Pillars of Governmental Environmental Public Health A Guide to Scalable Environmental Public Health Programs

Authors

Gina Bare, RN, National Environmental Health Association Thuy N. Kim, MPH, PhD, University of Minnesota School of Public Health Craig W. Hedberg, PhD, University of Minnesota School of Public Health Nicole Dutra, MPH, National Environmental Health Association Christopher Walker, MSEH, REHS, National Environmental Health Association David Dyjack, DrPH, CIH, National Environmental Health Association

Acknowledgements

The authors gratefully acknowledge the environmental public health professionals who participated in focus groups, key informant interviews, and the national field survey. Their generous contribution of time, expertise, and insights made this guide possible. We also thank the members of the Delphi panel who helped identify the core EPH programs, and the National Environmental Health Association Board of Directors for their support of this project.

Funding acknowledgement: Phase I of this two-phase project was supported by the Centers for Disease Control and Prevention (CDC) of the U.S. Department of Health and Human Services (HHS) under federal award #NU38OT000300-04-07 in the amount of $25,000 or approximately 11% of the entire project. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, or the U.S. government.

Contents Introduction ………………………………………………………………………………………………………………………………………………………… 4

Background ………………………………………………………………………………………………………………………………………………………… 6

Characteristics of a Successful Environmental Public Health Department ……………………………………………………. 7

Core Environmental Public Health Programs …………………………………………………………………………………………………… 9 Food Safety and Protection …………………………………………………………………………………………………………………………………………………………..14

Swimming Pools and Recreational Water Safety ………………………………………………………………………………………………………………………17

Onsite Wastewater ………………………………………………………………………………………………………………………………………………………………………..19

School Safety and Inspection ……………………………………………………………………………………………………………………………………………………….23

Early Childcare and Daycare …………………………………………………………………………………………………………………………………………………………26

Zoonoses and Vector Control ……………………………………………………………………………………………………………………………………………………….28

Emergency Preparedness ……………………………………………………………………………………………………………………………………………………………..31

Potable Water ………………………………………………………………………………………………………………………………………………………………………………..34

Lead Prevention ……………………………………………………………………………………………………………………………………………………………………………..37

Body Art ………………………………………………………………………………………………………………………………………………………………………………………….40

Non-School Institutions and Licensed Establishments ……………………………………………………………………………………………………………..43

Secondary Environmental Public Health Programs ………………………………………………………………………………………..43 Climate Health ……………………………………………………………………………………………………………………………………………………………………………….44

Air Quality ……………………………………………………………………………………………………………………………………………………………………………………….45

Healthy Homes ………………………………………………………………………………………………………………………………………………………………………………45

Hazardous Materials ………………………………………………………………………………………………………………………………………………………………………46

Other Considerations for Secondary EPH Programs …………………………………………………………………………………………………………………47

Strategic Considerations for Program Enhancement………………………………………………………………………………………48 Building on Common Foundations ……………………………………………………………………………………………………………………………………………..48

From Guidelines to Implementation …………………………………………………………………………………………………………………………………………….49

The Evolving Landscape of Environmental Public Health ………………………………………………………………………………………………………..49

A Call to Action ………………………………………………………………………………………………………………………………………………………………………………49

Conclusion …………………………………………………………………………………………………………………………………………………………49

References …………………………………………………………………………………………………………………………………………………………50

Appendices ………………………………………………………………………………………………………………………………………………………..55

3

Environmental public health (EPH) professionals play a crucial role in safeguarding public health and ensuring the well-being and prosperity of our communities. Local governmental EPH programs employ a sig- nificant number of dedicated professionals who work tirelessly to pro- tect the food we consume, the air we breathe, the water we drink, and the environments in which we live, work, and play. The importance of local governmental EPH programs cannot be overstated, as they con- tribute to the overall health of the public and serve a vital function in national security.

Research has consistently demonstrated the positive impact of local health department (LHD) activities and investments on reducing the inci- dence of EPH-related diseases (Bekemeier et al., 2015; Fan et al., 2020). Moreover, senior leadership at both state and local health departments has recognized the essential nature of EPH services (Leider et al., 2015). Despite the crucial role EPH professionals play in promoting and protect- ing public health, national guidance on the optimal structure and organi- zation of local EPH departments is absent.

The absence of a standardized framework for local EPH departments poses significant challenges for EPH officials seeking to secure the nec- essary resources, including staff, funding, and equipment, to effectively carry out their duties. Without clear benchmarks and guidelines, EPH programs struggle to justify their needs, potentially compromising the health, safety, and prosperity of the communities they serve. To address this gap, this guide presents scalable program guidelines that can be adapted to meet the diverse needs, resources, and organizational struc- tures of EPH departments across different jurisdictions, while maintain- ing essential standards for protecting community health.

Introduction

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How This Document Was Developed

The Pillars of Governmental Environmental Public Health was developed through a comprehensive research collab- oration between the National Environmental Health Asso- ciation (NEHA) and the University of Minnesota (UMN) School of Public Health. This framework emerged from an extensive study conducted in 2024 that surveyed hun- dreds of environmental public health professionals across 45 states, the District of Columbia, and Puerto Rico. The research was built on previous work in 2023 that identified 11 core EPH programs through a Delphi panel of senior EPH professionals, followed by focus groups and key informant interviews to capture qualitative insights. This research was specifically designed to gather perspectives from EPH professionals, capturing insights on program structure, staffing standards, educational requirements, credentialing needs, and workload expectations across multiple program areas. The resulting guidelines pre- sented reflect the collective wisdom and practical expe- rience of hundreds of EPH professionals who understand the day-to-day realities of protecting public health while working within diverse organizational structures and resource constraints.

Scalable Guidelines Approach

The recommendations provided are intended as scalable guidelines rather than rigid requirements. Most jurisdic- tions possess unique EPH challenges, resources, demo- graphics, and governmental structures. What works in a large urban government agency might not be suitable for a

small, rural jurisdiction with different priorities and poten- tially fewer resources.

The scalable guidelines presented here offer a flexible framework that can be adapted to:

• Jurisdictions of varying sizes.

• Agencies with different levels of resources and staffing.

• Communities with distinct environmental health priorities based on culture, geography, climate, industry, and population characteristics.

• Diverse governance structures, including county, city, district, or combined jurisdictions.

• Inconsistent regulatory authorities granted under state and local laws.

The purpose of this guide is to provide EPH directors, man- agers, supervisors, and field staff with evidence-based recommendations that help them develop, implement, and sustain effective programs. These guidelines serve as a starting point for program assessment and advo- cacy efforts, offering benchmarks for staffing, education, training, certification, outcome measures, and equipment needs that can be adapted to match specific departmental and community circumstances. EPH leaders can consider these guidelines as a starting point for program develop- ment and assessment, adapting the recommendations to match their specific circumstances. Rather than present- ing a one-size-fits-all approach, this guide provides evi- dence-based parameters that can be scaled up or down based on department and community needs, regulatory responsibilities, and available resources.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

EPH is a crucial facet of public health that focuses on the interplay between the intersection of environment and human health. It encompasses a wide array of programs and services designed to protect and enhance the health and well-being of communities. These programs iden- tify, assess, and mitigate environmental factors that can adversely impact human health.

The environment plays a significant role in shaping our health outcomes. Exposure to environmental hazards can lead to a range of health effects from acute illnesses to chronic diseases and premature death. According to the World Health Organization, an estimated 24% of the global disease burden and 23% of all deaths can be attributed to environmental factors (Prüss-Üstün et al., 2016). By addressing these environmental determinants of health, EPH professionals contribute to the preven- tion of disease, the promotion of health, and the overall well-being of communities.

EPH professionals comprise a diverse and highly skilled workforce, including specialists, scientists, technicians, and sanitarians. They possess expertise in a wide range of disciplines, such as epidemiology, toxicology, risk assess- ment, and environmental science. The EPH workforce is the second-largest profession within the public health workforce, after nursing (NACCHO, 2019). Despite their crucial role, EPH professionals often face numerous chal- lenges such as insufficient staffing, limited resources, and a lack of standardized guidelines for the structure and funding of EPH departments.

Local EPH departments play a vital role in protecting and promoting public health at the community level. They are

responsible for providing a wide range of services, includ- ing food safety inspections, water quality monitoring, haz- ardous waste management, vector control, and emergency preparedness, response, and recovery. These services are essential for preventing the spread of infectious diseases, reducing exposure to environmental hazards, and ensuring the overall health and safety of communities.

Studies have consistently demonstrated the positive impact of local EPH department activities and investments on pub- lic health outcomes. For example, Bekemeier et al. (2015) found that increased local health department food safety and sanitation expenditures were associated with signifi- cant reductions in enteric disease rates. Similarly, Fan et al. (2020) highlighted the critical role of EPH professionals in responding to the COVID-19 pandemic, emphasizing the importance of effective public health and safety nets in mit- igating the impact of public health emergencies.

Despite the clear evidence of the value of EPH services, local EPH departments often struggle to secure the nec- essary resources and support to carry out their essential functions effectively. The lack of national standards and guidance for the structure, staffing, and funding of EPH departments creates significant challenges for local public health officials in advocating for the resources necessary to protect the health of their communities.

This guide recognizes the importance of EPH and the need for a stronger, more resilient EPH system. Further, it provides national benchmarks and recommendations for the structure, staffing, and funding of local EPH depart- ments—a roadmap for strengthening the EPH workforce to ensure communities have access to essential services.

Background

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

A successful environmental public health department works to protect public health through prevention activities, respon- sive services, and community engagement while maintaining adaptability to emerging challenges. Based on findings from focus groups, interviews, and surveys with EPH profession- als, the following characteristics are commonly observed in well-performing environmental public health departments across various sizes, structures, and program configurations.

Silent Success Through Prevention

The hallmark of a well-functioning EPH department is often what does not happen—disease outbreaks pre- vented, environmental hazards mitigated, and injuries avoided. This “silent success,” sometimes referred to as “negative space,” represents the primary mission of EPH— prevention. When an EPH department functions optimally, the community might be largely unaware of its daily activ- ities, as the absence of environmental health crises often reflects effective performance.

Science-Based Decision-Making

EPH departments that perform well generally ground their operations in scientific evidence, using data collection, sur- veillance, and analysis to identify trends, determine prior- ities, and guide resource allocation. These departments typically maintain suitable data systems to track environ- mental conditions, monitor health outcomes, and evaluate program effectiveness, with decisions based on quantifi- able and relevant metrics.

Equitable Service Delivery

Excellence in EPH often involves identifying and address- ing disparities in environmental health conditions across populations and communities. High-performing depart- ments frequently assess the distribution of environmen- tal health burdens, target resources to areas of greatest need, and work to ensure services are accessible, cultur- ally appropriate, and designed to reduce health inequities.

Balance of Regulatory and Consultative Approaches

While enforcement of environmental health regulations remains essential, many departments increasingly balance traditional regulatory roles with consultative approaches.

This expanded model emphasizes education, technical assistance, and partnership with regulated entities to achieve compliance through collaboration rather than rely- ing primarily on fines and citations.

Effective Partner Relationships

The development and maintenance of strong relation- ships represents a core competency of many successful environmental public health departments. These relation- ships span regulated establishments, community partners, healthcare providers, academic institutions, and other governmental agencies. Strong relationships foster trust, enhance communication, facilitate information exchange, and extend the department’s impact beyond what can be achieved through direct service provision alone.

Workforce Excellence and Development

Effective EPH departments often invest in their workforce through comprehensive training, continuing education, and professional development opportunities. They cultivate environmental health professionals who possess technical expertise and skills in communication, customer service, cultural competence, and adaptability. These departments frequently create pathways for career advancement and knowledge transfer to ensure continuity of expertise.

Integration and Coordination

Effective EPH departments often integrate their services and coordinate across program areas. This integrated approach recognizes the interconnected nature of environ- mental health challenges and enables more efficient use of resources, reduces duplication of efforts, and provides more seamless services.

A successful environmental public health department works to protect public health through prevention activities, responsive services, and community engagement while maintaining adapt- ability to emerging challenges.

Characteristics of a Successful Environmental Public Health Department

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Adequate and Sustainable Resources

Successful EPH departments work to secure and maintain the resources—funding, staffing, equipment, and facili- ties—necessary to fulfill their core functions. They often diversify funding sources, develop fee structures that reflect service costs, and effectively communicate their value to secure appropriate budget allocations. These departments typically maintain the capacity to respond to routine demands while remaining prepared for emergen- cies and emerging threats.

Continuous Quality Improvement

Excellence in EPH frequently involves ongoing assessment and improvement. Effective departments often establish meaningful performance measures, regularly evaluate their effectiveness, identify opportunities for enhancement, and implement changes based on evaluation findings. This culture of continuous improvement enables departments to adapt to evolving science, community needs, and envi- ronmental challenges.

Public Trust and Transparency

By maintaining transparent operations, clear communica- tion about environmental health risks and regulations, and demonstrated commitment to protecting public health, effective EPH departments often earn the trust of their

communities. This trust facilitates cooperation during rou- tine operations and proves valuable during emergency response situations when public compliance with health guidance becomes important.

The characteristics outlined above provide a framework for EPH departments to assess their current operations and identify opportunities for growth. While specific program implementations will vary based on community needs, regulatory requirements, and available resources, these foundational elements are commonly observed across well-functioning jurisdictions of various sizes.

Additional Resources

This guide also includes information on the 10 Essential Environmental Public Health Performance Standards and the Public Health Accreditation Board (PHAB) as appen- dices at the end of the document to provide additional context and guidance for program development and assessment. Additionally, EPH departments may find value in utilizing community health assessment (CHA) and community health improvement plan (CHIP) pro- cesses to identify local environmental health priorities and align program development with broader community health needs. Furthermore, a comprehensive reference section includes resources that were consulted during the development of this guide.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Protecting Families and Communities

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Secondary EPH Programs

Secondary EPH Programs11 Core EPH Programs

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Pillars of Environmental Public Health

A Guide to Scalable Environmental Public Health Programs

Core Environmental Public Health Programs Core EPH programs represent the most common and essential services that local EPH departments typically provide to protect and promote the health and well-be- ing of the communities they serve. These programs are designed to address the most pressing EPH concerns and are considered foundational to the mission of EPH. The 11 core EPH programs identified in research con- ducted by NEHA, in cooperation with UMN, include food safety and protection, potable water, swimming pools and recreational water safety, onsite wastewater, lead prevention, zoonoses and vector control, emergency pre- paredness, school safety and inspection, early childcare and daycare, body art, and non-school institutions and licensed establishments.

When local EPH departments focus on these core pro- grams, they can work to provide comprehensive services essential to safeguard public health. Delivery does require adequate staff, funds, and resources, which vary signifi- cantly across jurisdictions.

In addition to the 11 core EPH programs, local EPH departments can also provide secondary programs that address specific EPH concerns within their jurisdictions. These secondary programs (e.g., climate health, air qual- ity, healthy homes, hazardous materials) could be con- sidered core programs by some departments based on the unique needs and priorities of the communities they serve (NEHA, 2022).

The determination of which programs might be consid- ered core or secondary likely varies across jurisdictions, as EPH challenges and community needs can differ significantly from one area to another. For example, a jurisdiction with a history of poor air quality or indus- trial pollution might prioritize air quality monitoring and enforcement as a core program, while another jurisdiction could focus on healthy homes due to elevated rates of childhood asthma.

To effectively identify and prioritize core and secondary EPH programs, local EPH departments can collect and analyze data on the EPH status of their communities, assess community needs and priorities, review appli- cable regulatory requirements, and engage with inter-

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

ested partners. This data-driven, community-informed approach can help ensure that EPH departments allocate their resources and efforts toward the programs that will have the greatest impact on protecting and promoting public health.

When local EPH departments tailor their core and second- ary EPH programs to the specific needs of their communi- ties, they can develop a comprehensive, responsive, and effective EPH strategy that addresses the most pressing concerns and promotes health equity.

In the sections that follow, we define each core EPH pro- gram based on comprehensive research conducted jointly by NEHA and UMN. Through focus groups, interviews, and a national field survey with participants from hundreds of diverse local EPH departments, we provide meaningful outcome measures, staffing benchmarks, educational and certification requirements, essential equipment needs, and common funding sources for each program. This evi- dence-based information enables EPH departments to develop strong, sustainable programs tailored to their communities’ unique needs.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Core Environmental Public Health Programs at a Glance: Key Findings and Recommendations The following table provides an overview of 10 of the 11 core EPH programs identified through our research. This summary synthesizes key findings from focus groups, inter- views, and surveys with EPH professionals nationwide to present essential information for each program area. The 11th program area, Non-School Institutions and Licensed Establishments, is not included in this table due to the sig- nificant variability in how jurisdictions define and organize these facilities, which is discussed in detail later in this guide.

All recommendations in this table are designed to be scalable based on jurisdiction size, community needs,

available resources, and regulatory requirements. The information shown reflects consensus levels among surveyed professionals and indicates strong field sup- port for these evidence-based benchmarks. Jurisdictions should view this information as a starting point for pro- gram development rather than rigid requirements and adapt the recommendations to their specific circum- stances and priorities.

The detailed program descriptions that follow in this guide will expand on each of these elements and provide the context and rationale behind these recommendations.

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Food Safety and Protection

3–4 inspections per field day

• Bachelor’s in science • REHS/RS credential • CP-FS credential

• Thermometers and pH meters

• Test strips and sampling kits

• Food Code book • Cameras • Hairnets and hats • Mobile technology

and inspection forms

• Number of foodborne illness outbreaks

• Number of foodborne illnesses

• Number of inspections

• Number of critical violations

Swimming Pools and Recreational Water

3–4 inspections per field day

• Bachelor’s in science • Certified Pool

Operator • REHS/RS credential

• Pool chemistry test kits

• Tape measures • Optical scanners • Laboratory access • Cameras • Mobile technology

and inspection forms

• Number of inspections completed

• Number of critical violations

• Closure frequency

Onsite Wastewater 4–5 activities per week

• Bachelor’s in science • REHS/RS credential • Installer training

programs

• Soil augers and rock hammers

• Tile probes and levels

• GPS units and CAD software

• Sludge judge sampler

• Cameras • Mobile technology

and inspection forms

• Contaminated wells ratio

• Permit review timelines

• System failure reports

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

School Safety and Inspection

2–3 inspections per field day

• Bachelor’s in science • REHS/RS credential

• Infrared thermometers

• Air quality monitors • Light meters • Playground

inspection kits • Cameras • Mobile technology

and inspection forms

• Repeat violations • Staff hazard

identification • Technical

consultations

Early Childcare and Daycare

3–4 inspections per week

• Bachelor’s in science • REHS/RS credential • Playground safety

certification • IPM training

• Thermometers and light meters

• Flashlights • Sanitizer test strips • Educational

materials • Cameras • Mobile technology

and inspection forms

• Number of critical violations

• Outbreak control timeframes

• Facility closure rate

Zoonoses and Vector Control

Variable by disease burden

• Bachelor’s in science • REHS/RS credential • Vector control

technician training • IPM training

• Traps and collection tools

• PPE • Lab supplies and

microscopes • Adulticides and

larvicides • Mobile technology

and documentation forms

• Cameras

• Training hours per inspector

• Number of human disease cases

• Vector index thresholds

Emergency Preparedness

As needed basis • Bachelor’s in science or other degree

• REHS/RS credential • ICS 100, 200,

700, 800 • EHTER courses

• Communication systems

• Emergency power sources

• Specialized response equipment

• Laboratory access

• Number of staff with required certifications

• Response time • Plan review

currency

Potable Water 3–4 field activities per week

• Bachelor’s in science • REHS/RS credential • Drinking water

operator certification

• Water quality kits and sampling supplies

• Cameras • Measuring tapes

and rulers

• Number of well inspections

• Safety of water samples

• Number of waterborne illnesses associated with drinking water

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Potable Water continued

• Mobile technology and inspection forms

• Educational materials

• Number of educational events

• Number of voluntary well water samples submitted

• Number of plan reviews completed

Lead Prevention 2–3 field activities per week

• Bachelor’s in science • REHS/RS credential • Lead risk assessor

certification

• XRF analyzers • Dust wipe

sampling supplies • PPE • Educational

demonstration kits

• Blood lead level reductions

• Number of properties deemed lead safe

• Environmental assessment completion rates

Body Art 3–4 inspections per week (Based on part-time employee. See program specific staffing details.)

• Bachelor’s in science • REHS/RS credential • Bloodborne

pathogen training

• Thermometers • pH meters • Flashlight • Test strips • Cameras • PPE

• Number of high priority violations cited per establishment

• Number of unlicensed or expired licensed artists per establishment

• Number of unlicensed artists found who then underwent the process to get licensed

• Number of adverse events directly attributed to body art per establishment

• Number of complaints received per 50 establishments

Note. Workload recommendations assume staff perform duties other than field work, such as training, meetings, report writing, complaint fol- low-up, enforcement action, quality assurance, and plan reviews, and are generally not in the field 5 days a week. Assumptions also include that EPH professionals have transportation to sites as needed, basic office supplies, inspection forms, and hands-on training opportunities. It should be noted that some jurisdictions take alternate approaches to requiring degrees. It should further be noted that the 11th core program area, Non- School Institutions and Licensed Establishments, is not included in this table. See full discussion in the program descriptions section. CAD = com- puter-aided design; CP-FS: Certified Professional–Food Safety; EHTER = Environmental Health Training in Emergency Response; FTE = full-time employee; ICS = Incident Command System; IPM = integrated pest management; PPE = personal protective equipment; REHS/RS = Registered Environmental Health Specialist/Registered Sanitarian.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Food Safety and Protection

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Food Safety & Protection

3-4 inspections per field day

• Bachelor’s in science • REHS/RS credential • CP-FS credential

• Thermometers and pH meters

• Mobile technology and inspection forms

• Test strips and sampling kits

• Food Code book • Cameras • Hair nets/hats

• Number of foodborne illness outbreaks

• Number of foodborne illnesses

• Number of inspections

• Number of critical violations

Definition

Food safety and food protection EPH programs involve inspection, permitting, plan review, and complaint and outbreak investigation of food establishments. These establishments include but are not limited to brick-and- mortar restaurants, mobile food units, temporary food events, commissary kitchens or shared kitchens, and food manufacturing and distribution facilities where applicable to promote the safe preparation, production, and service of food in sanitary food facilities; to protect the health of food handlers and consumers by encouraging safe and sanitary on-the-job working conditions; and to ensure consumers have access to proper menu labeling.

Characteristics of a Successful Food Safety Program

The Voluntary National Retail Food Regulatory Program Standards from the Food and Drug Administration (FDA) provide a framework for many food safety programs. In addition to these standards, some departments might want to consider additional areas that the Program Standards do not currently address, such as comprehensive food handler education, alternative enforcement approaches, program sustainability, and succession planning.

Program success is generally measured by reducing vio- lations over time, which corresponds to illness prevention. For many jurisdictions, however, the methods for achiev- ing these outcomes are evolving from traditional enforce- ment-focused approaches toward consultative models that emphasize education, technical assistance, and rela- tionship-building with regulated entities.

The consultative approach encompasses several key ele- ments: providing and requiring education for food han- dlers, assisting establishment operators in implementing effective control measures, collaborating with operators during outbreak investigations, and fostering positive rela- tionships with both operators and the general public. This shift represents a fundamental change in how EPH profes- sionals interact with the regulated community.

