointed out. By lagging behind public consciousness, the field runs the risk of making itself irrelevant:

The public and public policy leaders know that pollution kills fish, limits visibility, creates foul stenches, ruins lakes and rivers, degrades recreational areas, and endangers plant and animal life. Environmental health practitioners must develop the capacity to embrace ecological issues as precursors to health problems.... Failure to embrace ecological components has been among the reasons many environmental health responsibilities have been assigned to agencies other than health departments.

There is an ominous allusion in this analysis to the period of the late 1960s and early 1970s, when the reluctance of public health agencies to deal with issues of pollution, then the most prominent threats to human health, led to the loss of those responsibilities and the formation of environmental protection agencies in which human health concerns were not the primary mandate. Many in environmental health consider this development to have been detrimental not just to health departments but to the interests of public health itself.

Gordon sees a similar drama unfolding in the present:

Except for the voice

Source: Journal of Environmental Health

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