Some jurisdictions have implemented hands-on techni- cal assistance programs where EPH staff guide operators in adopting policies and practices that reduce violations. These consultative approaches have shown promis- ing results in pilot programs, with at least one federally

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

funded initiative demonstrating significant decreases in priority violations. Other jurisdictions have engaged exter- nal consultants to provide specialized technical assistance to operators.

As consultative approaches become more widespread, comprehensive evaluation of their effectiveness in reduc- ing both violations and foodborne illness becomes increas- ingly important. Such evaluation can occur at both local and national levels to determine best practices and inform broader adoption of these innovative program models across the field.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Number of critical violations identified per 1,000 food establishments per year *

• Number of complaints received per year *

Workload management

• Average number of inspections per facility type per year

Public health protection

• Number of foodborne illness outbreaks per year

• Number of foodborne illnesses per year

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

FDA reports that most agencies responsible for the over- sight of restaurants and other retail food facilities have adopted some version of the FDA Food Code. Additionally, many food safety programs also use the FDA Voluntary National Retail Food Regulatory Program Standards as a foundation for program evaluation. Risk factor analyses that examine trends in violation citations and foodborne illness patterns can inform targeted interventions, such as training programs for EPH staff and educational programs for food workers and operators.

Common program effectiveness measures include track- ing violation patterns by facility type, which helps iden- tify systemic issues and target resources appropriately. Performance and workload evaluation measures typically encompass the number of inspections completed, as well as time efficiency metrics for inspection completion.

The development of meaningful outcome measures is an emerging challenge for consultative visits, as these have not yet been well-established in the field. Consultative approaches present measurement difficulties because they are more conceptual than traditional violation-based inspections and are often co-mingled with standard reg- ulatory activities. Programs implementing consultative models could benefit from innovative metrics that cap- ture the preventive value and educational impact of these interactions, potentially including measures such as vol- untary compliance improvements, operator knowledge gains, or reductions in repeat violations following consul- tative interventions.

As the field continues to evolve toward more collabora- tive and educational approaches, developing effective outcome measures for these activities can help demon- strate program value and effectiveness beyond traditional enforcement metrics. The following metrics were derived from the national field survey data.

Staffing

Food safety programs commonly use FDA Standard 8 (280–320 inspections per full-time employee [FTE] per year) as general guidance for staffing rates, though actual inspection volumes vary significantly across jurisdictions. Survey data from local departments show a median of 331 routine inspections per FTE annually (range 184–333), with some programs reporting as low as 280 inspections per FTE while others conduct up to 580 inspections per FTE.

These benchmarks are specific to 1 FTE in food safety pro- grams and might need to be adjusted when EPH profes- sionals also perform duties in other programs. Workload calculations could account for non-food safety responsibil- ities, which might result in lower inspection targets. Addi- tionally, essential duties such as reporting, responding to

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

operator inquiries, and public communications could be factored into staffing determinations.

Daily inspection expectations typically range from 2–3 inspections per day on the low end to 4–5 inspections on the high end, based on departmental experience and oper- ational needs. These expectations can remain adaptable, however, as inspection methods and community needs evolve to ensure an appropriate balance between inspec- tion quality and quantity. Based on a typical 48-week work year (allowing for vacations, holidays, and sick time) and 3 inspections per field day, full-time inspectors would need to be in the field 2–4 days per week depending on departmen- tal demands, with 2–3 field days being more common. This schedule allows time for administrative duties, plan reviews, complaint investigations, and other program responsibilities.

Several facility characteristics can significantly affect inspection duration and daily productivity:

• Facilities with special or lengthy food preparation processes (e.g., ethnic cuisines, smoking, curing, sushi preparation)

• Establishments with attached grocery, deli, or butcher components requiring extended inspection time

• Inspections requiring translation services or cultural consultations

• Mix of full-service restaurants versus fast food or chain establishments

• Type of inspection conducted (violation-focused versus consultation-based visits)

There is growing interest in consultative inspection approaches that emphasize education and prevention over traditional violation-based methods. One jurisdiction adopted a successful inspection model that allocated 0.1 FTE to traditional inspections and 0.75 FTE to consultation services, and the model resulted in a significant reduction in facility-related outbreaks. This consultative model shows promise for food safety and other communicable disease prevention programs, though implementation might require additional staff training or partnerships with external con- sultants to provide specialized technical assistance.

Education/Training/Certifications

For food safety programs, a bachelor’s degree in science combined with Certified Professional–Food Safety (CP- FS) credential provides foundational preparation for suc- cessfully executing food safety duties. A strong science background offers a solid foundation on which to build specialized EPH expertise and technical competencies.

The Registered Environmental Health Specialist/Regis- tered Sanitarian (REHS/RS) credential was also recog- nized as a valuable credential across all program areas.

Our research found that jurisdictions could face challenges in workforce recruitment due to limited candidate pools, particularly in areas experiencing outmigration of col- lege-educated individuals to other states. One suggested approach to address these challenges is for jurisdictions to make EPH positions competitive through appropriate compensation and professional development opportu- nities rather than reduce educational standards for sci- ence-based programs.

While the consultative approach emphasizes education and customer service, a scientific foundation remains crucial for program staffing. EPH professionals need to understand and translate the public health significance underlying reg- ulations. Although strong customer service skills enhance communication, they cannot replace scientific knowledge.

Equipment Needs

Common equipment suggested for this program includes transportation or personal vehicle mileage reimburse- ment, thermometers, pH meter, test strips, hairnets, lab coats (for manufacturing facilitates), sampling kits, tem- perature discs, humidity meters, phones with cameras, computers or tablets, Food Code book, access to transla- tion services, and inspection sheets or forms. Participants indicated that they expect the operators to have much of this equipment and will ask that they demonstrate their use. Some departments have portable printers to print the inspection report or educational materials while on the premises during an inspection.

Funding Sources/Barriers

Food safety programs are typically funded through per- mitting and inspection fees or general fund appropriations. Some jurisdictions also generate revenue through food

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handler permits for individual workers, which require reg- ular renewal. Fee-funded programs that achieve self-suf- ficiency can provide more reliable revenue streams and can offer protection from staffing and service reductions during budget constraints.

Approaches to fees vary across jurisdictions. Some are set through state statutes with local regulatory imple- mentation, some use commissioning boards with estab- lished processes for fee determination, others implement sliding scales based on establishment gross receipts, and some conduct periodic fee assessments tied to population growth and program costs.

Gradual fee increases tend to be more acceptable to the reg- ulated community than substantial periodic adjustments.

For example, annual modest increases could generate less resistance than larger increases every 3–5 years. Similarly, incremental staffing increases of 0.5 FTE can be more man- ageable for both budgeting and workforce development.

External factors can influence fee structures and program operations. Competition with neighboring jurisdictions might constrain fee-setting flexibility, with some fees remaining static for extended periods. Lack of reciprocity agreements or memoranda of understanding between adjacent health agencies can create additional burdens for mobile food vendors, who need to obtain separate permits and inspections for each jurisdiction where they operate. These factors can result in fee structures driven by exter- nal competitive pressures rather than internal program needs and community requirements.

Swimming Pools and Recreational Water Safety

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Swimming Pools and Recreational Water

3–4 inspections per field day

• Bachelor’s in science • Certified Pool

Operator • REHS/RS credential

• Pool chemistry test kits

• Tape measures • Optical scanners • Laboratory access • Cameras • Mobile technology

and inspection forms

• Number of inspections completed

• Number of critical violations

• Closure frequency

Definition An EPH swimming pools and recreational water safety program conducts health, safety, and structural assess- ments of recreational water venues such as public swimming pools and beaches to identify and mitigate imminent health and safety threats. Program activities include evaluating pool areas and surrounding infrastruc- ture such as decks, handrails, ladders, and fencing for compliance with safety standards. These programs also respond to sewage or toxic chemical spills affecting rec- reational water sources and conduct water quality test- ing to monitor bacterial contamination levels and ensure safe recreational water conditions for public use.

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Characteristics of a Successful Swimming Pools and Recreational Water Safety Program

A swimming pools and recreational water program gener- ally conducts damage and health and safety assessments of public swimming pools, spas, hot tubs, splash pads, lazy rivers, and other recreational water venues, as well as public beaches that can pose imminent health and safety threats. This oversight generally includes the areas sur- rounding pools and water sources such as decks, handrails, ladders, and fencing. These programs can also respond to program-specific sewage or toxic chemical spills and con- duct water quality testing of recreational water sources to determine levels of bacterial contamination.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of required pool inspections completed during peak operating season (May–August) annually

Workload management

• Average number of pool/recreational water inspections completed per inspector during peak season (May–August) annually *

• Percentage of inspections completed at target rate

Public health protection

• Number of critical violations identified per 100 pool inspections annually *

• Number of disinfectant violations per 50 facilities per year

• Number of in-compliance facilities per number of facilities per year

• Number of facility closures per year

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

Though not specifically discussed in the survey, the Model Aquatic Health Code (MAHC) was established by the Cen- ters for Disease Control and Prevention (CDC) in 2014 and guides jurisdictions to help develop and update their pool codes based on current science and best practices. Based on this code or others like it, programs might find value in tracking the rate of in-compliance pools as a measure of success. Research has shown that some agencies

aim for specific reduction targets, such as a 2% decrease for violations of disinfectant levels and a 10% decrease for other violations. Given the typically smaller number of pools compared to restaurants, tracking violation trends is a relatively accessible activity to monitor program prog- ress, and many programs are already implementing this approach. Violations severe enough to warrant facility clo- sure are also important to track as they could represent key indicators of program performance

Staffing

Staffing needs for swimming pools and recreational water safety programs are predominantly seasonal, with peak demand occurring in spring as facilities prepare for the swimming season. Even programs with dedicated year- round FTE positions require additional staffing during facility opening periods to accommodate the inspection workload, particularly for outdoor facilities. During colder months, workload generally decreases and focuses pri- marily on indoor facilities that maintain year-round oper- ations. This seasonal variation creates unique staffing challenges that differ from other EPH programs with more consistent year-round demands.

For programs that reported needing additional FTEs beyond their current capacity, the suggested number of recreational water facilities/swimming pools, if the budget is not a con- straint, would be an average of 180 inspections annually per 1 FTE (range 60–417). This wide range reflects varia- tions in facility complexity, inspection requirements, and local program scope across different jurisdictions.

Programs could consider flexible staffing models that can accommodate seasonal peaks through temporary staff, overtime provisions, or cross-training with other EPH programs to ensure adequate coverage during cru- cial opening periods while maintaining cost-effectiveness during lower-demand months.

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Education/Training/Certifications

This program area shows flexibility in educational require- ments, with a bachelor’s degree in science being the pre- ferred qualification. Though the REHS/RS credential was recognized as valuable across all programs, there was no strong consensus for this program. Essential qualifications include passing the Certified Pool Operator and Certified Pool Inspector examinations. Practical training through shadowing experienced inspectors is highly recommended, with programs typically requiring 25–30 supervised inspec- tions before allowing independent work. This hands-on approach ensures new inspectors develop competency in identifying violations and understanding facility operations

Equipment Needs

Equipment for swimming pools and recreational water safety programs typically serves as backup to the equip- ment that operators are required to maintain. Programs find it more useful to verify that operators possess and

can properly use their water testing equipment rather than inspectors carrying duplicate supplies.

Essential equipment includes pool water chemistry test kits and tape measures for verifying compliance with spacing requirements for fencing and water depth mark- ings. Some programs have invested in optical scanners that replace traditional water chemistry test strips. While these scanners require additional time and supplies such as chemical tablets, they can be useful for inspectors and operators who have difficulty interpreting color-based test results. Some agencies test for microbiological contamina- tion in water and, therefore, require some type of labora- tory capacity or partnership to perform those tests.

Funding Sources/Barriers

Swimming pools and recreational water safety pro- grams are typically funded through permit and inspec- tion fees, often supplemented by general municipal funding. According to the research, this fee-based model generally provides adequate revenue for cur- rent program operations. Some programs operate on a consultative basis rather than an enforcement basis, with enforcement occurring at a different jurisdictional level. In these cases, operators might use consulta- tive inspections as preparation for official enforcement inspections. This arrangement might have implications for funding and staffing, as the need for consultative activities can be less predictable without the direct enforcement component.

Onsite Wastewater

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Onsite Wastewater 4–5 activities per week

• Bachelor’s in science • REHS/RS credential • Installer training

programs

• Soil augers and rock hammers

• Tile probes and levels

• GPS units and CAD software

• Sludge judge sampler

• Cameras • Mobile technology

and inspection forms

• Contaminated wells ratio

• Permit review timelines

• System failure reports

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Definition Onsite wastewater programs involve the planning, permit- ting, inspection, monitoring, and complaint response for systems used to treat and dispose of or recycle wastewa- ter from onsite sewage treatment and disposal systems. Jurisdictional responsibility for onsite systems varies and can be defined by daily volume capacity, wastewater type and characteristics, facility square footage requiring soil sizing, or population served. These defining factors gen- erally distinguish onsite systems from community-wide wastewater systems, which are typically regulated by state agencies. Program scope often encompasses the full lifecycle of onsite wastewater management from initial system design through ongoing operational oversight.

Characteristics of a Successful Onsite Wastewater Program

Success in onsite wastewater programs can be demon- strated through the prevention of contamination of water sources through early detection and prompt remediation of older, damaged, failing, or illegally installed systems while minimizing repair timeframes to protect both public health and property owners from extended exposure to contaminated conditions.

Effective programs might emphasize collaboration and education with property owners, contractors, installers, and academic institutions through a customer service approach. We found that some jurisdictions conduct indus- try surveys to assess relationship quality with wastewa- ter system installers and other partners, recognizing that positive industry relationships facilitate compliance and system quality. Regulatory consistency across jurisdic- tions can also improve program effectiveness by allowing installers to work efficiently across multiple areas with uniform codes and fee structures.

Some EPH departments are involved in plan review and initial permitting. Ongoing maintenance and monitoring activities represent important considerations for long-term public health protection, though such activities were not reported as common across many jurisdictions.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Number of contaminated wells within a certain distance of a septic system/ number of inspected wells within a certain distance of a septic system

• Number of complaints per year

Workload management

• Average time (in days) from plan submission to permit approval per year *

• Number of initial permit reviews performed within 2 weeks

• Number of site location assessments completed per year *

Public health protection

• Number of repaired septic systems/number of detected failing systems

Partner engagement • Number of partner education events/contacts conducted per year

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

To measure success, a program can benefit from having records of the location of wastewater systems within its jurisdiction. EPH departments with adequate resources can store geolocation for systems in the jurisdiction in a centralized electronic database. This process allows wastewater programs to more easily monitor and maintain current systems, plan the installation of new systems, or expedite the identification of problematic systems.

For areas with both wells and septic systems, the number of wells showing sewage contamination (exceeding criti- cal coliform limits) could indicate how well the inspection program is performing. In areas where there are agricul-

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tural activities, testing samples for coliforms might not be a good indicator as it could be difficult to determine the source of contamination—human or livestock. In these cases, programs can use presence/absence testing for coli- forms or markers from detergents (e.g., optical brighten- ers) to determine areas of interest and then investigate the source of contamination with further bacteriology.

Plan review was noted as an important EPH function for most jurisdictions. A metric of program function could be the length of time to perform permit review from submis- sion to determination. Additionally, the number of initial permit reviews performed or completed within a certain number of days could provide insight into program effec- tiveness. A reflection of how well plan review and con- struction permitting activities are functioning could be seen in the number of failing septic systems, which are typically reported by the public to the EPH department. Assuming that complaint calls have a high sensitivity rate due to unmistakable sewage odor, this metric could also be measured by how many complaint calls are received about failing systems. In areas where pumping and main- tenance of septic systems are required by EPH depart- ments, a measure of EPH education to the public could be the percentage of homeowners who are fulfilling the requirement of pumping and maintenance.

Septic systems might not be appropriate to install in pop- ulation-dense areas, as they can contaminate groundwa- ter. Therefore, a metric based on population would need to consider codes that require connection to community sewage systems within a certain distance of a service line.

Although customer service was identified as a potential characteristic of success, measuring this quality using methods like customer satisfaction surveys can be chal- lenging. Often, customers are satisfied or dissatisfied with the installation process or quality, which is per- formed by third-party private companies not associated with the EPH department. Even if the initial installation was efficient from the EPH department perspective, cus- tomers might not know who to contact for installation failures. Therefore, outcome measures for customer ser- vice might not prove helpful. Given that environmental public health departments generally take complaints of various kinds, customers could be more likely to complain to the department even though the issue is reflective of the department’s part in the process. Therefore, the met- ric of complaints per year is recommended for the pur- pose of ensuring the department has methods to receive complaints related to onsite wastewater issues from the public and can assess possible well water contamination to advise on next steps.

Staffing

Onsite wastewater programs typically involve permitting, inspection, and complaint follow-up activities, with third- party contractors often responsible for soil evaluation and system installation. Research participants suggested cal- culating staffing rates by the number of systems inspected per person per day, excluding complaints and follow-up monitoring activities.

A reasonable inspection rate was noted as two septic sys- tem inspections per person per field day, with each sys- tem requiring 2–4 hours of work. Staffing needs increase significantly if EPH professionals are responsible for soil evaluation and design proposal rather than just field ver- ification. Programs requiring comprehensive technical evaluation should adjust staffing ratios accordingly. If EPH professionals are responsible for permitting and evaluating soil and proposing a design rather than just field checking, then that should be considered when determining staffing rates. As population density grows, staffing rates should consider the number and size of new and proposed subdi- visions in the jurisdiction.

Staffing benchmarks vary based on program scope and local conditions. One approach allocates 1 FTE for 120 new and repair systems annually, while another sug- gests a maximum of 350 systems per FTE per year. Pop- ulation-based calculations might use 10,000 population served per FTE, though this number can be adjusted based on population density and development patterns. These metrics could have limited applicability in urban areas with centralized sewer systems or rural areas where septic sys- tems predominate, requiring jurisdictions to adapt bench- marks to their specific infrastructure mix.

Regular assessment of whether onsite wastewater duties can be completed with available FTEs is import-

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ant for maintaining program effectiveness. University partnerships can supplement capacity by providing some additional testing capacity, such as sampling groundwa- ter for contaminants of human metabolites that indicate sewage contamination.

Staff numbers are often constrained by available funding through permit fees and supplemental funding sources rather than actual workload needs. Research findings indi- cated efforts to align staffing with demand, particularly during periods of increased permit activity. Some jurisdic- tions indicated having notable increases in new septic per- mits, yet the number of FTEs remained unchanged. Hiring generalist EPH professionals could be easier for flexible staffing allocation between programs during periods of expanding or contracting needs, but at a minimum, staff members should have backups to allow for continuity of duties during staff absences.

Education/Training/Certifications

Educational requirements for onsite wastewater programs show flexibility, with a bachelor’s degree in science being the preferred qualification. Research participants agreed that the REHS/RS credential provides comprehensive foun- dational knowledge for program duties. For jurisdictions not requiring an REHS/RS credential, a bachelor’s degree in sci- ence with coursework in hydrology, soil science, or geology could provide useful foundational knowledge.

EPH departments could send EPH inspectors to the same certificate training that wastewater installers attend, which might be available through state-specific organizations or local colleges or universities. These certifications are desirable in addition to the REHS/RS. The National Onsite Wastewater Recycling Association (NOWRA) provides generally recognized training. Hands-on training in the form of joint inspections with more experienced EPH profession- als that go through various stages of the permitting and construction process might be preferable as well.

Research indicates that some jurisdictions use alternate approaches to degree requirements when unable to hire candidates with specific degrees. These jurisdictions focus on skills-based hiring that prioritizes communication abil- ities, learning capacity, and customer service skills over formal education. Participants from these programs noted that inspection skills are primarily acquired through on-the- job experience. They also noted that degree requirements can limit access to the EPH field for individuals who have the aptitude but lack resources for a formal education. Pro- fessional certifications and training programs could offer an alternative educational pathway for individuals without formal degrees.

Programs might choose to balance accessibility with tech- nical competency requirements, potentially establishing tiered qualification systems that allow various entry path- ways while ensuring appropriate expertise for different system types and responsibilities.

Equipment Needs

For EPH professionals evaluating soil, useful tools include soil augers and rock hammers. Tools for inspection include tile probes, engineering scales, tape and optical measures, measuring wheels, lock levels, laser levels, sludge judges for evaluating depth of sludge in septic systems, and U.S. Department of Agriculture soil texture charts.

Technology needs can include computers, cameras for doc- umentation, GPS units for system location mapping, and computer-aided design (CAD) software for plan review and system design activities.

General program equipment includes some type of reli- able transportation, either through county or state-owned vehicles or personal vehicle reimbursement programs. Cell phones with good coverage in rural areas are important considerations, as onsite wastewater systems are typically installed in more rural areas.

Programs can ensure equipment is properly maintained and calibrated to support accurate field assessments and regulatory compliance documentation. The specialized nature of onsite wastewater work requires an investment in quality tools that can withstand field conditions while providing precise measurements important for public health protection.

Funding Sources/Barriers

Research indicates that onsite wastewater programs are primarily fee-funded for most jurisdictions, with new construction permits generating the most revenue. Juris-

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dictions experiencing limited new construction, however, can encounter funding challenges under this model. Some jurisdictions have low permit fees, but if they were to move to a fully fee-funded model, the fees would reach over $1,000 per permit, which might not be desirable to the public or supported by local political will.

State and county funding availability varies significantly, but it might provide more sustainable support for juris- dictions with minimal new construction or areas where ordinances require sewer connections within specified distances of existing lines. Programs operating under statewide oversight might benefit from enhanced state funding support, though many jurisdictions report that current state contributions do not cover inspection costs, requiring supplementation through county levy funding or general funds.

Research participants noted keeping costs to the public for the services of this program in line with expectations is an important consideration. It is their opinion that fees associated with a program can be set at an amount that is reasonable enough to cover the costs of the program but should not be excessive or inflated to support other (non-onsite wastewater) programs for public transpar- ency and accountability.

Another potential source of funding, while not applicable to most jurisdictions, comes from oil and gas industry revenue. With this funding, there are some departments that can support one half of their environmental health EPH depart- ment while the other half comes from the fees incurred from permitting. This model demonstrates how alternative reve- nue sources can provide funding stability for EPH programs in specific geographic or economic contexts.

School Safety and Inspection

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

School Safety and Inspection

2–3 inspections per field day

• Bachelor’s in science • REHS/RS credential

• Infrared thermometers

• Air quality monitors • Light meters • Playground

inspection kits • Cameras • Mobile technology

and inspection forms

• Repeat violations • Staff hazard

identification • Technical

consultations

Definition

A school safety and inspection program generally involves comprehensive inspection of educational facilities to protect the health and safety of students, staff, and visitors. Activi- ties include the inspection of food preparation areas, chem- ical safety and storage practices, emergency procedures, indoor air quality, climate and extreme weather prepared- ness, pest management, facility planning, and facilities and equipment management. Inspections cover various school infrastructure including playgrounds, portable classrooms, and other educational facilities to ensure they are in proper condition to protect the health of students, staff, and visitors.

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Characteristics of a Successful School Safety and Inspection Program

The ultimate measure of program success is to establish schools as healthy, safe, and equitable learning environ- ments for all students. This goal encompasses not only regulatory compliance but also the creation of educational settings that actively support student health, safety, and academic achievement. Successful programs ensure that all facility components, from food service areas to class- rooms and recreational spaces, contribute to an environ- ment where students can learn and thrive without health or safety concerns.

Success in school safety and inspection programs could be demonstrated when school facilities can serve as models for other establishments. For example, bringing operators of struggling facilities into well-managed schools to demon- strate best practices in safety and compliance standards.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of permitted school cafeterias inspected annually *

• Decrease in the number of major or repeat violations per school per inspection cycle

Workload management

• Percentage of school inspections completed during peak season (September– November) annually

• Average number of school safety inspections completed per inspector annually *

Public health protection

• Number of critical violations identified per 100 school inspections annually

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

A key measure of program effectiveness and educational impact is the reduction in repeat violations cited during inspections. Violation severity is typically weighted based on population impact and problem scope, with system-wide issues such as malfunctioning plumbing that affects entire schools receiving higher priority than localized problems like individual classroom handwash sink failures.

Educational effectiveness can be measured through the school staff’s ability to identify and address potential haz- ards between formal inspections. Programs that operate on multiyear inspection cycles should track reductions in both major violations and repeat violations as indicators of successful knowledge transfer and technical assistance.

Staffing

The number of staff for school safety and inspection pro- grams varies based on local funding mechanisms, jurisdic- tion size, and inspection frequency requirements. Research findings indicate that some programs use county-level funding based on income tax revenue and the number of schools requiring inspection, creating direct connections between local resources and program capacity.

Inspection scheduling affects staffing needs significantly. Programs operating on rotating schedules, such as full school inspections every 3 years with kitchen inspections each semester, require different staffing models than annual inspection programs. To meet the demands of per- forming school inspections during school operational peri- ods, research findings indicate that programs might use multiple staff members who can perform these inspections quickly and then return to other EPH programs, demon- strating how shared staffing approaches can address the timing constraints of educational facility inspections.

Calculations to determine the number of staff needed might consider the percentage of FTE time dedicated to school routine inspections. Factors include school types within the jurisdiction, inspection capacity per workday for different school categories, and the balance between routine and non-routine inspection activities. Survey data indicates a median of 140 school inspections per FTE annually across programs. Staff time could be allocated to other program

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areas during summer months when schools are generally closed, such as vector control or recreational water pro- grams that experience increased activity during this period.

Staffing assignments can consider the geographic location of schools and drive time, as well as factor in the type of schools assigned to each inspector. High schools tend to take longer to inspect than elementary schools and larger facilities usually take longer than smaller schools. Pro- grams can periodically change the routes of inspection assignments to redistribute the workload and get a fresh pair of eyes to evaluate the inspected facilities.

Education/Training/Certifications

A bachelor’s degree in science and an REHS/RS credential were both identified as important for this role, providing the technical background useful to understand complex facility systems and health hazards. Additional certifi- cations, such as a certified playground safety inspector, could enhance program effectiveness for specific facility components. Additional training on topics such as inte- grated pest management (IPM) and other school-specific topics could expand inspector competency beyond basic EPH knowledge.

In-house shadowing and training through shadowing experienced inspectors were noted as important for developing competency across different educational set- tings. Research participants recommend that new inspec- tors shadow experienced inspectors for at least three school levels—elementary, junior high, and high school. While elementary schools can be more straightforward, higher-level schools have chemistry laboratories or other programs that require more involved inspections. Having exposure to these types of schools and the inspections they entail gives a new inspector the breadth needed to

graduate to conduct joint inspections with limited over- sight and then eventually solo inspections.

Equipment Needs

School safety and inspection programs need equipment for school inspections, including temperature measurement tools such as infrared thermometers to check classroom temperatures to ensure they are within state requirements.

Indoor air quality assessment equipment such as rotating vane anemometers that can measure air velocity, air vol- ume, and temperature, and similar monitors and detectors can check indoor air quality and relative humidity. Light meters are useful to ensure classrooms are not too dark.

General inspection tools include flashlights to aid in look- ing under sinks and checking for pest activity. Infrared cam- eras can help identify moisture issues in walls and ceilings.

A playground inspection kit for playground safety inspec- tions is highly recommended. Additionally, for programs that also conduct school kitchen inspections, similar tools needed for food safety inspections are needed for school kitchen inspections as well—thermometers, chemical test strips for pH and cleaning solutions for dishwashers, etc.

Funding Sources/Barriers

School safety and inspection programs are funded through varied mechanisms, with significant differences across jurisdictions.

Common sources of funds include state appropriations and general funds that provide funding for school EPH programs in some states; local health department gen- eral funds that often support school inspections as part of broader EPH services; fee-based systems where some jurisdictions charge inspection or permit fees to schools; and grant funding through EPH education grants from the U.S. Environmental Protection Agency (U.S. EPA), school integrated pest management grants, and other competi- tive federal and state grant programs.

Challenges around funding include jurisdictional com- plexity where the authority for school EPH often spans multiple agencies (e.g., health departments, education departments, facilities management). These challenges create issues in coordinating resources and responsibilities and limit the dedicated funding streams for school EPH programs, with some programs competing for resources within broader EPH or education budgets, infrastructure funding gaps, and inequitable resource distribution.

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Early Childcare and Daycare

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Early Childcare and Daycare

3–4 inspections per week

• Bachelor’s in science • REHS/RS credential • Playground safety

certification • IPM training

• Thermometers and light meters

• Flashlights • Sanitizer test strips • Educational

materials • Cameras • Mobile technology

and inspection forms

• Number of critical violations

• Outbreak control timeframes

• Facility closure rate

Definition

An early childcare and daycare program generally involves comprehensive inspection of facility cleanliness, safety, and pest control management; verification of proper sanitizing and disinfecting procedures; ensuring appropriate storage of medications and chemicals; measuring hot water tempera- tures; providing education to control communicable disease transmission; facilitating disease management; ensuring appropriate vaccinations of attendees and staff; assessing safety hazards including pools, playgrounds, electrical out- lets, strangulation risks, and tip hazards; documenting pres- ence of required policies and procedures for diapering, potty training, handwashing, emergency preparedness, and illness exclusion; connecting facilities to mental health resources; and conducting kitchen inspections where applicable.

Childcare and daycare facilities are typically categorized as residential or commercial operations. Some jurisdic- tions also establish limits on the number of children allowed in residential settings. Inspections are generally conducted as part of licensing processes. Sometimes the licensing process is administered by agencies other than EPH departments. When multiple agencies are involved in licensing, each might focus on different facility aspects, requiring coordination to ensure comprehensive oversight while avoiding duplication of efforts.

Characteristics of a Successful Early Childcare and Daycare Program

Success in early childcare and daycare programs is primar- ily defined by the ability to effectively control communi- cable disease transmission within care facilities. Effective

programs work with operators to create safe and healthy environments where parents can confidently place their children, knowing that appropriate health and safety stan- dards are maintained and enforced.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Average number of critical violations cited per 100 facilities per year *

• Decrease in the number of facility closures per year *

Workload management

• Number of inspections completed per inspector per year

Public health protection

• Average number of days between illness outbreak detection and the end of transmission per year.

• Percentage of facilities with complete vaccination records *

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

Disease prevention in childcare settings involves ensuring proper vaccine documentation and limiting the spread of disease. Disease can transmit easily in childcare facilities; therefore, EPH programs should verify that facilities main-

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tain vaccination records and ensure attendees and staff are properly vaccinated.

Facility closures due to unsatisfactory conditions could be seen as a measure of program performance. Facilities remaining open could indicate good compliance. Like other EPH inspection programs, tracking the number and types of violations cited provides important outcome measures.

Research participants did not feel that illness or outbreak numbers would be good measures of program success or effectiveness. Diseases such as norovirus, influenza, and hand, foot, and mouth disease inevitably occur in these types of facilities, especially for diseases where no vaccine currently exists. Tracking outbreak control timeframes from detection to resolution could provide insight into facility preparedness. While not the consensus opinion, EPH pro- grams might find it useful to track how long it takes to con- trol an outbreak once detected and whether it has spread to the community. Shorter control periods could indicate that facility staff were trained in infection control measures and had proper protocols to prevent ongoing transmission.

Inspection completion rates represent another practical outcome measure. Some research participants mentioned that their programs aimed to complete 90% of required childcare and school inspections per year, which leaves flexibility for seasonal camps and similar facilities that might not operate during certain seasons. Such facilities maintain licenses but do not require inspection when non-operational.

Staffing

Adequate staffing levels might enable programs to com- plete required facility inspections within established time- frames. Programs that track inspection completion rates, such as achieving 90% of required inspections annually as

mentioned by participants, can use these metrics to iden- tify when staffing adjustments are necessary.

For some participants, being able to track the amount of time in each type of facility (i.e., childcare, family care homes, group care) can help determine the amount of staffing needed for this program. Research findings indi- cate that 3–4 early childcare or daycare facility inspections per week were considered reasonable by both staff and managers for full-time staff.

Education/Training/Certifications

A bachelor’s degree in a field of science was identified as the preferred minimum education requirement for early childcare and daycare programs. REHS/RS credentialing was also recommended for professionals working in this program area.

Participants suggest a playground safety inspection cer- tification as it provides good training for a setting where there are many hazards to child health and safety. Having some type of IPM training (not necessarily a certificate) would be useful, as EPH professionals would be more informed about pesticide applications in areas where chil- dren are exposed.

On-the-job training was valued for early childcare and day- care programs. Participants mentioned considering a person to be a fully trained EPH specialist after 2 years of training.

Participants noted that if departments make registration a mandatory educational requirement, it is important that they build in the resources to enable staff to pursue and maintain this registration.

Equipment Needs

Early childcare and daycare inspection programs will likely require standard EPH equipment to assess facility condi-

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tions and safety compliance. Participants recommended thermometers, light meters, tape measures, sanitizer test strips, thermal labels or heat disks, labels for cleaning solutions, gloves, masks, and shoe booties or covers.

Funding Sources/Barriers

Childcare and daycare EPH programs operate under dif- ferent funding models. Some programs are fee-based, while others receive funding from general funds through taxes. Participants noted that in less urban or sparsely

populated areas, general fund allocations do not fully cover program needs.

Some participants whose programs rely on general funds expressed interest in implementing permit fees for childcare facilities. These participants indicated that permit fees could generate revenue to supplement gen- eral funds, particularly in less populated areas. Accord- ing to participants, consistent funding supports both routine inspections and less frequent activities such as outbreak investigations.

Zoonoses and Vector Control

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Zoonoses and Vector Control

Variable by disease burden

• Bachelor’s in science • REHS/RS credential • Vector control

technician training • IPM training

• Traps and collection tools

• PPE • Lab supplies

and microscopes • Adulticides

and larvicides • Cameras • Mobile technology

and documentation forms

• Training hours • per inspector • Number of human

disease cases • Vector index

thresholds

Definition

A zoonoses and vector control program generally involves the surveillance, investigation, and control of diseases directly or indirectly transmitted by animals and insects that affect human health. These include mosquito-borne diseases, tickborne diseases, rabies, fleaborne diseases such as plague, and other diseases transmissible from animals and insects to humans. Activities include case investigations, mapping of vector sources, implementation of vector awareness strategies, monitoring of emerging and reemerging vectorborne diseases, response to outbreaks, and assistance with the coordination of specimen collection and safe disposal of animals and vectors.

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Characteristics of a Successful Zoonoses and Vector Control Program

Phased response plans for disease response and miti- gation are an important part of success and include the ability to analyze historical data to determine thresholds. Public trust and good customer service are valuable driv- ers that ensure programs address non-outbreak-related vectorborne disease issues in a way that instills confidence and trust in public health. This strategy could mean reg- ular assessment of program gaps and response to those gaps to strengthen areas of weakness.

Forecasts are an important element for the success and con- tinued success of a vectorborne program as climate change expands the range of vectors that can carry diseases. Human disease tracking and surveillance can detect vec- tor movement and disease emergence in a jurisdiction. For example, mosquito indices can be calculated as the average number of infected vectors collected per trap-night.

A vector index for mosquitoes, such as an index of 0.5 for 2 weeks, can help departments know when to consider implementation of more drastic control measures like aerial spraying.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Number of disease outbreaks responded to within target timeframe per year *

• Number of case investigations completed within the required timeframe per year

• Number of specimen collections and safe disposals completed per season.

Workforce development

• Percentage of staff completing required integrated pest management training annually *

Partner engagement • Number of partner education events/contacts conducted per year *

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

Support of the public is important because funding for pro- gram activities often comes from taxes and special districts.

This support is difficult to measure, but departments can use needs assessments to try to capture some indicators.

Our research found that training completion serves as an important outcome measure for this program. Specifically, tracking whether staff receive annual integrated pest or vector management training provides a key indicator of program implementation success.

EPH departments often develop risk thresholds for each disease relevant to their area and have a plan to act once the thresholds are surpassed. These thresholds might be vector-specific, such as a vector index, and/or human-spe- cific, such as the number of human disease cases. Data analysis of disease trends plays a big part in establishing thresholds and considering environmental and surveil- lance factors into disease response is essential for this program with very mobile vectors. For example, assuming surveillance is consistent, a department’s jurisdiction could be in a vulnerable position if surveillance does not detect disease activity for an extended period. In the case of West Nile virus, this could mean that the birds in the area are increasingly susceptible to the virus, therefore increasing the viral abundance in the environment, which might result in an increase in human cases in the upcoming year.

Staffing

The workload for this program is disease and vector dependent; the more diseases that are monitored and investigated, the more staffing is generally necessary. Mosquitoes seem to be a ubiquitous problem, but some diseases like hantavirus or Lyme disease tend to be regional or in concentrated areas.

Tourism might also play a role in the determination of staff numbers. Mosquitoes and pests can hinder the growth of a tourism economy and, therefore, some jurisdictions where tourism is a big economic driver might choose to invest more in their mosquito or pest control programs in target areas.

Partnerships and internships with local universities can provide some seasonal staffing support from students needing to fulfill a practicum or applied experience intern-

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ship. Given its seasonal nature, it was suggested that the student workforce might be better used for special proj- ects or disease investigation rather than routine duties.

Participants suggest having dedicated staff for each of the various EPH programs to ensure programs are operating as necessary. They shared an example where during a large outbreak of a vectorborne disease, the media reported that because EPH staff were pulled from conducting restaurant inspections to outbreak response, many of the restaurants were not being inspected. To avoid a drastic shift in func- tionality, they advocate for at least one dedicated staff person per EPH program area to maintain consistency. Unfortunately, in jurisdictions where there are no dedi- cated mosquito control districts or dedicated programs, EPH professionals are likely doing mosquito control work as an add-on duty to their regular roles, which can lead to under-training and potentially less effective prevention efforts. Contrarily, specialization might make it difficult to move staff between programs to support seasonal needs.

Access to an entomologist and veterinarian could prove helpful to jurisdictions. Sometimes these relationships exist through partnerships with state health departments. Additionally, partnerships with laboratories for testing are also essential to confirm disease presence.

Overall, staffing for this program is generally driven by the number of diseases and vectors relevant to the geographic area of the department, economic needs and funding avail- ability, and population served. From the key informant interviews, we estimate about 0.45 FTEs per 100,000 pop- ulation served for a jurisdiction where tourism is not a big factor. In an area with higher tourism, we estimate a need of approximately 1.35 FTEs per 100,000 population served.

Education/Training/Certifications

For supervisory positions, participants recommend a bach- elor’s degree in the science field.

The REHS/RS credential was recommended for this pro- gram area, particularly for supervisory positions, though specialized vector control certifications and training were often prioritized. For some jurisdictions, a vector control technician certification license could be required by the state. Because vectors are geographically significant, EPH professionals might seek training specific to their state.

Integrated pest and vector management training was identified as valuable for professionals in this program area. Due to the potentially hazardous chemicals and risks involved, such as pesticide spraying and vector trapping and flagging, participants recommend that EPH profes- sionals performing the duties of a vectorborne program be properly and specially trained for each activity.

Equipment Needs

Field work often requires specialized equipment, including protective gear (e.g., insect repellent, Tyvek suits), collec- tion tools (e.g., flea drags, tick cloths, traps, lures, aspira- tors, vials, insect cages), inspection tools (e.g., plumbing snakes for rodent burrow examination), and control prod- ucts (e.g., adulticides and larvicides).

Common unspecialized equipment includes flashlights, UV lights for detecting urine, and probes for testing holes (since openings larger than 1/4 in. can allow small mice to enter or exit). Additional basic tools include cameras or phones for documentation, computers or tablets for recording information, and personal protective equipment (PPE) such as eye protection and gloves.

Jurisdictions with laboratory facilities might require special- ized equipment, including dedicated refrigerators and freez- ers for sample storage, coolers and ice packs for shipping specimens to labs, microscopes for examination, forceps for handling specimens, pinning equipment for mounting, and larval or sorting trays for organizing samples.

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Funding Sources/Barriers

For many jurisdictions, vectorborne program funding orig- inated with local general funds. Some participants shared that their programs receive some funds from the state through property taxes. Federal funding through grants like the Public Health Emergency Preparedness grant or the Epi- demiology Laboratory Capacity Cooperative Agreement has provided resources for activities like laboratory testing for pri- ority diseases, such as mosquito testing for West Nile virus.

Grants through member-based organizations have pro- vided some one-off funding for some programs, but pur- suing these types of opportunities can sometimes require adapting the program to meet funding requirements rather than the needs of the communities the departments serve.

For a few participants, funding is a multifactorial pro- cess that takes into consideration the tourism industry

and public opinion and support. Media coverage of dis- ease outbreaks, such as a West Nile virus outbreak or even resulting lawsuits, can garner public attention and incentivize politicians to allocate more funds to the vec- torborne program. This method of funding, however, can be unpredictable and unsustainable but has provided a much-needed funding boost for the programs that other- wise would not have received it.

Potential sources of revenue for this program could be through a variety of taxes or fees on the populace—mos- quito abatement fees on utility bills, income taxes, prop- erty and parcel taxes, or pet registration taxes. Participants spoke about an instance where the National Park Service was able to negotiate an agreement with a local public health program to pay them for services. Using the funds from this agreement, the environmental public health pro- gram was able to hire an FTE for this program.

Emergency Preparedness

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Emergency Preparedness

As needed basis • Bachelor’s in science or other degree

• REHS/RS credential • ICS 100, 200,

700, 800 • EHTER courses

• Communication systems

• Emergency power sources

• Specialized response equipment

• Laboratory access

• Number of staff with required certifications

• Response time • COOP plan

review currency

Definition

The role of EPH programs in emergency preparedness is primarily thought of as a program concentrating on human health and the environmental effects in the preparation and response to natural and human-made emergencies and disasters. EPH professionals are important to the assessment and restoration of many services in the com- munity such as food supply, sewage treatment, drinking water, solid waste disposal, and other essential services.

It is important to note that many state public health agen- cies have an emergency preparedness program; however, disaster response is profoundly local. EPH responders are not typically thought of as first responders, but they have a vital role in response and recovery.

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Characteristics of a Successful Emergency Preparedness Program

Because EPH professionals are not necessarily perform- ing emergency preparedness activities as daily duties, building and maintaining relationships with emergency preparedness professionals and agencies in their state is essential to a successful emergency response. As one participant stated, “You don’t want to exchange business cards at the disaster.”

You don’t want to exchange business cards at the disaster.

Successful programs would have updated policies and procedures, such as a continuity of operations plan (COOP) that supports the EPH workforce’s ability to respond.

As an emergency preparedness capacity workforce, it is important that EPH departments clearly outline the roles, responsibilities, and competencies of their EPH profession- als related to emergency response. This outline fosters a shared understanding of the skills and training that EPH professionals possess and expedites mutual aid requests between agencies.

While not specifically discussed in this research, juris- dictions might find our Environmental Public Health Emergency Preparedness and Response (EPHEPR) capa- bility framework helpful. EPHEPR provides guidance for assessing and strengthening readiness to address core public health issues in disasters. The framework includes 15 functional areas with corresponding tasks that explain each function necessary to protect against environmental health threats. Additionally, our guidance on EPH strike teams is available to support the development of scalable units that can deliver targeted assistance during emergen- cies. More information on these resources can be found at https://www.neha.org/epr-framework and https://www. neha.org/PDFs/Strike_Team_White_Paper_FINAL.pdf

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of staff who complete at least one emergency preparedness training per quarter annually

• Percentage of emergency response plans and protocols reviewed and updated per year *

• Percentage of continuity of operations plans reviewed or updated annually *

• Percentage of staff with required ICS certifications (100, 200, 700, 800) per year *

• Percentage of emergency responses followed by completed after-action reviews with documented lessons learned per year *

Response capability • Average time from emergency notification to full operational response (in hours) per year *

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

The ability to provide a capable and competent work- force in the field when needed is a meaningful measure of EPH capacity in emergency preparedness and response. Training for the EPH workforce to serve as responders to health-related emergencies is an important metric of response capacity. After-action reviews that recommend actionable steps to improve planning and response to future emergencies provide a meaningful perspective on the effectiveness of those trainings.

Staffing

EPH capacity in emergency response is generally based on a comprehensive threat assessment and vulnerability analysis to determine potential needs. Some emergencies or natural disasters, such as tsunamis, earthquakes, wild- fires, hurricanes, and flooding affect some jurisdictions and not others.

Participants shared that EPH professionals in their juris- dictions are trained in emergency response so that they could be deployed in an emergency capacity. Though not

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generally housed in EPH, jurisdictions shared that approx- imately 30% of 1 emergency coordinator FTE was dedi- cated to their jurisdictions per roughly 50,000 people.

Education/Training/Certifications

Participants indicated that a bachelor’s degree was the preferred educational requirement for emergency pre- paredness programs. Additionally, some participants mentioned that having a master of public health (MPH) would also adequately prepare someone to lead envi- ronmental public health planning and actions during an emergency response.

While the REHS/RS credential was recognized as valuable for this program area, it was not considered as essential as program-specific emergency management training.

Appropriate and up-to-date training was noted as import- ant and recommended for EPH emergency responders. These trainings include the Federal Emergency Manage- ment Agency’s Incident Command Systems (ICS) courses that are available online for free:

• ICS 100: Introduction to the Incident Command System

• ICS 200: Basic Incident Command System for Initial Response

• ICS 700: National Incident Management System (NIMS), an Introduction

• ICS 800: National Response Framework (NRF), an Introduction

Participants also noted that first aid, cardiopulmonary resuscitation (CPR), and AED training could be important training for some professionals, depending on their roles. Also recommended was the Center for Domestic Pre- paredness’s Environmental Health Training in Emergency Response (EHTER), a 5-day in-person training at FEMA facilities in Anniston, Alabama, which has been well-re- ceived and highly recommended by participants.

Participants mentioned other useful credentials, but these credentials were not recommended to be required of EPH professionals. These included the certified hazardous materials manager certification and emergency manage- ment certification.

Equipment Needs

Access to or a relationship with a laboratory to conduct food, water, and air quality testing was noted as being important for biological and environmental monitoring to detect and monitor emergency situations. Communication among responders is also important during emergencies; therefore, recommended equipment includes cell phones, radios, internet, computers, and government emergency telephone systems (GETS) and Wireless Priority Service (WPS) to maintain uninterrupted communication lines. To support this technological equipment, generators or alternative sources of power were also noted as import- ant. Specialized equipment could be required for specific types of emergencies and disasters, such as radioactive detection equipment to handle emergencies involving radioactive waste.

Funding Sources/Barriers

Participants indicated that funding for emergency pre- paredness programs often comes through federal grants and from general funds. Some jurisdictions reported using hotel occupation tax or tipping fees from waste haulers at landfills to fund emergency preparedness activities. Reve- nue generated by state lotteries was mentioned as another potential funding source, though participants noted these funds are not always sustainable.

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Potable Water

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Potable Water 3–4 field activities per week

• Bachelor’s in science • REHS/RS credential • Drinking water

operator certification

• Water quality kits and sampling supplies

• Cameras • Measuring tapes

and rulers • Mobile technology

and inspection forms • Educational

materials

• Number of well inspections

• Safety of water samples

• Number of waterborne illnesses associated with drinking water

• Number of educational events

• Number of voluntary well water samples submitted

• Number of plan reviews completed

Definition

Potable water programs in EPH departments can include public drinking water systems; ground or well water disinfection, construction, testing, sealing, and repair; chemical runoff; leaking or failing sewage sys- tems; and severe weather effects (e.g., drought, severe cold, severe heat).

These programs work to ensure safe drinking water through oversight of water systems. Programs perform activities such as approving new water systems and wells through permitting processes, conducting testing for con- taminants, performing inspections for compliance with health and safety standards, and implementing enforce- ment actions when necessary. Programs also issue water safety advisories and provide education on water safety practices to protect public health.

Characteristics of a Successful Potable Water Program

A potable water program generally works to ensure safe locations for wells and onsite wastewater systems through sanitary surveys. The program ensures that wells are properly constructed, and that the groundwater source is safe through appropriate sampling to test for coliforms and other contaminants in drinking water.

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Part of ensuring a safe location for wells for many juris- dictions includes having a registry that identifies where these systems and onsite wastewater systems are in the jurisdiction. If the information is not housed locally, having access to state-level data of well locations and depths can be useful in constructing or decommissioning wells, if such data exists.

Education for property owners, well drillers, builders, and other industry partners is an important activity for potable water programs. Strong relationships with associations for well drillers, building and safety, and onsite wastewater help EPH professionals serve as a resource for industry partners as they do their work. Often, government agen- cies that permit oil, gas, or mining industries are differ- ent from health agencies. In these cases, collaboration between health agencies and these industry partners pro- tects groundwater and prevents contamination of drinking water supplies.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of well inspections completed within required timeframes per year *

• Percentage of plan reviews completed within target timeframes per year.

Workload management

• Average number of potable water activities completed per staff member per week annually.

Public health protection

• Percentage of water samples meeting all applicable quality standards per year.

• Number of waterborne illness cases associated with regulated water systems per 100,000 population per year *

Partner engagement • Number of education events on water testing conducted per year.

• Number of voluntary well water samples submitted per 1,000 known wells per year *

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

Potable water program outcome measures should consider weather seasonality as contaminant levels are affected by rainfall, drought, and other weather-related incidents.

Population density can affect the number of possible con- tamination sources and should be considered when devel- oping policies allowing new well construction and drilling.

As a metric of the impact of consumer education, potable water programs could estimate the number of well water samples voluntarily submitted for contaminant testing by well owners per the number of known wells in the juris- diction per year.

Staffing

Potable water program responsibilities differ among agen- cies. Some agencies ensure the proposed site of a well is suitable, while some are more involved in siting, survey- ing, and maintenance. Staffing rate determination for this program mighty consider the level of involvement of EPH personnel from reviewing permits, ground surveying, sit- ing location, and construction oversight, to providing edu- cation and routine maintenance inspections.

Research indicated that 3–4 potable water field activities per week were considered reasonable for EPH profession- als. Jurisdictions need to have a general understanding of how many annual field activities are anticipated to deter- mine the FTE needed for their potable water program.

In addition to considering the potable water efforts of local departments, consideration should be given to what other agencies—such as state agencies and academic part- ners—are doing to support the protection of public health in this field.

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Additionally, as demands for new construction of homes with private wells increase and in- and out-migration occur, the need for more dedicated staff is rising for many jurisdictions. To allow for maximum flexibility, adequate staffing for this program would mean existing wells are inspected and maintained the appropriate number of times required by legislation.

Education/Training/Certifications

A bachelor of science in a science field with some courses in geology, biology, microbiology, and hydrology is highly recommended by survey respondents.

Given the intricacies of installing and maintaining a pota- ble water system that go hand-in-hand with onsite waste- water systems, participants also recommend requiring an REHS/RS credential for inspectors performing potable water program activities.

Additionally, drinking water operator and public systems certifications offered by many states and well driller asso- ciations can help EPH professionals become more accli- mated to perform some of the duties of this program.

Equipment Needs

Equipment for potable water programs varies based on specific program responsibilities and activities. Common equipment includes inspection and assessment tools such as measuring tapes, rulers, and digital cameras for docu- mentation purposes.

Water sampling and testing equipment represent a criti- cal component of potable water programs. This includes

sterile water sampling containers, sample preservation materials and coolers, chain of custody documentation forms, and transportation materials for sample delivery to laboratories. Programs often rely on proper sampling equipment to ensure accurate water quality assessment and regulatory compliance. Educational and outreach materials, including brochures and fact sheets about water safety, support programs in communicating important information to system operators and the public. Adminis- trative and technical equipment encompasses computers and printers for plan review and documentation, technical reference materials and regulatory guides, communication devices (cell phones, two-way radios), and vehicles for field inspections and site visits.

Programs that engage in soil sampling or well-siting activities might require additional specialized equipment, including soil sampling tools for contamination assess- ment and basic surveying equipment for well-siting eval- uations. Equipment selection varies based on the scope of services provided and specific regulatory requirements within each jurisdiction.

Funding Sources/Barriers

Funding for potable water programs in many jurisdic- tions is based on fees incurred from the construction and maintenance of potable water systems. New construction fees are common among participating departments in this focus group. Some departments charge an annual fee for maintenance inspections. Participants did not charge a fee for operating wells, which could mean that their primary source of income for this program relies solely on new construction, thereby making their program vulnerable to population migration.

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Lead Prevention

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Lead Prevention 2–3 field activities per week

• Bachelor’s in science • REHS/RS credential • Lead risk assessor

certification

• XRF analyzers • Dust wipe

sampling supplies • PPE • Educational

demonstration kits

• Blood lead level reductions

• Number of properties deemed lead safe

• Environmental assessment completion rates

Definition

An EPH lead prevention program generally involves the sur- veillance, investigation, remediation referrals, and education of lead exposure in response to child blood lead detection. Exposure sources can occur from lead-based paint, lead water service lines, food, or lead-contaminated soil.

Lead prevention programs usually have two main compo- nents: 1) exposure-driven intervention and 2) prevention, education, and outreach.

It was noted by participants that the term “elevated child blood lead levels,” though still often used, is being reconsidered. This terminology shift emphasizes that there is no acceptable level of lead in the blood of chil- dren, with an understanding that testing instrument limitations can limit detection, and departments might choose to only investigate cases where results yield a reading of over 3.5 μg/L of lead per dL of blood per CDC and U.S. EPA guidelines.

Characteristics of a Successful Lead Prevention Program

A successful lead prevention program often has good community awareness and relationships so that the com- munities it serves feel comfortable using the services. The program engages communities, empowers nonprofit or community-based organizations to assist, and facilitates the relationships needed to protect the health of those in the communities.

The program addresses the needs of the community by conducting surveillance and educational programs and, equally as important, helps the community follow through to remediate issues that are found through the surveillance.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of home inspections completed where lead hazards were identified and addressed annually *

• Percentage of elevated blood lead level investigations completed within target timeframe annually *

• Percentage of children with elevated levels whose blood lead levels returned to acceptable ranges within target timeframe annually *

Workload management

• Average number of lead prevention activities completed per staff member per week annually

Public health protection

• Percentage reduction in children with elevated blood lead levels annually *

Partner engagement

• Number of public education events or contacts about lead exposures conducted per year

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

Based on the authority given to the EPH department, some can enforce remediation activities such as removal of lead-based paint from homes within their jurisdiction

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whether it be rental properties or owner-occupied prop- erties. Because rental homes often provide housing for people who have lower incomes, it is important to make sure the program protects the health of this at-risk popu- lation to ensure that rental properties comply with lead- safe requirements through assessment and remediation. Lead testing as part of a rental registry can help identify properties of concern. An outcome measure could be the proportion of rental properties that have been deemed lead-safe out of the number of rental property registra- tions there are. This measure can apply to rental property permits but also construction permits. When a contrac- tor applies for a construction permit on an older home, a meaningful outcome measure would be how many of those permits or homes have a lead assessment con- ducted by the EPH program.

Another helpful measure was stated as being able to track the number of children with blood lead levels and how many of those cases continue to have elevated levels after multiple tests and having their property undergo remedi- ation strategies once they enter the surveillance system. This measure requires surveillance systems that can track individuals and laboratory reports over time.

Partnerships with community-based organizations to reach at-risk communities might also be an important part of their work. There could be community development organizations that serve as community ambassadors and consultants who can conduct lead consultations. Through partnerships with these organizations, healthcare provid- ers, and clinics, programs can promote screening and edu- cation so that children are tested for blood lead levels.

Staffing

Lead prevention programs can determine staffing based on three key factors: 1) population served, 2) number of pre-1978 properties, and 3) geographic coverage area. Home visits generally represent a core program function, particularly when children test positive for lead. The travel

time required for these visits directly affects staff capacity and workload.

Research indicates that 2–3 lead prevention activities per week were considered reasonable for EPH professionals. Programs can use this guidance along with their estimated annual activity needs to determine appropriate staffing levels. Respondents in the focus groups also noted that jurisdictions could consider the desirable minimum staffing for this EPH program as a median of 1.2 FTEs per 100,000 population served.

Some participants also noted that much of the remediation work is currently being conducted by private third-party companies who can charge property owners drastically different prices. Additionally, some noted that jurisdictions might want dedicated FTEs to do the remediation work that is currently done by third-party companies, though there was no consensus on this suggestion.

Education/Training/Certifications

A bachelor’s degree in a science field was identified as the preferred minimum education requirement for lead pre- vention programs. For some specialized roles, participants noted that community health educator positions could benefit from degrees in public health or nutrition, while community health worker roles could have a high school diploma as a minimum requirement.

The REHS/RS credential was recognized as valuable for this program area. While not considered essential for per- forming lead prevention duties, the credential provides foundational knowledge that supports EPH professionals across program areas.

A state lead risk assessor license might be necessary in some jurisdictions to conduct lead investigations and make recommendations for remediation. Respondents men- tioned that for some state requirements, only a sanitarian

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with a 4-year degree in science, 3 years of mentoring, and a lead risk assessor license can fully perform the duties needed for this program.

It is also important to note that U.S. EPA requires individ- uals and firms who perform abatement projects in pre- 1978 target housing and child-occupied facilities to be certified and follow specific work practices. Many states have additional requirements for conducting lead services, including lead inspection, lead risk assessment, lead haz- ard screening, lead mitigation, and lead abatement work and supervision in regulated facilities.

Aside from educational requirements, participants noted that meticulous notetaking skills and being able to use analytical tools and retain and apply knowledge are desir- able skills.

Equipment Needs

Essential equipment for lead prevention programs includes various categories of specialized tools and safety equipment.

For sampling and testing, programs might use lead dust wipe sampling supplies that meet ASTM E1792-96 standards, paint chip collection tools and containers for laboratory anal- ysis, and soil sampling equipment for exterior assessments. Clean sample collection containers that will not contaminate samples are useful, along with sample documentation mate- rials such as labels and chain of custody forms. Measuring tools such as tape measures and rulers help calculate sam- ple areas, while digital cameras document conditions. Tem- plates for standardized dust wipe sampling areas can help ensure consistent collection procedures.

Analytical equipment may include X-Ray Fluorescence (XRF) analyzers for non-destructive lead paint testing, which allows for surface-by-surface paint inspection with- out damaging materials. Field test kits provide preliminary screening capabilities, though laboratory confirmation is

typically required for regulatory compliance. Access to accredited laboratory services is helpful for analysis of collected samples.

Personal protective equipment supports staff safety and can include disposable nitrile gloves to prevent skin contact with lead-containing materials, N95 respirators or half-mask respirators with P100 filters specifically designed for lead when disturbing lead-containing materi- als, and disposable protective clothing such as Tyvek suits to prevent contamination of personal clothing. Shoe covers help prevent tracking lead dust, while safety glasses or goggles protect eyes from dust. Handwashing and equip- ment decontamination supplies support proper hygiene and safety protocols.

Programs that conduct educational outreach can maintain demonstration kits and educational materials to help res- idents, property owners, and contractors understand lead hazards and prevention measures. Digital tools for data collection and case management are useful for tracking at-risk properties and follow-up activities.

Equipment selection varies based on the program’s scope and the types of lead hazard assessments conducted. Programs that focus primarily on surveillance and edu- cational activities usually use less specialized equipment than those programs that conduct comprehensive lead risk assessments and clearance testing.

Funding Sources/Barriers

Research showed that many jurisdiction lead programs are funded through a variety of state and federal government money, including U.S. Department of Housing and Urban Development (HUD) funds for replacement windows and doors for qualifying property owners. State delegated authority might pay an average fee for testing, Medicaid funds testing in children, and city general funds support lead safe certificate programs. A variety of smaller grants through coalitions and other nongovernment organiza- tions can provide some funding for incentives for property owners to remediate their properties.

Focus group participants believed that funding should be expanded to incentivize remediation rather than being limited to surveillance and education. Participants felt that grant funding, such as that available through HUD, should be based on the number of people served. A large portion of participant funding currently comes from U.S. EPA as their jurisdiction is a superfund site. Most of the funding for this program seems to be allo- cated to education and outreach programs for screening, assessing, and advertising.

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Body Art

Program Overview and Core Services/Activities

PROGRAM RECOMMENDED WORKLOAD

EDUCATION AND CREDENTIALS

EQUIPMENT KEY METRICS

Body Art 3–4 inspections per week*

• Bachelor’s in science • REHS/RS credential • Bloodborne

pathogen training

• Thermometers • pH meters • Flashlight • Test strips • Cameras • PPE

• Number of high priority violations cited per establishment

• Number of unlicensed or expired licensed artists per establishment

• Number of unlicensed artists found who then underwent the process to get licensed

• Number of adverse events directly attributed to body art per establishment

• Number of complaints received/50 establishments

* Research findings indicate that 3–4 body art inspections per week were considered reasonable for part-time EPH professionals, keeping in mind that most participants reported they did not have enough facilities for a full-time inspector.

Definition Body art programs often include the licensing/permitting, inspection, enforcement, plan review, and provision of edu- cation information for or to technicians, establishments, events, and consumers of and about body art practices, including but not limited to piercing (microdermal and der- mal), tattooing, branding, scarification, cosmetic tattooing, permanent or temporary subcutaneous skin art, and other body markings or modification practices.

Characteristics of a Successful Body Art Program

While each department has its levels of priority and viola- tion thresholds for permitting, body art program success can be defined by the absence or decrease in the risk of commu- nicable disease, infection, or injury resulting from body art practices. Another, although less easily quantifiable, some participants defined success by the degree of confidence in

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the level of public safety they feel with their performance and their interactions with operators and artists. Programs can work toward achieving these characteristics by having a thorough onboarding process for inspectors that can help ensure consistent and effective inspection practices, build- ing relationships with operators and artists, and ensuring inspectors conduct follow-through actions related to con- sumer complaints and waste disposal.

Trust building with operators and artists is important for success, as this allows them to be honest about the proce- dures they are doing and to gain information from inspec- tors to protect their clients and themselves. As a participant put it simply, “The goal isn’t necessarily compliance with the rule as it’s written. The goal is public health.”

The regulatory authority of a body art program in terms of licensing and permitting contributes to how the program can successfully implement enforcement and infection and injury control measures. Some departments license or per- mit the establishment only, some license each body artist only, and some license both.

Those programs that license or permit only the body art establishment indicate that the state agency licenses indi- vidual artists. In this situation, oversight is on both enti- ties involved in body art—the artist and the establishment in which the artist practices. Those programs licensing or permitting the artists indicated that the licensing and per- mitting is tied to a body art establishment. Relocation of an artist would require the artist to get a new license. For those that license and permit both the establishment and artist, it was important to them that they retain the abil- ity to take regulatory action, if necessary, on either entity, depending on where an issue occurs.

While not part of the original research, jurisdictions might find it helpful to use the Body Art Model Code (BAMC) developed by NEHA in 1998, with subsequent updates in 2019 and 2024. Created with input from environmental health and industry professionals, the BAMC serves as voluntary guidance that jurisdictions can use as a resource to develop or update their body art codes, which can help reduce the risk of bloodborne pathogen transmission and other health hazards associated with body art procedures.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of body art establishments inspected within required timeframes per year

• Number of violations identified per 100 body art inspections per year *

• Percentage of body art establishments maintaining current permits and licenses per year *

• Percentage of body artists maintaining current licenses per year *

• Percentage of inspection staff completing required bloodborne pathogens training annually *

Workload management

• Average number of body art inspections completed per staff member per week and annually

Public health protection

• Number of reported infections and/ or adverse events associated with body art establishments per year *

• Number of complaints received annually

* EPH professionals who participated in focus groups, key informant interviews, and/or the national field survey consistently identified this metric as moderately to extremely useful.

The number and type of violations being cited during inspections of body art establishments can be meaning- ful measures of how well body art inspection programs are educating operators and artists to prevent exposure to potential health hazards. Along these lines, the frequency of re-inspections and complaint inspections can also be useful measures.

For situations where different agencies are licensing estab- lishments and artists, navigating multiple licensing pro- cesses might be complicated and can result in unlicensed artists, a common citation according to some participants. In these instances, the ability of the body art program inspectors to assist operators and artists in navigating these processes and becoming licensed can be reflected in an outcome metric.

While direct attribution of bloodborne disease incidence to a specific body art procedure might be difficult due to long incubation periods, acute skin infections at the body art site could be a useful metric for body art inspection programs

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where operators are required to notify health department staff on recognition of such infections. This metric can also be a measure of how well a program’s complaint surveil- lance is working to detect adverse events.

Staffing

Many participants reported their body art programs use a fee-based model. Given that most participants indicated having fewer than 200 body art establishments in their jurisdictions, staff in this program likely perform duties in other EPH programs. Body art establishments can be assigned to inspectors based on geographic location in dis- tricts and routes, specialties of the establishment, special- ties of the inspector, or proximity of the establishment to other establishments that need inspecting, while keeping in mind maintaining a balanced workload for each inspector.

Research findings indicate that 3–4 body art inspections per week were considered reasonable for part-time EPH professionals, keeping in mind that most participants reported they did not have enough facilities for a full-time inspector. Programs can use this guidance along with their estimated number of annual body art inspection needs to determine appropriate staffing levels.

In addition to confirmation that establishments receive the requisite number of inspections per year in each jurisdiction, one way to determine needed staffing levels is to consider the number of facilities, number of artists, and number of inspections required to be performed per year. Participants who license artists suggest that staffing rates might also need to consider the number of artists per establishment, and another suggested consideration of the volume of business the shop does to determine length of time of an inspection. In addition to drive time factors, these elements could influence staffing needs for programs that require check-ins with each artist.

When programs consider staffing needs, participants note that inspector workload analysis helps determine if more staffing is needed and have provided evidence of unmet inspection frequency requirements to support staffing requests.

Education/Training/Certifications

A bachelor’s degree in a science field was identified as the preferred education requirement for body art programs, though some participants noted that a 4-year degree might not be essential for performing body art program duties specifically.

The REHS/RS credential was also recommended for EPH professionals in body art programs.

On-the-job training is also recommended for body art pro- gram staff. Additionally, bloodborne pathogen training is recommended for body art program staff and might be required by many jurisdictions. Participants indicated that inspectors of body art programs benefit from undergoing the same training and testing that is required of operators and artists in their jurisdiction.

Equipment Needs

Much of the equipment used by inspectors for body art pro- grams are non-specific tools that can be used when per- forming duties for other EPH programs, such as computers, thermometers, cell phones with cameras, flashlights, light meters, and educational materials for operators.

For establishments with an autoclave, a Type 5 integrator/ Cat 5 test strips are needed to ensure the autoclave is run- ning appropriately.

Processes, protocols, and guidance documents provide the foundation that supports EPH professionals who inspect body art facilities, which underlies all these basic equip- ment needs.

Funding Sources/Barriers

Body art programs are largely fee-based in that they gen- erate revenue by charging licensing or permitting fees of the establishments and/or artists.

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Given the fact that body art programs are typically smaller compared to other EPH programs such as food safety, most participants felt that the fees generated from this program were enough to adequately cover the cost of the program. For some programs, however, body art fees were not enough to sustain the program without additional funding from other EPH services that they provide or from local taxes.

For participants, being fee funded is favorable as it allows EPH to define itself because it can often fund itself without reliance on grant or state money of which they get very little. This income self-sufficiency also provides a sense of security for the program and the overall department in times of departmental budget reductions.

Non-School Institutions and Licensed Establishments

Program Overview and Core Services/Activities

The survey section for this program differed from other sections because no qualitative data were collected for this

program. There were considerable differences among par- ticipants in how to group these facilities and what settings should be included. For this survey, those participants who indicated performing tasks related to non-school institu- tions and licensed establishments were asked what set- tings they would include in this ambiguous title. Of the 172 respondents of this question, the most often identified settings included hotels/motels/lodging facilities, nursing facilities, assisted living facilities, hospice, group homes, halfway houses, hospitals, campgrounds, jails/correc- tional/detention facilities, shelters, Greek life organization campus residences (i.e., fraternity and sorority houses), mobile home parks, rehabilitation centers, country clubs, private social clubs, and many more.

Given this wide array of settings that could define this title, it is difficult to pinpoint potential priorities or develop a group of questions that could accurately reflect the type and num- ber of activities required of EPH professionals. While many of these settings entail a lodging component, many specifi- cally cater to at-risk populations, meaning specialized train- ing for staff could be beneficial. Future research to classify and define the settings mentioned here might be helpful.

Secondary Environmental Public Health Programs Introduction to Secondary Program Recommendations

While the core EPH programs form the foundation of gov- ernmental EPH services, secondary programs are meant to address additional environmental health concerns that might be priorities based on specific community needs, geographic considerations, or emerging environmen- tal challenges. This section provides recommendations for four key secondary EPH programs: climate health, air quality, healthy homes, and hazardous materials.

Unlike the core program recommendations, which were developed through primary research, including focus groups, key informant interviews, and surveys of EPH professionals, these secondary program recommendations were devel- oped through complementary methodological approaches.

These approaches included:

1. Analysis of existing secondary program structures in exemplary EPH departments across various jurisdictions.

2. Review of professional standards and guidance documents from relevant national organizations.

3. Consultation with subject matter experts in each program area.

4. Examination of peer-reviewed literature on program effectiveness.

5. Synthesis of common elements from established programs to create scalable recommendations.

The recommendations for each secondary EPH program follow the same structure as the core programs, but use the approaches listed above. By using these methods, each secondary program provides recommendation that are scalable to different department sizes and adaptable to various jurisdictional contexts. Each secondary EPH program includes:

• Definition

• Characteristics of a successful program

• Meaningful outcome measures

EPH departments can evaluate these secondary programs in the context of their specific community needs, existing regulatory responsibilities, available resources, and strate- gic priorities. While not every department will implement secondary programs, this guidance provides a framework for those seeking to develop or strengthen these import- ant EPH services.

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Climate Health

Definition

A climate health program can involve surveillance, assess- ment, planning, education, and response to health impacts related to climate change. Activities include monitoring climate-sensitive health outcomes, conducting vulnerabil- ity assessments, developing climate adaptation and mit- igation strategies, implementing education and outreach initiatives, collaborating with multiple sectors, and partic- ipating in emergency response related to climate events like extreme heat, flooding, wildfires, and vectorborne disease outbreaks. Climate adaptation focuses on adjust- ing systems and communities to reduce vulnerability to current and expected climate impacts, while mitigation involves efforts to address the underlying causes of cli- mate change and prevent further impacts.

Characteristics of a Successful Program

A successful climate health program likely establishes clear metrics for tracking climate-related health impacts and vulnerabilities, integrates climate considerations into existing environmental health programs, and implements targeted interventions that protect vulnerable popula- tions. The program can build community resilience through education, partnerships, and policy advocacy while main- taining the capacity to respond to climate-related emer- gencies. Success might be demonstrated through reduced climate-related morbidity and mortality, especially among at-risk populations, and increased community understand- ing of climate health connections.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of vulnerable populations (e.g., older adults, children, low- income individuals) covered by climate adaptation interventions annually

• Number of climate adaptation and mitigation strategies implemented per year

Public health protection

• Number of heat-related emergency department visits and hospitalizations per 100,000 population during extreme heat events per year.

Partner engagement • Number of climate health educational materials distributed or training sessions conducted per year

• Number of formalized partnerships with other departments and organizations addressing climate change per year

Climate health programs can track metrics that demon- strate both preparedness for climate impacts and effective- ness in reducing climate-related health burdens. Essential metrics include tracking climate-sensitive diseases (e.g., heat-related illnesses, vectorborne diseases), assessing community climate vulnerability, monitoring implementa- tion of adaptation measures, and evaluating emergency response effectiveness during climate events.

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Air Quality

Definition

An air quality program can involve the assessment, mon- itoring, education, and mitigation of both indoor and out- door air pollutants that affect human health. Pollutants of concern include particulate matter, ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide, volatile organic compounds, radon, mold, allergens, and secondhand smoke. Core activities might include ambient air moni- toring, indoor air assessments, air quality forecasting and alerts, radon testing and mitigation guidance, developing and enforcing relevant regulations, educating the public about air quality risks, and collaborating with partners including planning departments, transportation agencies, housing authorities, schools, and healthcare providers to improve air quality.

Characteristics of a Successful Program

A successful air quality program likely establishes clear standards and guidelines for air quality, maintains effec- tive monitoring and technical assistance services, devel- ops effective warning systems for poor air quality days, implements educational resources for the public and pro- fessionals, and builds partnerships that extend program reach. The program might identify high-risk populations and settings for targeted interventions while maintaining the capacity to respond to emerging air quality concerns, such as wildfire smoke or industrial releases. Success is demonstrated through improved air quality indicators, implementation of mitigation measures, and reduced prev- alence of respiratory and cardiovascular conditions related to air pollution.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of homes that completed mitigation for elevated radon (≥4 pCi/L) per year

Workload management

• Number of indoor air quality assessments conducted per year

Public health protection

• Number of days the Air Quality Index exceeds unhealthy levels per year

Partner engagement • Number of air quality educational events or alerts conducted per year

Air quality programs can track metrics that demonstrate both program activities and health outcomes. Import- ant metrics include tracking air quality indices, mitigation implementation, exposure levels, related health condi- tions, and educational reach.

Healthy Homes

Definition

An EPH healthy homes program takes a comprehensive approach to address multiple housing-related health and safety concerns simultaneously, rather than focusing on single hazards. This integrated approach addresses lead hazards, indoor air quality, mold and moisture, pest manage- ment, injury hazards, asthma triggers, and general housing conditions that affect health. Core activities include home assessments, education and outreach, referrals for remedia- tion services, policy development, and cross-sector collabo- ration with housing, healthcare, and social service providers.

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Characteristics of a Successful Program

Successful EPH healthy homes program generally implement the seven principles of healthy housing (keep it dry, clean, safe, well-ventilated, pest-free, contami- nant-free, and maintained) through a coordinated set of assessment, education, and intervention services. The program successfully identifies high-risk households for targeted interventions, builds capacity among housing providers and residents to address housing hazards, and advocates for policies that promote healthy housing at scale. Success is demonstrated through improved hous- ing conditions, reduced housing-related illnesses and injuries, and increased community capacity to maintain healthy homes.

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Percentage of identified hazards successfully remediated following assessment and intervention per year

• Number of housing policies, codes, or standards adopted that incorporate healthy homes principles per year

Workload management

• Number of comprehensive healthy homes assessments conducted per year

Public health protection

• Percent reduction in asthma-related emergency department visits or hospitalizations among program participants per year

Partner engagement • Number of individuals who receive healthy homes training per year

• Number of healthy homes training sessions conducted per year

EPH healthy homes programs can track metrics that demonstrate both improvements in housing conditions and resulting health outcomes. Essential metrics include track- ing assessment and intervention activities, physical housing improvements, health outcomes, and policy changes.

Hazardous Materials

Definition

A hazardous materials program includes the oversight, regulation, and management of substances that pose sig- nificant risks to human health and the environment when improperly handled, stored, transported, or disposed of. Core activities include permitting and inspecting facili- ties that generate, store, or handle hazardous materials; responding to spills or releases; providing technical assis- tance and education to businesses and communities; coor- dinating with emergency response agencies; and enforcing relevant regulations to protect the health of the public and their communities.

Characteristics of a Successful Hazardous Materials Program

A successful hazardous materials program establishes clear standards and compliance requirements, maintains effective inspection and enforcement systems, develops emergency response capabilities, provides effective tech- nical assistance to regulated entities, and builds partner- ships with emergency management agencies. The program works to successfully prevent unplanned releases of haz- ardous materials while maintaining the capacity to respond effectively when incidents occur. Success is likely demon- strated through high compliance rates, reduced incidents, effective response to emergencies, and protection of pub- lic health during hazardous material events.

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Pillars of Governmental Environmental Public Health | A Guide to Scalable Environmental Public Health Programs

Meaningful Outcome Measures

PURPOSE METRIC

Program effectiveness

• Number of hazardous materials incidents or spills per year

• Average response time to hazardous materials incidents (in hours) per year

• Number of enforcement actions taken and resolved per year

• Number of technical assistance activities or training sessions provided to regulated facilities per year.

Workload management

• Number of regulated facilities inspected per year

Hazardous materials programs can track metrics that demonstrate both regulatory compliance activities and emergency response capabilities. Essential metrics include tracking inspection activities, compliance rates, incident response, and educational outreach.

Other Considerations for Secondary EPH Programs

Staffing Considerations

While our research did not encompass specific FTE rec- ommendations for these programs, jurisdictions can determine appropriate staffing levels based on several interconnected factors. Secondary EPH programs benefit from flexible staffing approaches that can be adapted to each jurisdiction’s specific needs and context, including community-specific EPH needs, population characteristics, geographic considerations, regulatory requirements, inte- gration opportunities with core EPH programs, available funding sources, and program maturity and scope.

Furthermore, departments might consider recording their staffing decisions and rationale to contribute to the development of evidence-based staffing models for these important, often under-resourced program areas. This approach acknowledges the diversity of EPH challenges across jurisdictions while providing a framework for mak- ing informed staffing decisions that align with local prior- ities and capacity.

Education and Training Considerations

Staff in secondary EPH programs would benefit from educational qualifications that align with the special- ized knowledge needed while remaining adaptable to each jurisdiction’s context and capacity. While the scope of our research did not establish specific educational requirements for these programs, jurisdictions can con- sider the technical complexity of program responsibili- ties, regulatory requirements, availability of qualified professionals in their region, and integration with core EPH programs when establishing minimum qualifica- tions. A foundation in environmental health sciences, public health, or related fields provides essential back- ground knowledge, with specialized training or certifica- tions in program-specific areas enhancing effectiveness. EPH departments should balance the need for special- ized expertise against workforce realities, potentially establishing tiered qualification systems that allow entry-level positions while requiring advanced degrees or certifications for leadership roles. Departments can support ongoing professional development to build capacity in these emerging areas of practice. This flexi- ble approach to educational requirements acknowledges the evolving nature of secondary EPH programs while maintaining the professional standards necessary for protecting public health.

Equipment Considerations

Secondary EPH programs may need to utilize diverse equipment portfolios that balance specialized techni- cal needs with practical budget constraints. Equipment requirements typically include standard field assess- ment tools, monitoring devices specific to program areas, mobile technology for data collection and documenta- tion, communication systems for emergency response and public outreach, and personal protective equipment appropriate to program hazards. Programs can prioritize equipment that serves multiple functions across program areas while ensuring access to specialized tools neces- sary for technical assessments and regulatory compli- ance. Departments could consider equipment sharing arrangements, partnerships with other agencies or insti- tutions, and phased acquisition plans that align with program development stages. Regular maintenance, calibration, and replacement planning is essential for ensuring equipment reliability and to meet professional standards. The diversity of secondary program equip- ment needs benefits from strategic planning that con- siders both immediate operational requirements and long-term program sustainability.

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Funding Considerations

While our research did not establish specific funding considerations for these programs, secondary EPH pro- grams likely face unique funding challenges due to their cross-cutting nature and emerging status within tradi- tional environmental health frameworks. Funding strat- egies might combine multiple sources, including federal grants, state appropriations, fee-based revenue from reg- ulated entities, foundation grants, and partnerships with other sectors such as healthcare, housing, and emergency management. The evolving nature of these programs often benefits from flexible funding approaches that can adapt to changing priorities and available opportunities. Departments can develop diversified funding portfolios to reduce the dependence on single sources while build- ing sustainable revenue streams through permit fees, inspection charges, and cost-recovery mechanisms where appropriate. Grant funding often provides initial program development support, but long-term sustainability can benefit from integration with ongoing operational bud- gets. Cross-sector partnerships can extend program reach and effectiveness while sharing costs across multiple ben- efiting agencies and organizations.

Strategic Considerations for Program Enhancement While this guide focuses on EPH programs, EPH leaders might recognize several cross-cutting elements that can strengthen their program implementation. These include topics such as:

• Development of integrated approaches that address multiple EPH issues simultaneously.

• Incorporation of health equity principles to address disparities.

• Implementation of effective data systems to track activities and outcomes.

• Community engagement through transparent risk communication.

• Adaptation to climate change impacts across programs.

• Preparation for emerging environmental hazards.

• Development of sustainable funding strategies.

• Investment in workforce development, succession planning, and staff retention.

• Engagement in policy development and advocacy.

• Cultivation of interagency collaborations and partnerships.

• Implementation of performance management systems for continuous improvement.

These considerations, though beyond the scope of our project, may prove important for EPH leadership that seeks to maximize their impact on public health and adapt successfully to evolving EPH challenges.

Building on Common Foundations While this guide has outlined specific core program con- siderations for staffing, education, equipment, and funding, several common foundations emerge across EPH programs:

1. Qualified, well-trained personnel are the most essential resource for EPH programs. The combina- tion of appropriate education, specialized training, and professional credentials provides the foundation for effective practice. Departments can prioritize both the recruitment of qualified professionals and ongoing professional development to maintain and enhance workforce capacity.

2. Adaptable program structures that can be scaled to meet local needs and resources are essential for effec- tive implementation. This guidance offers a starting point that can be tailored to match community-specific needs, department resources, and regulatory require- ments across jurisdictions of varying sizes and contexts.

3. Data-driven approaches enable departments to target resources effectively, measure progress, and demonstrate impact. Investment in effective data systems, assessment methodologies, and outcome evaluation is a crucial com- ponent of modern EPH practice.

4. Sustainable funding mechanisms are important for program stability and effectiveness. EPH departments can develop diverse funding strategies that combine fee-based revenue, governmental appropriations, grants, and innovative financing approaches to ensure program sustainability.

5. Strategic partnerships extend the reach and impact of EPH programs. Collaboration with community organizations, healthcare systems, academic insti- tutions, and other governmental agencies multiplies the resources available for addressing environmental health challenges.

6. Properly equipped staff with appropriate tools, tech- nology, and resources are fundamental to program effectiveness. EPH professionals benefit from special-

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ized equipment for field assessments, reliable trans- portation for site visits, current technology for data collection and analysis, and adequate facilities for labo- ratory work and administrative functions. Departments can regularly assess and update equipment inventories to ensure staff can perform their duties safely, efficiently, and in accordance with current professional standards.

From Guidelines to Implementation The guidance provided in this document serves as a road- map, but ultimately, implementation benefits from leader- ship, commitment, and adaptation to local contexts. EPH directors and managers can use these guidelines as a starting point to:

• Assess current program strengths and gaps

• Develop strategic plans for program enhancement or development

• Advocate for appropriate resources and authority

• Establish meaningful metrics for program evaluation

• Build the partnerships necessary for effective implementation

While the document outlines 11 core and 4 secondary EPH program areas, jurisdictions can prioritize the program areas based on their unique EPH challenges, community needs, and available resources. This prioritization can be informed by EPH assessment data, partner collaboration, and consideration of the most significant local health risks.

The Evolving Landscape of Environmental Public Health The field of EPH has evolved significantly since its origins in sanitation and infectious disease control. Today’s EPH professionals address complex challenges, including cli- mate change impacts, emerging contaminants, techno- logical innovations, and persistent EPH disparities. As our understanding of EPH connections deepens, the scope of EPH practice continues to expand, benefiting from greater integration and collaboration across program areas, disci- plines, sectors, and jurisdictions.

Despite this evolution, the foundational principles of EPH remain constant. Prevention remains the primary goal, with EPH programs designed to identify and mitigate haz- ards before they result in disease, injury, or harm. Science remains the cornerstone of practice, with evidence-based approaches guiding program development and implemen-

tation. By the same token, equity remains a central con- cern, recognizing that the benefits and burdens of EPH are not evenly distributed across American society.

A Call to Action The work of EPH professionals often goes unnoticed when it is most successful. When contamination is prevented, when health outcomes improve, when outbreaks are avoided—these successes rarely make headlines. Yet this work forms an essential foundation for public health and community wellbeing.

As communities face environmental challenges that increase daily, from climate change impacts to emerging infectious diseases, the role of EPH professionals becomes ever more crucial. This might involve:

• Elevation of the visibility and value of EPH work through effective communication and documentation of impact.

• Strengthened EPH workforce through recruitment, training, retention, and succession planning.

• Modernized systems and approaches that leverage new technologies, data science, and integrated program delivery.

• Enhanced community engagement and trust through transparent practices and meaningful participatory opportunities.

• Advocacy for policies and resources that recognize the essential role of EPH in overall community health and wellbeing.

Conclusion EPH stands at the intersection of human health and the environments in which we live, work, and play. As this guide has demonstrated, the field encompasses a broad range of core and secondary programs, each of which contributes to the essential mission to protect and pro- mote public health through environmental interventions. The Pillars of Governmental Environmental Public Health guide provides a framework to build effective and resil- ient EPH departments capable of responding to both longstanding and emerging challenges. Through the application of this framework at scales that meet com- munity needs, EPH departments can build the capacity to meet today’s challenges while they prepare for tomor- row’s demands.

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Gerding, J.A., Landeen, E., Kelly, K.R., Whitehead, S., Dyjack, D.T., Sarisky, J., & Brooks, B.W. (2019). Uncovering environmental health: An initial assessment of the profession’s health department workforce and practice. Journal of Environmental Health, 81(10), 10–17.

Green & Healthy Homes Initiative. (2025). Home page. https://www.greenandhealthyhomes.org/

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Herb, J., Marino, E., & Vendetti, C. (2021). Advancing climate change environmental health literacy: Building the foundation for environmental public health tracking. Association of State and Territorial Health Officials.

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Kim, T.N., Bare, G., Hedberg, C.W., Dutra, N., Walker, C., & Dyjack, D. (2025). Identifying characteristics of local governmental environmental public health programs. Journal of Environmental Health, 88(1), 20–28. https:// doi.org/10.70387/001c.141566

Kim, T.N., Karnik, H., Leider, J.P., & Hedberg, C.W. (2023). Environmental health department food safety programs structure project report [Internal report]. National Environmental Health Association.

Leider, J.P., Castrucci, B.C., Robins, M., Bork, R.H., Fraser, M.R., Savoia, E., Piltch-Loeb, R., & Koh, H.K. (2023). The exodus of state and local public health employees: Separations started before and continued throughout

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COVID-19. Health Affairs, 42(3), 394–402. https://doi. org/10.1377/hlthaff.2022.01251

Leider, J.P., Harper, E., Bharthapudi, K., & Castrucci, B.C. (2015). Educational attainment of the public health workforce and its implications for workforce development. Journal of Public Health Management and Practice, 21(Suppl. 6), S56–S68. https://doi. org/10.1097/PHH.0000000000000306

Leider, J.P., McCullough, J.M., Singh, S.R., Sieger, A., Robins, M., Fisher, J.S., Kuehnert, P., & Castrucci, B.C. (2023). Staffing up and sustaining the public health workforce. Journal of Public Health Management and Practice, 29(3), E100–E107. https://doi.org/10.1097/ PHH.0000000000001614

Los Angeles County Department of Public Health. (2024). Office of environmental justice and climate health. http://publichealth.lacounty.gov/eh/about/ environmental-justice-climate-health.htm

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Michigan Department of Environment, Great Lakes, and Energy. (2025). Michigan indoor radon program. https://www.michigan.gov/egle/about/organization/ materials-management/indoor-radon

Monterey County. (2025). Hazardous materials management services. https://www.countyofmonterey. gov/government/departments-a-h/health/environmental- health/hazardous-material-management

National Association of County and City Health Officials. (2005). Operational definition of a functional local health department.

National Association of County and City Health Officials. (2011). Local public health workforce benchmarks. https://www.naccho.org/uploads/downloadable- resources/local-public-health-workforce-staffing- benchmarks.pdf

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National Association of County and City Health Officials. (2024a). 2022 national profile of local health departments. https://www.naccho.org/uploads/ downloadable-resources/NACCHO-2022-Profile- Report.pdf

National Association of County and City Health Officials. (2024b). Public Health–Seattle & King County: Climate & health equity initiative (CHEI). https://www.naccho. org/blog/articles/public-health-seattle-king-county- climate-health-equity-initiative-chei

National Association of County and City Health Officials. (2024c). Pulling together: A guide to building collaboration at hazardous waste sites. https://www. naccho.org/programs/environmental-health/hazards/ pulling-together

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National Environmental Health Association. (2024b). Environmental public health emergency preparedness and response (EPHEPR) capability framework. https:// www.neha.org/epr-framework

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Appendices

Appendix A

10 Essential Environmental Public Health Performance Standards The 10 Essential Environmental Public Health Services, developed by the Centers for Disease Control and Pre- vention (CDC, 2021) and derived from CDC’s 10 Essen- tial Public Health Services, comprise the “collective set of capacities and activities necessary in an environmental public health system or program to effectively support the provision of services and programs needed to improve and protect environmental health.”

They also serve as the framework for CDC’s Environ- mental Public Health Performance Standards, which is an instrument that EPH programs can use to assess their performance and identify areas for improvement (CDC, 2010), as well as for the Public Health Accredita- tion Board’s (2013) Standards and Measures, which are

used to demonstrate eligibility for public health depart- ment accreditation.

These services are consistent with the foundational capa- bilities of the Institute of Medicine (2012), which are a set of six competencies that all public health departments should have the capacity to support, as well as the Foun- dational Public Health Services and the Public Health National Center for Innovations (de Beaumont, 2025; PHNCI, 2022). Many of these EPH services are also indi- cated in the World Health Organization’s (WHO, 2018) International Health Regulations. Most of the recommen- dations given by the documents included in this review can be categorized into one of the 10 Essential Services, which are enumerated and described in detail:

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Assess and monitor population health status and community needs.

Jurisdictions should perform regular community health assessments to identify trends in health problems and environmental hazards. Health offcials can use the results of this assessment to identify health disparities and inequities, prioritize issues and allocate resources, and compare their community to state and national health indi- cators (Association of State and Territorial Health Offcials [ASTHO], 2018; PHNCI, 2022).

A survey conducted by the Association of State and Territorial Health Offcials (ASTHO) in 2012 found that only 45% of state EPH departments had completed a health impact assessment in the past 2 years, although this number was up from 23% in 2010 (ASTHO, 2014). Resources for conducting assessments include the National Association of County and City Health Offcials’ (NACCHO) Protocol for Assessing Community Excel- lence in Environmental Health, NACCHO’s Mobilizing for Action Through Planning and Partnerships Hand- book (NACCHO, 2015), and the National Association of Local Boards of Health’s (NALBOH) Public Health Gov- erning Entity Assessment Handbook (NALBOH, 2013). Once the assessment is completed, NACCHO’s Local Implementation Guide can be used to help local health departments take action based on the identified trends (NACCHO, 2013).

In addition to a community health assessment, jurisdictions should have the capacity to collect, store, and analyze EPH data using the most up-to-date methods and technologies (American Public Health Association [APHA], 2001; NAC- CHO, 2005). They should be able to interpret results and visualize trends over time and have a plan to address any gaps in data. Jurisdictions should also participate in a sur- veillance system that enables them to undertake rapid risk assessments of environment-related diseases and should maintain records and documentation of all surveillance activities (APHA, 2001; NALBOH, 2013).

Investigate, diagnose, and address health problems and hazards.

EPH programs ideally should have 24/7 access to labo- ratories that can support public health laboratory testing and timely EPH investigations, which can enable staff to quickly respond to outbreaks (NALBOH, 2013; PHNCI, 2022). Staff should also be able to perform inspections, testing, licensing, and regulation of a wide range of estab- lishments, including food service facilities, recreational waters, drinking water, wastewater, body art facilities,

schools, childcare facilities, and other institutions. Every department must develop an all-hazards emergency response plan, as EPH plays a role in preparing for and responding to all disaster types, including natural, biolog- ical (including pandemics), chemical, and radiological pub- lic health emergencies (PHNCI, 2022).

Inform, educate, and empower people about EPH issues.

EPH professionals should be able to effectively commu- nicate environmental health risks and convey the impor- tance of EPH programs to partners, media, and the public (APHA, 2001; NALBOH, 2013; PHNCI, 2022). A success- ful EPH program is often “invisible,” meaning the commu- nity is generally unaware of the benefits of EPH, so it is diffcult to generate support (CDC, 2003; Herb et al., 2021). Communication plans should disseminate data from the community health assessment (APHA, 2001) and should include an emergency communication plan developed alongside the program’s all-hazard emergency response plan. Jurisdictions should also create policies and inter- ventions that promote health education (NALBOH, 2013; PHNCI, 2022). All information, resources, and communica- tions should be accessible and culturally and linguistically appropriate (APHA, 2001; ASTHO, 2018; NALBOH, 2013; PHNCI, 2022).

Mobilize community partnerships.

To maximize EPH program effectiveness, staff should partner with other government agencies, academic and research institutions, and members of the private sec- tor who can contribute to or benefit from environmental health. Potential partner organizations include health, transportation, housing, and environmental groups (PHNCI, 2022). Creating partnerships might involve iden- tifying key constituents and partners, maintaining a com- prehensive directory of those groups with an interest in EPH services, and encouraging constituents to participate in decision-making and policy development.

Wherever possible, staff should share data and resources and collaborate with partners to address EPH problems, including health equity and access to resources (APHA, 2001; ASTHO, 2018; ASTHO, 2021; NALBOH, 2013).

Create and implement policies, plans, and laws.

Data collected by EPH programs should be used to inform policies, programs, and interventions intended to improve community health (NALBOH, 2013; PHNCI, 2022). This

1

2

3

4

5

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work involves developing and implementing a health department strategic plan, including establishing the department’s mission, vision, objectives, and strengths and weaknesses, as well as a community health improve- ment plan. These plans should include input from com- munity partners, should identify and address causes of health inequity (ASTHO, 2018), and should demonstrate progress toward goal achievement.

Jurisdictions should develop an emergency response plan that must be tested regularly via drills or exercises. Jurisdictions should also incorporate the principle of Health in All Policies, which calls for public health and EPH to be considered in all the jurisdiction’s policies, not just those policies implemented by the health depart- ment. Plans and policies should be regularly reviewed and revised as needed.

Enforce laws and regulations that protect public health.

EPH professionals should protect the public from envi- ronmental risks of exposure through enforcement of their jurisdiction’s laws and regulations. Existing laws should be regularly reviewed, and jurisdictions should change or create new laws as necessary, incorporating commu- nity input wherever possible. It is also the responsibil- ity of the EPH department to ensure that constituents understand the requirements and the importance of these regulations.

Laws should be applied consistently throughout the juris- diction while considering any impacts the law could have on health equity, and standards should be maintained for licensing, fees, and inspections (ASTHO, 2018; NALBOH, 2013). Staff should also collect data on enforcement activities and share information with constituents and other jurisdictions.

Link people to needed EPH services and care.

EPH staff should ensure equitable access to EPH services. This work includes identifying populations that might face barriers to services and taking steps to mitigate these bar- riers, as well as ensuring that community members can take advantage of available EPH resources (ASTHO, 2018; NALBOH, 2013). To achieve this goal, EPH staff might need to work with partners who can help close gaps in the provision of services.

Build a competent and diverse EPH workforce.

Each EPH department should complete a workforce assessment to determine the number and types of posi- tions to be included in the EPH program, as well as core competencies for each position. Staff should also iden- tify and address current gaps in training and competence (NALBOH, 2013). Departments should offer continued training, leadership development, education, and men- toring, including annual performance reviews for all EPH employees. Additionally, a community’s EPH workforce should reflect the unique demographics of that commu- nity, and staff should understand their community’s cul- tural, political, and economic underpinnings (APHA, 2001; ASTHO, 2018).

Evaluate effectiveness, accessibility, and quality of EPH services.

EPH program staff should use a performance manage- ment system to monitor internal activities and achieve- ment of objectives, as well as assess community satisfaction with EPH services. Existing assessments— such as NACCHO’s National Public Health Performance Standards Local Assessment Instrument (NACCHO, 2013) and the CDC’s Environmental Public Health Per- formance Standards (CDC, 2014)—can be used. Jurisdic- tions should develop a written quality improvement plan that involves all partner organizations. Staff should also monitor the best practices of other organizations and agencies. Any data collected should be used to modify services and allocate resources to achieve health equity and improve community health (ASTHO, 2018; NAL- BOH, 2013).

Research for new insights and innovative solutions to EPH problems.

EPH programs should have the capacity to participate in applied research and share findings with partners. Results of any research should be incorporated into health department policies and programs (NALBOH, 2013). Staff should also encourage community involve- ment in research.

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8

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10

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Appendix B Public Health Accreditation and Environmental Public Health Public health accreditation is a voluntary process that health departments can undertake to demonstrate their capacity to deliver essential public health services effec- tively and efficiently. The Public Health Accreditation Board (PHAB, 2013) is the national accrediting body for public health departments, and it has established a set of standards and measures that health departments must meet to achieve accreditation status.

The accreditation process is important for EPH depart- ments within health departments because it provides a framework for continuous quality improvement and ensures that EPH programs meet national standards for performance and effectiveness. By contributing to their health department’s accreditation, EPH departments can demonstrate their commitment to protecting and promot- ing the health of their communities and can gain recogni- tion for their efforts.

To be eligible for accreditation, health departments must demonstrate that their EPH programs are meeting the PHAB standards and measures, which are closely aligned with the 10 Essential Environmental Public Health Services described previously. These measures include having a strong infrastructure for assessment, investigation, and enforcement; effective communication and community engagement strategies; and a competent and diverse workforce.

Health departments must also demonstrate that their EPH programs are providing the core programs and services that are essential for protecting public health, such as food safety, water quality, and vector control. These core pro- grams should be based on the unique needs and priori- ties of the community served by the health department, as identified through community health assessments and other data-driven processes.

In addition to meeting the PHAB standards and measures, health departments with EPH programs seeking accred- itation must also demonstrate that they have a culture of quality improvement and performance management. These measures include having systems in place for mon- itoring and evaluating the effectiveness of EPH programs and services and using data to drive decision-making and resource allocation.

By participating in their health department’s accreditation process, EPH departments can strengthen their capacity to provide high-quality, evidence-based services that are responsive to the needs of their communities. Accredi- tation can also help health departments and their EPH departments to build partnerships and collaborations with other agencies and organizations, and to secure funding and resources to support their programs and services.

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July 2025 neha.org

60

An Interdisciplinary Analysis of the Causes

of Economic Growth

In: Case Studies in Interdisciplinary Research

By: Rick Szostak

Pub. Date: 2013

Access Date: January 31, 2021

Publishing Company: SAGE Publications, Inc.

City: Thousand Oaks

Print ISBN: 9781412982481

Online ISBN: 9781483349541

DOI: https://dx.doi.org/10.4135/9781483349541

Print pages: 159-190

© 2012 SAGE Publications, Inc. All Rights Reserved.

This PDF has been generated from SAGE Research Methods. Please note that the pagination of the

online version will vary from the pagination of the print book.

An Interdisciplinary Analysis of the Causes of Economic Growth

RickSzostak

Introduction

With billions of people still living in poverty in the world, there is perhaps no more important question in human

science than what are the causes of economic growth. Moreover, it is a very complex question, for economic

growth is influenced by interactions among a host of economic, political, social, cultural, and geographical

phenomena. This chapter discusses how a process for interdisciplinary research can usefully be applied to

the study of economic growth. It is thus simultaneously an exploration of how to do interdisciplinary social

science and how to develop a more comprehensive understanding of economic growth. It shows how a

variety of distinct research programs across all social science disciplines can be integrated to enhance our

understanding of the causes of economic growth.

This chapter is organized according to the steps in the interdisciplinary process.1 Although the chapter

will review each of the various steps ideally involved in interdisciplinary analysis, the presentation focuses

primarily on how “common ground” can be achieved among disciplinary insights that conflict, notably with

respect to the role of government, the role of international trade relationships, and the process by which

economic institutions are and should be developed. Lessons are drawn for each step regarding both our

understanding of economic growth and how best to perform interdisciplinary research.

AUTHOR'S NOTE: My chapter summarizes and comments upon my book The Causes of Economic Growth:

Interdisciplinary Perspectives (Szostak, Rick, 2009, Berlin: Springer).

The question addressed in this chapter is both very complicated and very broad. Both characteristics increase

the difficulty of performing any of the steps as completely as one might like (though perhaps especially

the literature survey). The question is complicated because a variety of phenomena combine to influence

economic growth. By asking the question at the general level rather than with respect to a particular time and

place, we broaden the scope of inquiry significantly: We could forget about questions of basic property rights

if we focused on only the rich world, for example. That is, the breadth of the question forces us to engage

its full complexity. We thus need a broader literature survey, and we need to identify, evaluate, and integrate

across a much broader set of disciplinary insights than would normally be the case. One possible exception

may be the first step: It may be just as easy to frame a broad question as a narrow one. Indeed, it may be

easier, for the narrow question requires detailed definition of the boundaries of the question.

Identify an Interdisciplinary Research Question

We have selected our question: What are the causes of economic growth? It is then necessary to ask whether

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2012 SAGE Publications, Ltd. All Rights Reserved.

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Page 2 of 30 An Interdisciplinary Analysis of the Causes of Economic Growth

this question is suitably interdisciplinary in nature. Can economic growth be understood by relying only on

the insights of one discipline? Or does our understanding increase markedly if insights from many disciplines

are integrated? Economic growth must, in the first instance, involve an increase in the resources devoted

to production—broadly, labor, capital, and natural resources (including land itself)—and/or the productivity

with which these resources are combined to produce output. These four variables—labor, capital, natural

resources, and productivity—are commonly termed the proximate causes of growth, and economists (and

economic historians, who are treated as a separate discipline here) dominate the study of the question

of which of these is most important in driving particular episodes of economic growth. As we shall see,

economists are far from achieving consensus on this basic question. Moreover, economists have long

appreciated that this question then invites a more complicated set of questions, such as the following:

• Why is labor more skilled in some countries than in others?

• Why is there more (saving and) investment in some countries than in others?

• Why do some countries use resources more productively than do others?

• Why is productivity higher in some countries than in others?

These questions tend naturally to invite interdisciplinary speculation. How does a society's culture or social

structure or politics influence its educational attainment, work effort, saving rate, or environmental policy? The

study of these deeper causal influences is pursued across the human sciences (see below).

Special mention should be made here of institutions and technology. The formal rules of a society—its

legal system, economic regulations, firm structure, and so on—have a profound influence on its economic

performance, and yet such institutions arguably (see below) emerge from a historical process involving

political, social, and cultural influences. Likewise, technological innovation is an important source of (at least

modern) economic growth, and again, it seems likely that the rate of innovation in a society may well be

influenced by a host of non-economic factors.

Even the statistical analyses of economists point toward interdisciplinary analysis. Political, institutional, and

social variables are often found to be important in cross-country analyses of postwar growth experience

(Snowdon, 2002, pp. 97–99)—and this despite the twin facts that such variables are often hard to measure

and likely exert their effects over a very long time. Surveying this evidence and the widely divergent growth

experiences of postwar economies more generally, Snowdon concludes:

To understand why some countries have performed so much better than others with respect to

growth it is therefore necessary to go beyond the proximate causes of growth and delve into the

wider fundamental determinants. This implies that we cannot hope to find the magic bullet by

economic analysis alone. (p. 100)

The observation that it is crucial to look beyond proximate causes provides an important insight regarding

interdisciplinary research more generally. Economists have, until recently, been able to view the causes of

economic growth as a strictly disciplinary question by looking only at the interaction of a handful of economic

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Page 3 of 30 An Interdisciplinary Analysis of the Causes of Economic Growth

variables. Interdisciplinarians need to be sensitive to the precise wording of their focus question (and be

prepared to revise it as they perform later steps), in order to ensure that relevant disciplines are not arbitrarily

excluded from examination. Even though we are striving to explain movements in an economic variable, our

question becomes interdisciplinary once we embrace a wide range of potential causes.

Identifying Relevant Phenomena, Theories, Methods, and Disciplines

The next step or steps must involve the gathering of relevant disciplinary insights. How does the researcher

know where to look? There are two complementary strategies identified in Repko (2008). One is to reflect

on the character of different disciplines and identify those that are likely to have something to say about the

issue of concern. The second—and the one pursued in this chapter—is to ask what phenomena, theories, or

methods are implicated, and then ask which disciplines study each phenomenon identified and/or apply each

theory or method. This approach reduces the risk of favoring the larger and most familiar disciplines (Szostak,

2002). Szostak (2004) develops exhaustive classifications of phenomena, theory types, and methods to

facilitate the latter approach: In the absence of these, it is all too easy to assume that the subset of relevant

theory, method, or phenomena pursued by disciplines is somehow appropriate. Repko (2008) identifies the

defining elements of disciplines in terms of these and other classifications. One challenge the interdisciplinary

researcher will face is that library catalogues are organized by disciplines, and different terminology is used

in different disciplines to refer to the same phenomenon, theory, or method (Szostak [2007, 2008] addresses

how a classification suited to interdisciplinarity might be developed).

In the case of growth, it is embarrassingly easy to identify phenomena that, at least potentially, influence

growth but lie outside the (at least until recently) narrow gaze of economists. These include cultural attitudes,

political institutions, geographic constraints, and ethnic tensions, among others. It is thus straightforward to

implicate (parts of) all social science disciplines as well as the humanities in this study.

As for types of theories, economists rely almost exclusively on methodological individualism: Only individuals

are causal agents. Yet, surely the alternatives of relationship or group agency2 matter for at least some of the

proximate causes of growth. Historians have long since abandoned the idea of the heroic innovator working

in isolation in favor of an appreciation of the networks in which innovators operate; the same logic applies

to entrepreneurship and trade more generally, and surely institutional change cannot be fully appreciated

without recourse to relationships and groups.

Economists also stress rational decision making. Yet, the history of institutional change suggests that

rationality likely plays some role in institutional design—agents consciously design institutional

improvements—but also that tradition does—agents are cautious in moving away from existing institutions.

Historians of both science and technology have long appreciated that a mix of reason and intuition is

involved: The investigator consciously gathers relevant information, but insight comes subconsciously as

novel connections are drawn. Moreover, in a world awash in information, who can doubt that economic

agents often follow decision-making rules (“Buy when the market is rising”) rather than attempt rational

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calculations? Perhaps most important, both investment and innovation decisions must be made under

uncertainty—people simply cannot know the likelihood of particular outcomes—and people cannot fully rely

on rational decision making when faced with uncertainty (as economic theory admits), but necessarily follow

hunches or decision rules or mimic others. Various sorts of nonrational decision making have long been

studied outside economics, especially in sociology. Psychologists have long argued for different types of

decision making; brain imaging shows that different parts of the brain are activated at different times and

make decisions in different ways (Cohen, 2005).

Economists model growth solely in terms of steady-state (constant) growth rates. Yet, growth occurred in the

West much more rapidly in the 19th century than ever before and more rapidly in the first postwar decades

than before or since. In both the 19th and 20th centuries, one can discern multiple periods of a decade

or so in length in which growth was relatively slow (by the standards of those centuries) or negative. The

growth experience of other regions of the world is even more diverse. These diverse experiences suggest

that theories with either cyclical or stochastic elements—allowing growth rates to both rise and fall—should be

important. The fact that growth rates are, at least potentially, much higher than a mere two centuries ago (or

alternatively, common prognostications that growth will soon decline) suggests that theories positing dynamic

change in one direction may also have a role to play.

Various theories more commonly employed outside rather than within economics are thus important in

understanding economic growth (though each of these has its own limitations). Alternative theories worth

exploring include the following:

• Evolutionary theory can potentially embrace all types of agency, decision making, and time path.

• Systems theories (or structuralism/functionalism more generally) can also reflect a variety of types

of agency and decision making. In practice, systems theorists have tended to emphasize system

stability (equilibrium) and thus have had less to say than they might about dynamic processes of

change.

• Social constructionist theories stress the importance of attitudes and beliefs. This provides a useful

complement to the focus of most social science theory on actions, though social constructivists often

see their theories as substitute rather than complement.

• Modernization theories in the early postwar period posited that all countries would move toward

“Western” economic, political, and cultural realizations. These gave way to more pessimistic

dependency and world systems theories (inspired in part by Marxian analysis) that suggested that

poor countries would remain poor. These theories can each be valued for detailing possible links

among economic, political, cultural, and other phenomena without adopting their assumptions about

the inevitable outcome of these systems of interaction.

• Complexity theories can generate all types of time path. They are perhaps particularly valuable

in stressing stochastic outcomes. Complexity theories often emphasize system-level emergent

properties at the expense of careful specification of individual causal links.

• Various theories stress how culture shapes behavior. These theories are often characterized by

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vague terminology and fail to appreciate how cultures evolve.

• Psychological theories support the insight that decision making is not always rational, but these

theories have not often been carefully applied to economic decisions. (The emerging field of

behavioral economics aspires to change this.)

• Literary theory may also be useful. In studying technological diffusion, scholars have long

appreciated that people, not just blueprints, generally have to move from one locale to another.

There is a range of tacit knowledge that is imperfectly captured by the most careful instructions.

This observation is the same as that long made by theories of texts in general: There is always a

divergence between the textual signifier and that which it is presumed to signify.

A similar analysis could be performed with respect to research method. One of the key insights of Szostak

(2004) was that each method is better at investigating some theory types than others, and disciplines

thus choose mutually compatible sets of theory and method (and phenomena). Various case study

methods—observation, textual analysis, interviews—are better suited to the investigation of many of the

theories listed above than are the statistical analyses favored by economists. Moreover, different methods

shed different light on different theories: We should have the greatest confidence in a theory that is supported

by different methods. When examining a complex historical process such as economic growth, which involves

many causal interactions, recourse to multiple methods is particularly important.

There are four criteria for identifying a causal relationship: establishing correlation, establishing temporality

(the cause should generally appear before the effect), ruling out alternative explanations of the result, and

showing how the causal relationship unfolds in practice (including identifying intermediate variables; Singleton

& Strait, 1999). The methods of economists excel with respect to the first two. Their lack of attention to

alternative theories limits the third. With respect to the fourth, economists are often attracted to mathematical

models even when the evidence for particular causal relationships is quite limited. The latest type of economic

growth models—called unified growth models—attempts to model the course of economic performance over

the last millennium. These models posit that small changes (in the first models, changes in population density,

but later models treat other variables) eventually surpass some threshold where they begin to have dynamic

effects on growth. But of course, one can develop mathematical models such that any cause can have any

effect, if one assumes that small changes achieve big results. The creation of these models should not

enhance one's confidence in such a relationship in the absence of careful case study evidence.

Disciplinary perspectives will be treated briefly here. As both Szostak (2003) and Repko (2008) have

stressed, preferences with respect to theory and method and phenomena are critical components of

disciplinary perspective. Ideological, ethical, and epistemological predispositions need also to be appreciated

in evaluating disciplinary insights. In these latter respects, the following can be noted:

• On average, economists believe in markets more than other social scientists do. Although economic

theory suggests a variety of market imperfections that may arise, the average economist may,

nevertheless, tend to downplay the role of governments in the process of economic growth. In turn,

other disciplines may underestimate the role of markets in fostering growth.

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• Economists are generally consequentialist in ethical orientation, while other disciplines place greater

emphasis on tradition, virtue, or intuition. Economists in particular tend to think that economic growth

is good, while scholars in other disciplines are more likely to critique at least some elements of

growth. Although questions regarding the desirability of growth can be distinguished from questions

about causes, thoughts about one naturally influence thoughts about the other.

• Economists tend to be realists and assume that scholars can obtain reasonably accurate

understandings of a fixed external reality. Other disciplines, especially in the humanities, cast

a useful, if often exaggerated, skepticism on the possibility of human understanding. They thus

encourage scholars to be more careful in both their theorizing and policy advice. In particular, these

other disciplines are suspicious of broad generalizations and encourage careful context-dependent

research.

The preceding analysis has illustrated the following points regarding these steps in interdisciplinary analysis:

• Interdisciplinarians should be careful of curtailing the scope of their research unwittingly by following

major currents in the existing literature. In the case of economic growth, which other disciplines have

rarely stressed as a topic, it is particularly likely that scholars may produce valuable insights that are

relatively unheralded within their own discipline.

• Nevertheless, interdisciplinarians can usefully focus on particular disciplinary subfields. The danger

of missing relevant literature will be reduced if they also reflect on what theories and methods might

be relevant to the issue at hand.

• Interdisciplinarians must evaluate disciplinary insights in the context of disciplinary perspective and

with attention to the (complementary) strengths and weaknesses of different theory types and

methods.

Evaluating Disciplinary Insights

The interdisciplinary researcher must next evaluate the disciplinary insights generated by the relevant

theories and methods. This is an exercise in critical thinking. Interdisciplinarians must know how to distinguish

argument from assertion and assumption from evidence. In addition to standard strategies for the critical

analysis of any text, interdisciplinary analysis suggests several important strategies for critique:

• In what ways might a particular disciplinary insight be shaped by the particular “perspective” of that

discipline?

• More concretely, how might the insight be altered if the researcher(s) had examined a wider set of

phenomena?

• Likewise, what are the strengths and weaknesses of the theories and methods used by the discipline,

and how might the insight in question be shaped by these?

• Do the insights of one discipline point to possible weaknesses in the insights of another? Insights

from outside the academy can also be quite useful here.

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The analysis of the causes of economic growth provides examples of each of these evaluative strategies. As

we have seen, economists are likely to stress the role of individuals and rationality and may thus overlook the

actions of groups and/or various types of nonrational behavior. Economists have focused on a narrow set of

economic variables while downplaying the importance of, for example, culture. Economists stress equilibrium

or steady-state outcomes in their modeling exercises (in large part because this makes the math more

tractable, but also because of the emphasis of economists' general equilibrium theory on system stability);

in the real world, of course, growth has never been steady. Economic historians, sociologists, and political

scientists often stress that different countries have differing experiences of economic growth; this provides a

useful counterpoint to the economist tendency to identify central tendencies.

The interdisciplinarian can be heartened by the observation that other disciplines avoid at least some of these

biases in economic analysis. Yet, the interdisciplinarian should never forget that all disciplines have limiting

perspectives:

• The other social sciences have long stressed group or relationship agency (or viewed individuals as

constrained to act in a certain way by culture or institutions), without detailing how these constraints

emerge. In sociology, this approach has, in recent decades, been supplemented by individual-level

analysis, but syntheses of these approaches are rare. The interdisciplinarian must be prepared to

integrate insights that have rarely been juxtaposed in the past.

• Various sorts of nonrational behavior have been investigated in sociology and other social sciences.

As in economics, particular types of decision making are often assumed rather than established

empirically. The interdisciplinarian must thus be prepared to reflect on what sorts of decision making

motivate people in particular situations. This task is made more difficult by the fact that these are

often mixed in practice: An investor may only act if gut instinct, rational calculation, and the actions

of others all point in the same direction. The analyses of many social scientists present a further

challenge: They celebrate the “irrationality” of certain behaviors without carefully identifying what sort

of nonrational decision making is at work.

• The social sciences (including psychology) collectively employ each of the dozen methods utilized

in the scholarly enterprise. Yet, each of these is applied to only a subset of appropriate questions.

The interdisciplinarian, aware of the biases of one method, may look in vain for the application

of alternative methods to particular questions. For the present inquiry, this problem—of difficulty in

identifying work that applies different methods to the same question—is exacerbated by the fact that

scholars in other disciplines have rarely addressed economic growth itself.

• Other social sciences often assume processes involving sustained change in particular directions,

just as economists assume equilibrium outcomes. The important possibility of stochastic

(unpredictable) outcomes is much less commonly explored. The growth process likely entails

elements of each. Investment decisions at times seem to follow herd behavior and at times seem

inexplicable, and yet there is an amazing stability (lack of volatility) in average rates of return over

time. As with types of decision making, the interdisciplinarian generally has recourse to few previous

attempts to integrate insights reflecting these different perspectives.

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• Political scientists and sociologists often assume the superiority of governments over markets. Only

a minority of scholars in any discipline carefully compares the advantages of one or the other

for particular types of decisions (e.g., identifying the reasons why science is publicly funded but

technology is largely left to markets and the potential difficulties with each approach), and only a

minority appreciates that the ideal balance likely varies across time and place.

The lesson for interdisciplinary practice here is that the evaluative step should not be conflated with the next

step of finding common ground (even if, in presentational terms, it proves useful in this chapter to discuss

evaluation while outlining common ground). That is, disciplinary insights should not just be critiqued when

they conflict. The mere fact that different disciplines have asked different questions, and thus often not directly

disagreed with each other, should not render the interdisciplinarian sanguine about these disciplinary insights.

Interdisciplinarians can thus suggest useful clarifications or extensions to theories even in the absence of a

direct contrast among disciplinary insights.

Creating Common Ground

The almost-final step(s) involve finding some “common ground” that integrates (elements of) various

disciplinary insights. The role of creativity, intuition, and inspiration may loom large here. However, certain

straightforward techniques can be applied to find common ground:

• One can first ask to what extent seeming differences in disciplinary perspective are apparent rather

than real: Differences in terminology may mean that different disciplines are not actually talking about

the same causal process even when they appear to be. The interdisciplinarian can often redefine

concepts or extend a concept from one discipline to the subject matter of another.

• When concepts conflict, they can often be placed on a continuum: The tendency of economists to

stress rationality and of sociologists to stress irrationality can be handled by evaluating the degree of

rationality that individuals may display in a certain situation (Newell, 2007).

• One can then ask whether remaining differences can be overcome by small alterations in disciplinary

assumptions.

• The easiest path to creating common ground involves relaxing the assumption made by each

discipline that only its phenomena matter: Economists try to explain growth by focusing on a handful

of economic variables, while sociologists stress matters of culture and social structure (happily,

these attitudes are starting to change). In this simplest situation, the insights of different disciplines

can often be added together: Innovators may respond both to the economic incentives stressed by

economists and the cultural values emphasized by sociologists. Different disciplines are highlighting

different aspects of the question under investigation, but they are assuming other aspects do not

exist. Of course, integration is still required in order to identify how these different causes interact in

different circumstances.

• When different disciplines reach different conclusions regarding the same phenomena, the problem

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is often one of excessive generalization, and it can thus be solved by more carefully expressing the

range of applicability of the theories involved.

Examples of each technique can be readily provided. Economists use the word “investment” quite differently

from business scholars, for example: To economists, it means the actual production of buildings or equipment

that are then used in the production of other goods or services. Business scholars are likely to include any

effort to make a profit, such as speculation in various markets, in the term investment. Economists have

ignored certain things such as the influence of culture, the importance of networks, and the uneven path of

technological innovation. At times, the insights of other disciplines in these areas can simply be added to

the insights of economists—after each has been carefully evaluated in turn. Economists often assume that

a particular institution is optimal, while sociologists and political scientists show that institutions operate in a

complex web of social interactions: The different traditions can together strive to identify how well different

institutions serve economic growth in different contexts.

Rather than organizing this section in terms of the type of integration pursued, it will be more useful to

organize it by topic. Common ground will be found along a variety of different causal links generating

economic growth. Within each topic, though, care should and will be taken to identify the integrative strategies

utilized.

This approach—examining different causal links in turn (but not losing sight of emergent properties of

systems)—is different enough from the standard practice in economics of formally modeling several links

at a time that it deserves some comment. There are difficulties in applying the methodology of models to

open systems—ones which are clearly linked causally (as the economy surely is) to phenomena outside the

model. Although these problems do not destroy the model-building exercise, it is nevertheless true that such

models rely on an unrealistic assumption that the relationships observed in a system can remain fixed through

time. Notably, complexity theory takes a different approach, allowing different causal forces to operate along

different links, and does not assume any particular organizing principle (such as equilibrium) at the outset.

It should also be noted that this emphasis on causal links is not common to all efforts to identify best-practice

processes of interdisciplinary analysis. Interdisciplinarians often stress the importance of emergent properties

(e.g., Bammer, 2005). It is argued here that the two approaches are complementary and thus best pursued in

tandem. This strategy accords well with the general inclination toward integration by interdisciplinarians. As

well, interdisciplinarians have often said vaguely that there are different “facets” to complex problems. The

emphasis here on causal links provides a means of clarifying what might be meant by the vague term “facet.”

Since different causal links tend often to be the focus of different disciplines, the strategy of placing diverse

causal links within an overarching structure can be a powerful technique for interdisciplinary analysis. The

causal link approach helps us identify when different disciplines are, in fact, speaking about the same thing,

and thus it sets the stage for integrating disciplinary insights link by link.3

The Proximate Causes Themselves

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Economists have devoted an enormous amount of effort to “growth accounting” over the past decades. These

empirical exercises attempt to identify the relative importance of the proximate causes of growth: How much is

due to investment as opposed to innovation, for example? These exercises have been valuable: In particular,

economists in the 1960s were shocked by the fact that investment in physical capital accounted for only

about a third of economic growth over the previous century—and they were guided to pay more attention to

education and innovation as a result. Yet, these exercises rely on a rarely voiced assumption: The effect on

growth found for each proximate cause in one study should at least be a central tendency for all economies

at all times. This assumption is dangerous: Easterly (2002), an applied economist, describes how the World

Bank was led to a number of naïve policies over the years as a result, such as calculating the “required

investment” needed for certain target rates of growth and channeling those sums into countries ill-prepared

to utilize them productively.

Historians and economic historians have stressed the particularities of different cases. Economic historians

have long hypothesized that different generations of industrializers faced different challenges, and thus that

they necessarily developed in different ways (The classic argument was that of Gerschenkron [1962]; see

Sylla & Toniolo [1991] for an update). The same concern has been voiced, albeit using quite different theories,

by dependency and world systems theorists in sociology and other social sciences. But these scholars did

not (to my knowledge) directly address the assumptions of growth accounting, and thus it remains for the

interdisciplinarian to make the connection.

The assumption has a corollary: The proximate causes act independently. The main reason that the World

Bank strategy failed was that the return on investment in a country depends on many things: levels

of education, infrastructure, technology, and so on. Complicated relationships among such supposedly

independent variables are hard to capture within standard statistical procedures. That is, it is easy to estimate

how investment affects growth and education affects growth, but it is harder to establish how they combine

to do so. And thus a more nuanced understanding of how proximate causes interact will depend on detailed

case studies.

This adjustment in our understanding of the relationship between investment and growth is entirely in accord

with the strategies for interdisciplinary analysis outlined above: Growth accounting regressions naturally

omit many variables that condition this relationship; the structure of those regressions does not allow for

independent variables to act in concert; the approach reflects a disciplinary tendency to identify supposedly

enduring causal relationships without careful concern for the set of conditions in which these might hold;

and the growth accounting analyses thus represent a widespread tendency in scholarship to assume greater

generality for one's results than they deserve.

Trade and Growth

Solow (2005, p. 4) argues that there has been less modeling of growth in open economies than he would

have expected 50 years ago. Growth models tend to focus entirely on the internal dynamics of the growth

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process. This is unfortunate. Static economic analysis suggests that free trade is good because by pursuing

their comparative advantage, countries will be able to increase the value of their total output. They will export

goods that they are relatively good at producing and import goods that they are relatively poor at producing.

This is one of the most powerful insights in all of economics. But what if productivity (output per labor and

capital input) is advancing fastest in the goods a country imports? It will still benefit by being able to import

more as the international price of these goods falls, but it will not benefit as much as it would if its own

economy was experiencing rapid productivity growth. And thus there is a theoretical possibility that a country

may benefit in the long run by sacrificing some of the short-term gains from importing and exporting in order

to encourage production of goods where productivity advance is more likely.

Empirical research by economists has often suggested that the benefits from openness to trade are much

greater than static theory can explain: They thus point to dynamic benefits such as increased technology

transmission or greater competitive pressures on local firms. Yet, these empirical results have been

questioned even by economists, who note that they are not always obtained when different definitions of

“openness” are used or different time periods investigated. Economic historians, sociologists, and political

scientists have stressed that all successful developed economies have been protectionist early in their

development process. They have theorized that protectionism encouraged growth (see Miller, 2008).

Most economists will not readily accept a suggestion that openness to trade is not necessarily a good

thing (even this author finds it difficult). Yet, we have just seen that economists have proven willing to

accept arguments that the dynamic gains swamp the static comparative advantage gains. If arguments

for huge dynamic advantages are allowed, then arguments for dynamic disadvantages cannot simply be

ignored. Given the limited degree of theorization of dynamic effects, heavy weight must be placed on

the empirical evidence. The statistical analysis is not conclusive. The historical evidence points toward a

role for protectionism. But the historical record is also full of failed efforts to protect, of governments that

allowed protected industries to focus their energies on maintaining government support rather than becoming

internationally competitive. Case study analysis is tricky here: It is much easier to identify the many failed

infant industries—those that received protection from government but failed to grow up—than to observe

industries that developed behind tariff protection and establish that they could only have done so behind such

protection. In the second case, a counterfactual—what would have happened without protection—needs to

be carefully tested.

Although both theoretical and empirical analyses are thus more muddled than we might like on the grand

question of openness, some answers to narrower questions seem clearer:

• If a country protects, it must ensure that firms face clear incentives to enhance productivity.

• Countries with incompetent and/or corrupt bureaucracies should be particularly wary of managed

trade.4

• The inflow of information about technology and institutions should be encouraged, and trade in goods

is one way of doing so.

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• Tariffs are not the only, and perhaps not the best, strategy for supporting industrial development.

These important insights (which emerge from integrating insights from different disciplines) can be thought of

as “common ground” in the debate between advocates of openness and advocates of trade barriers. That is,

although it is difficult at present to sketch a common ground on the larger question of whether free trade is

good for growth, it is at least possible to identify certain circumstances under which this result is more or less

likely. These results, although limited, nevertheless carry important policy implications.

Technology and Growth

As noted above, economists were surprised when early efforts at growth accounting showed that investment

in physical capital could account for at most a third of the growth observed in developed countries.

Economists were guided to look elsewhere and came to stress the importance of education (i.e., investment

in human capital), technology, trade, and institutional changes that might enhance economic efficiency. The

earliest growth models treated technological innovation as exogenous: something that happened outside the

models. The latest generation of endogenous growth models try to bring technological innovation inside the

models; they argue that technological innovation results from another sort of investment—in research and

development—and thus can be explained in terms of economic variables. These models have been valuable

in encouraging economists to devote greater attention to the causes and effects of technological innovation.

Yet, the tendency to assume that the rate (and direction) of innovation can be understood entirely as a

function of economic variables carries the obvious danger that other influences on innovative activity will be

ignored.

Scholars of technology, whether historians of technology or scholars of science and technology studies (STS),

have certainly stressed a wide range of noneconomic influences on both the rate and direction of innovation.

Most obviously, historians of technology have traced how each innovation builds on preceding innovations.

Opportunities for innovation at any point in time (and space) are thus conditioned by the existing body of

knowledge. This insight, long appreciated in economic history, has begun to be voiced in economics itself.

The literature on General Purpose Technologies stresses that occasional “big” innovations set the stage for a

series of minor but cumulatively important follow-up innovations. There was thus more innovative potential in

the decades after the development of internal combustion (or steam) engines than in the decades before. Not

only was there scope for many small improvements to these engines, but they were applied to an increasing

range of uses, from factories to cars and planes.

Economists have shown less interest so far in the variety of other causal links identified by scholars of

technology.5 It is often thought—and not without cause—that STS scholars often assume, rather than identify,

cultural influences. When STS scholars claim that innovation is entirely a cultural product, unconstrained

by whether it reflects how the world works (an argument more often made with respect to science than

technology), skepticism is invited. This should hardly restrain other scholars from respecting more nuanced

arguments, and the evidence for them, that culture interacts with technological potential—and a host of

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other psychological, political, and social influences—to determine especially the direction but also the rate of

innovation.

In the case of technology, different disciplinary insights can largely be integrated by dropping the “only these

things matter” assumption. Different scholars have examined different causal influences on innovation, all

of which likely have a role to play. The popularity of extreme assumptions—that only economic, or cultural,

or technological influences matter—serves as a warning that scholars may assume rather than establish

the importance of different causal links. And thus, the interdisciplinarian attempting to evaluate the relative

importance of different links will need to carefully evaluate the arguments of all scholars. And he or she will

also need to be sensitive to the fact that—as with growth above—the relative importance of these links likely

changes across time and space.

Meeus and Hage (2006) edit an interdisciplinary handbook on innovation precisely because they believe that

management specialists, economists, sociologists, historians, political scientists, and others need to integrate

their efforts. They note that political scientists tend to stress government policies, management scholars look

at firm behavior, economists and sociologists emphasize industry-level analysis, and STS scholars stress

scientific innovation (but that until recently, very few scholars in any discipline have looked at behavior in

research laboratories); they urge a co-evolutionary perspective in which the interactions among different

levels of analysis are appreciated (p. 4).

Institutions

Do the right sort of institutions encourage growth (and if so how), and which sorts of functions are most

necessary for institutions to perform? Because there is abundant evidence that institutions are indeed

important, the question then arises how beneficial types of institutional change can be encouraged.

How important are institutions? Although economists have, in recent years, included many institutional

measures in growth regressions, it has proven difficult to establish any relationship empirically. This outcome

reflects, in part, the facts that different economists emphasize different theoretical arguments and that they

disagree over the precise definition of institution and which particular institutions might be most important.

Measures of social capital and social structure (see below) are often deemed “institutional.” These analyses

emphasize political over economic institutions, yet the former, for the most part, influence economic growth

only indirectly through the latter. Although there may be direct effects of political stability (e.g., on investor

confidence), the primary effect of stability and especially more mundane questions of electoral practices

or executive powers will be to shape the nature of economic institutions. Why not, then, stress economic

institutions in growth equations (with perhaps other equations linking economic and political institutions)?

A further problem is relevant here: It is all too easy for incompetent or corrupt governments to create the

appearance, but not the essence, of good institutions. Just as autocrats often glory in meaningless elections,

so in the economic sphere they can proclaim the protection of property while actively interfering with property

rights. They might expropriate property from citizens through fake legal proceedings or simply fail to enforce

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private contracts. Economists thus stress the quality of institutions (but a very limited set of them). But, of

course, quality is always hard to measure. Finally, the various institutional variables may interact with each

other and reflect feedback effects from growth itself, but simple regressions ignore these possible effects

(see Aron, 2000). Because different variables are strongly correlated, different economists identify different

institutional variables as most important (Lal, 1988).

Moreover, Aron (2000, pp. 100–101) worries that statistical analyses of growth in general face serious

problems of data, methodology, and identification. These are generally more severe than statistical analysis

elsewhere in economics. Although some of the problems identified by Aron can be alleviated by more

careful definitions and theoretical specifications, others cannot. Institutions are not particularly well-suited to

statistical analysis. Institutions are inherently unique. Countries may differ along various dimensions: The

courts may be fair but the police incompetent in one country, while rights may be enforced without much

recourse to courts in another. Such complexities call for comparative case studies and suggest that efforts to

describe a type of institution in terms of one numerical indicator are likely to be fraught with difficulty.

Economic historians have, indeed, investigated the relationship between institutions and growth using

comparative case studies. They have identified certain key institutional functions: protect property, enforce

contracts, facilitate financial intermediation, and so on. Even economic historians are sometimes less careful

than they could be: The right to property is actually a complex of rights (to earn income from, to use, to

change, to sell, to rent, etc.), and financial institutions serve several important functions. The connection

between institutions and growth has been little studied in other disciplines, with the important exception of

the literature on the role of government in economic development. One area in which much more research

is needed across disciplines is identifying the types of institution that serve various institutional functions.

Institutions differ a great deal across successful developed countries, and China has experienced rapid

growth against a backdrop of very peculiar institutions. Yet, it is clear that there are limits to the range of

supportive institutions.

The major insight of the literature on “the developmental state” (primarily in political science, but also

sociology) can be briefly summarized: “Sterile debates about ‘how much’ states intervene have to be replaced

with arguments about different kinds of involvement and their effects” (Evans, 1995, p. 10). That is, we

must move past attempts to identify best institutions to look at how well different institutions are enforced.

Scholars of the developmental state (such as the political scientist Kohli, 2004) tend to argue that effective

governments are necessary for any growth strategy to be effective. This insight has not been ignored

in economics, but in practice it is often neglected: It is generally much easier to identify whether a rule

exists than whether it matters. As noted above, the literature on trade and growth in economics has largely

eschewed the question of whether countries have the capability to manage whatever trade regime they

pursue. And thus, the literature on the developmental state can serve as an important reminder of the

importance of institutional quality.

Although the connection between institutions and growth has received limited attention in most disciplines,

the course of institutional change itself has been investigated across a range of disciplines (interest in

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institutions was reawakened in many disciplines in the 1980s). This wide range of approaches is potentially

complementary, at least once some extreme assumptions are pruned from them:

• Evolutionary theorists might posit that institutional change reflects selection over random institutional

changes, while rational choice theorists and functionalists (and social utilitarianism within sociology)

might assume that institutions represent the farsighted intentions of their creators. Institutions are

likely not the result of either perfect foresight or no foresight at all. So, then, it is an empirical question

to what extent agents know what they are doing and whether the institutions created serve the

purposes intended. Some scholars within all of these traditions relax assumptions of perfect foresight

or no foresight. Game theoretic analyses assume that agents feel their way toward institutional

solutions that work. While this is usually done in an equilibrium framework, this element can be

relaxed so that institutional change is viewed as a never-finished project.

• Whether equilibrium is assumed or not (but especially if it is not), path dependence—such that small

events can have important effects on the results of evolutionary processes—becomes possible and

can be used in explaining a variety of types of suboptimal outcomes of historical processes. Path-

dependent processes are important not just in economic history but in historical institutionalism in

political science, where interactions among a variety of institutions (including influences of political on

economic institutions), and among agents of unequal power, generate path-dependent processes.

The objection to path dependence comes only from rational choice scholars who assume optimal

outcomes.

• Once we move away from assumptions that institutions are purposely designed to serve societal

goals, scope is created for a variety of causal arguments. Most obviously, the relative power

of different agents comes into play. Power is stressed in sociology and political science and by

economists such as Knight or Acemoglu. And economic historians have a long tradition of

appreciating the role of power (e.g., in analyses of the feudal system; Greif, 2006). Political scientists

tend to tell both good stories of purposeful pursuit of beneficial institutional change and bad stories

of the exercise of power; these are likely complementary explanations rather than substitutes.

• The exercise of power is often obscured from view: Those exercising power generally wish not to

encourage an angry reaction and thus pretend to have other motives. Analyses of power, then,

are entirely compatible with analyses of legitimation. Both sociologists and political scientists speak

of legitimation. But as game theory analysis of institutional change suggests, cultural attitudes

are not easy to change purposefully. Scholars can usefully investigate, then, the degree to which

processes of legitimation serve the interests of the powerful or have a momentum of their own. Social

constructionism provides one useful hypothesis here: that institutions solidify over time into a form

that comes to seem natural. Another sociological hypothesis is that political institutions themselves

shape which other institutions are viewed as legitimate. Both could well capture important aspects of

legitimation.

• Sociological treatment of “ideas” encourages a broader exploration of the influence of culture on

institutions. If culture is not shaped entirely by the powerful, then cultural values may exert a range

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of influences on which institutions are thought to be desirable. The normative approach in political

science is similar. The “ideas” approach is particularly unique in emphasizing the role that social

science might play in establishing the desirability of certain institutions. The seeming reticence of

other social scientists to engage this line of argument is remarkable.

• Network analysis in sociology argues that agents are constrained by their networks: Institutional

change is only possible if supported actively by a sufficient network. Such an approach needs to look

at the resources that different network members bring, and it is thus compatible with an emphasis

on power (and culture). The business-labor analyses in political science can be seen as a particular

approach to network analysis, looking at how particular coalitions, whether within or across groups,

were formed and able to achieve change. Organizational institutionalism in sociology alternatively

examines the different motives of agents within an organization.

• Historical institutionalism is not alone in stressing the causal links between institutions. Both

structural institutionalism and social institutionalism emphasize the effects of certain sorts of

institutions on others.

These theories address links to institutions from each of the major categories of phenomena identified in

Szostak (2003, 2004), with the exception of the nonhuman environment and the two psychological categories.

Because each of these theories tends to be pursued in one or two disciplines, interdisciplinary integration

promises a more holistic outlook than any one discipline can provide. The treatment of cultural and social

phenomena tends to be too broad and diffuse and needs to more carefully focus on particular cultural and

social elements. Beyond this need for greater clarity, there are no obvious missing variables from the set of

theories as a whole.

In terms of theory types, different theories emphasize individuals (rational choice), relationships (game

theory, networks), groups (legitimation, cultural and social arguments), and nonintentional agents (historical

institutionalism's emphasis on interactions among institutions). There are hopeful signs of increased flexibility

within theories on this point: Although rational choice theory used to stress individuals and historical

institutionalism used to stress groups, both increasingly relate the behaviors of aggregates like unions to

those of members (Thelen, 1997, p. 378). Theories of institutional change naturally stress actions (more

rarely passive reaction, in some evolutionary and historical approaches), but some note the intermediate role

of ideas or values. Rational decision making is mentioned most explicitly, but game theory and evolutionary

approaches often refer to an intuitive groping for improvement. Structural institutionalism emphasizes how

decision-making processes or rules influence outcomes, but at the level of political institutions rather than

individual agents. Organizational institutionalism in sociology stresses the role of routines in behavior.

Legitimation approaches have a central place for virtue-based decisions. Path-dependent theories have an

obvious place for traditions, though agents need not argue explicitly from tradition in order to generate path-

dependent outcomes. Rational choice and game theory analyses stress equilibria (but not necessarily), but

most other approaches embrace dynamic or stochastic outcomes. In terms of theory types, then, the major

omission is in terms of decision making: More explicit attention to intuitive and traditional, and especially

virtue- and rule-based decisions, would be useful. These types of decision making are rarely found in the

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disciplines that have studied economic growth the most, but they are commonly explored in anthropology and

the humanities.

In establishing common ground, we would wish to know which theories or causal links are the most

important—and whether the relative importance varies by time or place or type of institution. Unfortunately,

the relative strengths of different theories are rarely compared in practice, for the simple reason that most

researchers favor and master only one.6 The empirical evidence collected in support of each theory is strong

enough, arguably, to urge the dismissal of the extreme arguments noted above that only one theory is correct.

Legions of political scientists and sociologists and economic historians have been fooling themselves, if

assumptions of perfect foresight or functionalism are entirely correct. The debate regarding path dependence

is more subtle: Although it is clear that path dependence is important over some time periods, the question of

whether optimal institutions are inevitably selected in the end is hard to establish uncontrovertibly, though the

diversity of economic institutions in countries of similar levels of development suggests otherwise.

Culture and Growth

It is noteworthy at the outset that the theories of institutional change referred to above almost all had some

role for culture. This insight accords with casual empiricism: Laws against littering or drugs are almost

impossible to enforce if many members of society view them as illegitimate. Yet, although economists admit

the importance of culture in this way, they tend to stop short of explicit cultural analysis. Greif (2006, pp. 8,

19–20) provides a good example of both attitudes. He not only recognizes that we must understand why rules

are enforced and obeyed, and cannot thus simply study the development of formal rules in isolation, but goes

so far as to define “institution” as a complementary complex of formal rules (what we and most others would

call institutions) and cultural elements.7 Institutional change is slow and path dependent because institutions

depend on “poorly understood and often unintentional processes of socialization, internalization, learning,

and experimentation,” including beliefs and ethical attitudes (p. 190). Yet, Greif worries that cultural elements

are largely unobservable, and he despairs of cultural explanations of anything for this reason: Because ad

hoc appeals to unobservable cultural elements can explain everything, they explain nothing (p. xv). He thus

focuses his analysis almost entirely on the observable formal rules, assuming that when these seem to work,

supporting cultural values and beliefs must be in place.

To argue that culture cannot be operationalized is to suggest that scholars of culture across a range of

disciplines and interdisciplinary fields have been wasting their time. Surveys are the most common source of

measures of cultural attitudes. Interviews and observation can usefully clarify whether survey questions are

both understood and answered honestly. In some cases, indirect quantitative measures are possible: Trust

can be defined as whether agents behave as they are expected to. There are thus a variety of ways in which

cultural attitudes can be operationalized.8

To be sure, there are problems with the existing scholarship on culture. The term itself is perhaps the vaguest

in all of human science: Thousands of different definitions exist, and individual scholars rarely bother to

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clarify what they mean by the term. Yet, culture can potentially be defined in terms of a host of attitudes

and behaviors; moreover, the works of individual cultural scholars can generally be understood as engaging

a handful of these (see Szostak, 2003). The ideological content of some versions of cultural studies raises

concerns that the important causal role of culture is simply assumed—but similar concerns have been raised

regarding other scholarly communities above.

The sociologist Beckert (2002) provides a compelling overview of the need for sociocultural analysis of

economic decisions. Economic theory itself suggests limits to the exercise of rationality in two common

circumstances. The first is when cooperation among agents is required, in which case economic calculations

depend on culturally conditioned expectations regarding the behavior of others. The second is when

uncertainty is present: If actors cannot rationally attach probabilities to the results that their actions might

produce, they must rely on various mental rules to guide behavior. Although individuals will differ in these,

there will also be cultural influences (and cooperation in the face of uncertainty would depend on similar

mental rules). He urges sociologists to focus on examining the social influences on those economic decisions

for which rationality is particularly problematic. This recommendation would have the effect of strengthening

the value of the research in each discipline to the other. He also urges sociologists to move away from

references to “irrationality” and instead identify specific strategies engaged in by actors when strictly rational

calculation is not feasible. This advice is similar to the advice of Newell (2007) to find common ground

between economists' emphasis on rationality and sociologists' stress on irrationality by thinking of a

continuum between the two. Although Beckert (2002) does not attempt to classify these non-strictly rational9

strategies, he makes frequent reference to following routines (which not only reduces costs of calculation,

but increases the predictability of the behavior of others) and following cultural guidelines—including respect

for widely shared values—and less frequent mention of intuition; thus, his analysis is consistent with the

elucidation of the five types of decision making above.

Economists tend to believe that there is one best value set for capitalist societies (Blim 2005, p. 307).

Modernization theory in sociology had also suggested that certain values, such as attitudes toward

achievement, were essential (p. 308). More recently, Fukuyama has stressed trust and Harrison has urged

future orientation, work effort, frugality, education, merit, trust, honesty, justice/fairness, dispersed authority,

and secularism (p. 309). Blim devotes several pages to detailing differences in institutions across modern

economies and then shows that these both reflect and support value differences. Different emphases

on individual versus community are reflected in lifetime employment in Japan and huge CEO salaries in

the United States. Values regarding competition versus collaboration are reflected in different approaches

to labor/management relations (p. 316). Again, careful specification of causal relationships, in concert

with careful attendance to differences across countries, produced a more complicated but more accurate

understanding.

In sum, the analysis of economists suggests that cultural values may be very important causes of economic

growth. Research in other disciplines has rarely addressed growth directly and has too often been

characterized by vague terminology and lack of careful empirical analysis. These problems can each be

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overcome. At present, though, the interdisciplinarian can most usefully provide advice to disciplinarians as to

how insights here can best be developed and/or clarified.

Networks

Networks of individuals serve a variety of social, political, and economic purposes. Networks are a third

way of organizing economic activity—along with the markets and organizational hierarchies that economists

have stressed until recently—and sociologists have shown that networks are critical in such important

economic activities as finding a job or locating a business contact. Moreover, network analysis focuses

on relationship agency, whereas economic analysis stresses individual agency. Network analysis is thus

potentially a valuable addition to the study of economic growth. Economists have rarely used network analysis

and tend, when they do, to stress a static analysis of how networks work, rather than looking at how networks

evolve. Network analysis has occasionally been applied to economic interactions but not directly to the study

of growth. As with culture, then, interdisciplinarians can provide advice on promising research strategies and

potential pitfalls. Scholars wishing to examine the relationship between networks and growth could benefit

from the following observations:

• Social capital is another vague term. There are three types of definition. The worst invites tautology

(and ignores the reality of bad outcomes being possible) by defining social capital solely in terms

of results. The second stresses cultural values such as trust. The third emphasizes networks and

perhaps organizations. The last two can be combined: Networks generate generally beneficial

outcomes by encouraging trust. This chapter will thus not address social capital, but rather address

culture and networks separately.

• As with culture, useful classifications of different types of network are needed. Sociologists stress

the importance of weak and/or cross-group links: Networks serve a critical role in transmitting

information, and the most important links may be the less obvious and less strong links between

individuals with access to quite different types of information.

• Then scholars must identify the links between different types of network and different economic

activities: investment most obviously, but also innovation (which scholars of both science and

technology increasingly appreciate occurs within networks) and institutional change (which is also

only possible if resources are mobilized through networks). It should not be forgotten in these

explorations that networks can serve to divert resources from growth; links between groups may be

particularly important in generating positive outcomes.

• In particular, network analysis may provide a means (though certainly not the only means) to get

a handle on the slippery concept of entrepreneurship (another topic treated more often outside

economics than within). Entrepreneurs can only be successful within networks, and thus both the

supply of entrepreneurs and their effectiveness will be influenced by the availability of networks that

provide access to diverse sources of information and resources. Ironically, Swedberg & Granovetter

(2001, pp. 12–13) observe that entrepreneurs often only succeed after migrating away from

expectations within networks of family and friends (e.g., expectations that they will employ family

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members).

• The reasons for differences in networks across countries can be explored in a comparative fashion.

Granovetter (2001) has argued that there are limits to the ability of an agent to forge links

instrumentally for gain. Instead, information often flows as a side-effect of relationships pursued for

social reasons. It has been hypothesized that networks are especially weak when social divisions

are sharp, poverty exists without a safety net, rule of law is weak, politics is not free and without real

choices, different groups do not see shared goals, war or famine undermine sense of stability, and

minorities are discriminated against.

• The question of whether networks (or markets) are a substitute or complement for institutions

deserves further attention: It is probably true that institutions can substitute for deficient networks in

some cases but not others. This question has important policy implications for countries with limited

“social capital.”

Social Structure

There is a general appreciation across all disciplines that social divisions—primarily ethnic and class

differences, but also gender and family divisions—can have negative economic and political effects. Writers

in each discipline show how, in at least some instances, these negative effects are of enormous importance.

Despite the general (and unusual) consensus on this point, there are still opportunities for one discipline to

learn from another. Economists tend to downplay issues of class or inequality, while other disciplines may

exaggerate these issues.

Economists rarely look at the sources of social division, and may thus too readily assume that they are

intractable. Geddes (2002) warns us not to take ethnic divisions as given, for individuals have choices about

how to identify themselves. People also decide whether to feel mistreated or threatened by other groups and

how to respond. She argues that this focus on malleability characterizes modern political science research

(p. 361).

Community Development

Among disadvantaged groups, both in poor countries and rich countries, economic growth may depend on

“community development”: Members of the community need to come together in order to identify strategies

that enhance economic growth prospects directly or indirectly (by improving education, health, legal, or a host

of other institutions and policies). Local communities often provide critical infrastructure, such as irrigation.

The World Bank increasingly makes unrestricted loans to local communities (Stiglitz, 2006, pp. 51–53).

Community development involves strengthening civil society (by strengthening links within the community

and its interaction with sources of academic and professional advice), in order to prioritize the actions and

perspectives of these communities in addressing the development of social/economic/environmental policies.

It thus involves empowerment: strengthening the capacity of both individuals and community-level institutions.

Community development, like the economic growth it may encourage, is best pursued in an interdisciplinary

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manner. This is, in part, because community development usually involves complex challenges, and thus

it requires input from a variety of academic disciplines and professions. As well, the diversity of insights

gives communities a freedom of choice (in how they integrate them) that they lack if presented with only one

discipline-grounded policy option. Moreover, there is a synergy between cross-disciplinary integration and the

integration of community insights with academic/professional insights: Both types of integration depend on

respect, forging a common vocabulary, and seeking a whole that is greater than its parts. Community activists

often need to oppose entrenched interests, just as interdisciplinarians must at times confront the entrenched

authority of disciplines (see Butterfield & Korazim-Körösy, 2007).

Emergent Properties

We must be careful that the study of individual causal links does not divert our attention from emergent

properties that might be apparent only at the level of broader systems of links. Two types of emergent

properties deserve particular attention.

First, growth itself can be considered to be an emergent property of a host of independent actions, mostly

undertaken without having the encouragement of growth as an objective. There is indeed a long tradition in

many fields of arguing that economic growth occurs only when many causal forces are combined. “Big push”

theories in economic development in the 1960s, Walt Rostow's “stages of growth” theory with its long list

of necessary conditions for a “takeoff into economic growth,” dependency and world systems theory (which

postulate a variety of ways in which poor countries might be kept poor by their interactions with rich countries)

in sociology and political science, among other approaches, have made this sort of argument.

Are the optimistic or pessimistic versions of these approaches more plausible? In terms of the three strategies

for dealing with differences in interdisciplinary insights (above), it is clear that this difference is not merely

semantic: Pessimists and optimists are talking about the same thing and reaching different conclusions. Do

these hypotheses have different ranges of applicability? It must seem that many of the world's poor countries

have achieved impressive rates of economic growth in recent decades and thus better fit the optimistic

outlook. Most of sub-Saharan Africa might better fit the pessimist scenario, though again, it must be recalled

that some of these countries grew rapidly in the 1960s. There might be some mechanism that ensures that

at least some poor countries remain poor. This leads to the third question: Could one achieve common

ground by changing some assumptions in one or the other perspective? Indeed one could. If one strips

away the determination to identify without doubt the future course of history, each perspective supports and

depends upon a set of causal arguments. It is entirely possible that all of these have some empirical merit,

and thus whether a country grows or not depends on which causal forces are operating most strongly at

certain times. And such a common ground can indeed be seen in the writings of both camps: Optimists often

talk about overcoming what they see as surmountable barriers (such as the absence of property rights or

decent infrastructure) to economic growth, while pessimists generally suggest that growth will only occur if

dramatic changes are made (say, in trade or foreign investment policies at the global level) to the way the

world operates.

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Although both optimists and pessimists appeal to issues of complexity, they have not, in general, emphasized

emergent properties but rather a set of mutually reinforcing causal links. This need not mean that emergent

properties are unimportant: Scholars across disciplines may be biased toward making narrow causal

arguments rather than appealing to emergent properties.

A second venue for emergent properties is economic fluctuations. Economic actors do not set out to generate

business cycles (indeed, this result is even less intended than economic growth), but cycles emerge from

the interactions among actors. Economists have struggled for decades to explain cycles precisely because

it is hard to move from an understanding of how individuals behave to an appreciation of how cycles are

generated. For present purposes, a few brief points can be made about fluctuations:

• In a world without growth and the structural change that accompanies it, economic cycles would be

mild or nonexistent. Cycles should thus be treated as largely an emergent property of the economic

growth process.

• In addition to the business cycles of a year or two in duration that economists have focused most

attention on, there are longer periods—of a decade or more—characterized by significant differences

in growth rates: The 1950s and 1960s saw more rapid growth in most developed countries than did

the 1930s or 1970s. Notably, these periods of rapid growth tend also to be characterized by less

severe cyclical behavior—perhaps because workers losing their jobs could quickly find others.

• However, economic models of growth predict a steady state outcome of some constant rate of

growth. It was noticed above that other disciplines are more likely than economics to stress

differences in growth experience across time and place. Interdisciplinarians should thus seek a

common ground that reflects the observed reality of alternating periods of fast and slow growth.

(Our appreciation above that technological innovation occurs unevenly through time might form an

important component of this common ground.)

Lessons for Interdisciplinary Practice

The foregoing analysis has, I hope, provided evidence of the advantages of a strategy of integrating insights

along different causal links (without neglecting the interactions among them) and also seeking emergent

properties of the system as a whole. The literature on interdisciplinarity often refers somewhat vaguely to

different “facets” of an issue. The stress here on causal links clarifies the focus of analysis and points again to

the advantages of an exhaustive table of the key phenomena studied by scholars across all disciplines: This

provides a “map” of the links addressed while also mitigating against ignoring links just because all disciplines

have ignored them (or the literature survey failed to find works that did).

Interdisciplinarians have understandably focused the most on integration when different disciplines provide

conflicting insights. Yet, the analysis above suggests that integrative strategies are also useful when gaps

exist between disciplines. In such cases, interdisciplinarians can usefully suggest avenues for research that

would bridge these gaps. The symbiotic relationship between disciplines and interdisciplinarity may then be

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easier to display to disciplinarians: Interdisciplinarians can point to valuable extensions to disciplinary analysis

without having first to outline the deficiencies of previous research.

Reflection and Communication

Establishing common ground is the most important single step in the integrative process. Yet, the

interdisciplinarian cannot simply stop at this point. As is true in specialized research, the act of insight should

be followed by careful attempts to evaluate and clarify the integrative insights obtained.

Interdisciplinarians are not free of bias themselves, though they will generally be more aware of the existence

of scholarly biases than specialized researchers. Interdisciplinarians as a whole may be biased toward

seeing good (or not) in all approaches, and they must thus be careful to scrutinize each insight they take

from any discipline. Individual interdisciplinarians may be characterized by a host of ideological, ethical,

epistemological, theoretical, methodological, and other biases. They may like some disciplines more than

others. All these possibilities should be reflected upon to see whether the integrative results obtained reflect

such biases.10

The interdisciplinarian should then ask whether there are ways in which his or her integrative understanding

might be tested. It may well be that a complex integrative understanding such as that sketched above cannot

be tested in its entirety (though it is useful to ask whether the set of insights as a whole is useful to the policy

maker). Rather, different tests may be required for different causal links. The interdisciplinarian will wish to

use multiple methods to test insights. If different methods suggest different conclusions, it is necessary to

revisit the strategies outlined above of interrogating assumptions and revisiting the strengths and weaknesses

of different theories and methods.

The final task involves communicating results in a format that is accessible to multiple audiences. This

involves appreciating both the knowledge bases of different audiences and their interests: The results should

be connected to issues that different audiences (especially disciplines) already care about.

Conclusion

In the end, did we end up with a chaos of conflicting arguments extending in too many directions? Or were

we able to put enough order into our reflections to make the effort worthwhile? Hardcore disciplinarians will

respond negatively: They can instill greater order by simply ignoring theories and methods other than their

own. But the interdisciplinarian strives toward an order that does not arbitrarily limit insight. The cause of

economic growth—and the billions of people who desperately need to experience more of this—is best served

by privileging integrated insight over narrower criteria.

It is useful to close by briefly reviewing the benefits to our understanding of growth of the various steps in the

interdisciplinary research process:

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• The scope for interdisciplinary analysis expands markedly when we move beyond studying the

proximate causes of growth to ask why some countries innovate or trade or invest more than others.

Economists—and far from all of these—have only recently extended their gaze beyond the proximate

causes, and they are held back by the difficulty of applying their usual theories and methods to

non-economic phenomena such as culture. The importance of not arbitrarily constraining a guiding

question along disciplinary lines could hardly be better illustrated.

• The second step(s) reviewed a wide range of theories and methods and established that each had

strengths for the study of growth that could compensate for weaknesses in others. The appreciation

of these strengths and weaknesses was invaluable when disciplinary insights were evaluated later.

The analysis also served usefully to justify in advance wide-ranging theoretical and methodological

explorations. For mainstream economists, the key message was that rational choice theorizing and

statistical analysis need to be supplemented with other—for the most part complementary—theories

and methods. Yet, the same message was communicated to all other disciplines.

• The identification of gaps in scholarly understanding is always a critical step in interdisciplinary

analysis. It has been particularly important in the case of economic growth, for scholars of networks

or culture or business cycles have only rarely addressed questions of economic growth (and vice

versa), and even much of the literature on technology and institutions is oriented toward quite

different questions. One of the main purposes of this research project has been to identify areas

where future research is needed and how this might be pursued.

• Asking about the possibility of emergent properties led us to two important areas of investigation:

poverty traps and the connection between growth and cycles.

• More generally, we were able to create a common ground across a range of causal links that is

superior to the insights of any one discipline. We will not reprise those analyses here, in part not to

detract attention from the other steps in the research process.

• Though we did not have space to describe the final steps in detail, our understanding of growth will

be greatly enhanced if we interrogate possible biases in our analysis, test our insights empirically,

and communicate them clearly to diverse audiences.

1. This chapter draws on Szostak (2009). That book is organized according to the 12 steps identified in

Szostak (2002). In this chapter, they are combined into four sets of steps. My process is broadly similar to

that in Repko (2008), though I tend to stress the identification of relevant phenomena, theories, and methods

more than Repko, and I also rely more than Repko on classifications of phenomena, theories, and methods in

evaluating disciplinary insights. Yet these are differences in emphasis only; Repko and I concur regarding the

broad outlines of the research process. In the book, I address the question of whether growth is “good.” For

rich countries especially, I urge the definition and measurement of growth in terms of output per hours worked

(and thus growth might just mean more leisure time) and with due regard to environmental repercussions. I

also stress that only some goods and services add to human well-being.

2. These are the three possible types of “intentional agency” or “nonintentional agency” identified in Szostak

(2004). They together form one of the five dimensions in the typology of theory cited in Repko (2008,

pp. 198–200). Others are addressed below. Durkheim had distinguished sociology from economics and

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psychology by emphasis on methodological holism. “Methodological holism in sociology has been an obstacle

to acceptance of the choice-theoretic approach underlying the new institutional paradigm”—it has isolated

sociology from changes in other social sciences (Nee, 1998, p. 11). But while this approach has dominated,

many analyses, from Tocqueville and Weber to today, have emphasized “rational action bounded by

institutions” (p. 4). Rather than debate individualism versus holism, “a more constructive approach is to

model the reciprocal interaction between purposive action and social structure” (p. 5). In other words, these

approaches can be integrated.

3. Some scholars would worry about the number of distinct causal links that would need to be investigated in

any complex study. We can hardly hope, though, for a simple understanding of a complex process. Szostak

(2009) shows how the causal link understandings can be organized into a coherent whole through reference

to an exhaustive classification of phenomena.

4. Economists, as we shall see, worry a great deal about the quality of institutions when discussing institutions

in general. That is, they recognize that countries differ a great deal in how well they manage/enforce

institutions that may look quite similar on paper. In the realm of trade policy, however, analysis tends to

proceed with respect to a dichotomy between openness and managed trade. There is usually an implicit

or explicit assumption that countries cannot manage trade very well. Kohli (2004), a political scientist,

argues that the key difference in developmental prospects is between countries that can manage/enforce

any institutions well and countries that can manage/enforce no economic institutions well. He argues, for

example, that South Korea effectively managed several years of import substitution as well as decades of

export promotion (i.e., the government was not “captured” by private industries and encouraged them to

improve productivity under both regimes). On the other hand, Nigeria failed miserably with respect to both

types of policies (both were perverted to reward friends of the government, and productivity advance was not

encouraged; p. 376). The broader literature on “the developmental state” makes similar arguments.

5. Historians of technology give roughly equal attention to the technological, economic, political, and

sociocultural influences on innovation. They increasingly pay attention to the long period of development after

a breakthrough innovation. They note that as technological systems harden, they limit human choices about

technological innovation (Nye, 2006).

6. The value of integrating these approaches has occasionally been appreciated in the literature. Thelen

(1997, p. 370) suggests that rational choice theorists can appreciate historical circumstances while historical

institutionalists can think more about why actors do what they do (and the importance of collective action

problems); all can recognize the role of norms in supporting institutions. Thelen's main argument is that

scholars cannot understand change without also understanding stability. Both the coordination emphasized

by rational choice theory and the shared cultural understandings of sociological institutionalism allow us to

understand continuity better than change (p. 386). Historical institutionalism, on the other hand, invokes sunk

costs and vested interests, and thus is good at identifying critical junctures that send countries on different

trajectories, but worse at explaining continuity.

7. Greif (2006) notes that different disciplines define institutions differently: as rules, as norms, as functional

solutions to particular problems. He urges the integration of these definitions. From our holistic perspective,

this is best done not by conflating quite distinct phenomena but by capturing in different causal links both the

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influence of culture on institutions and the role of institutions in solving particular problems. Greif's own wish

that different definitions be viewed as complements (p. 40) is best achieved in this manner. Greif's definition

encourages an emphasis on culture over other causal influences on/of institutions, while inviting us to treat

the culture-institutions nexus as a black box.

8. In the past decades, the availability of better data and techniques has induced some economists to study

culture. One popular approach is to look at whether membership in a particular ethnic or religious group

affects economic outcomes. The advantage of this approach is that such memberships are easily measured

and are also largely inherited: This overcomes the possible concern that any correlation between culture

and economy reflects causation in the other direction. Both internationally and within countries, ethnic and

religious differences do generate different economic outcomes (though within countries, studies of immigrants

suggest that these will lessen over time). Moreover, these differences are correlated with different values and

beliefs (trust, social mobility, fairness, hard work, fertility, thrift) in both regressions and experiments. Yet, such

studies can only be suggestive of links between these values and economic growth, and these links are hard

to establish statistically (Guiso, Spienza, & Zingales, 2006).

9. Beckert (2002), in distinguishing himself from the emphasis of other sociologists on irrationality, strives

to emphasize the “rationality” of other decision-making strategies. In this chapter, these can be seen as

reasoned but nonrational strategies. Note that semantic confusion between narrow and broad uses of the

word “rational” contribute to misunderstanding between sociologists and economists.

10. I am an economist, but one who has written methodological critiques of my discipline and my field of

economic history (Szostak, 1999, 2006). I have thus had the pleasure of being critiqued by non-economists

for being too much of an economist and by economists for being not quite enough of one. The reader can

best judge which—likely both—is the case here. I lack practitioner-level expertise in some of the disciplines

covered here, but I have considerable familiarity with most of the theory types and methods addressed. I am

a self-conscious interdisciplinarian and thus likely biased toward stressing the advantages of interdisciplinary

analysis. As should be clear by now, I believe in theoretical and methodological flexibility. I may thus be biased

toward seeing some good in all approaches. Indeed, I do suspect that any idea pursued at length by some

academic community must have some kernel of truth in it. But this need not prevent skepticism: One can

appreciate that those who thought the world was flat for millennia were misguided, while appreciating the

value of the ways they amassed evidence in support of their hypothesis. Still, I can imagine that disciplinarians

reading this chapter will readily imagine that I have been too harsh with respect to them and not harsh enough

in my treatment of others. And surely some of them will be right (but hopefully not to a considerable degree),

though I know not which.

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