The Science of the Total Environment 224 1998.

201]213

Indicators of human health in ecosystems: what do we

measure?

Donald C. Cole a,U John Eyles a , Brian L. Gibson a,b

a
McMaster Institute of En ironment and Health, Hamilton, Ontario, Canada
b
Occupational and En ironmental Health Programme, Lakeshore Area Multiser ice Project, Etobicoke, Ontario, Canada

Received 23 June 1998; accepted 25 September 1998

Abstract

Increasingly, scientists are being called upon to assist in the development of indicators for monitoring ecosystem
health. For human health indicators, they may draw on environmental exposure, human morbidityrmortality or
well-being and sustainability approaches. To improve the rigour of indicators, we propose six scientific criteria for
indicator selection: 1. data availability, suitability and representativeness of populations., 2. indicator validity face,
construct, predictive and convergent. and reliability; 3. indicator responsiveness to change; 4. indicator desegrega-
tion capability across personal and community characteristics .; 5. indicator comparability across populations and
jurisdictions.; and 6. indicator representativeness across important dimensions of concern.. We comment on our
current capacity to adhere to such criteria with examples of measures of environmental exposure, human health and
sustainability. We recognize the considerable work still required on documenting environment]human health
relationships and on monitoring potential indicators in similar ways over time. Yet we argue that such work is
essential in order for science to inform policy decisions which affect the health of ecosystems and human health.
Q 1998 Elsevier Science B.V. All rights reserved.

Keywords: Environmental exposure; Water pollutants; Air pollutants; Health status indicators; Morbidity; Mortality

U
Corresponding author. HSC 2C1, 1200 Main St. W., Hamilton, Ontario, Canada L8N 3Z5. Tel.: q1 905 5259140, ext. 22037; fax:
q1 905 5770017; e-mail: coledon@fhs.mcmaster.ca

0048-9697r98r$ - see front matter Q 1998 Elsevier Science B.V. All rights reserved.
P I I S 0 0 4 8 - 9 6 9 7 9 8 . 0 0 3 5 0 -7
202 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
1. Introduction
After many years of documenting the
widespread presence of both natural and anthro-
pogenic chemicals in the environment and in hu-
mans, environmental scientists are increasingly
being called upon to apply their findings in new
ways. Partly on the basis of their work, the exten-
sive connectedness between the natural environ-
ment and human beings is being discussed in
terms of ecosystems, both by human epidemi-
ologists concerned about the human health ef-
fects of widespread ecological changes Mc-
Michael et al., 1996. and by environmental man-
agers and policy makers. Thus, the Canadian
Council of Ministers of the Environment 1994.,
p. 3, adopt an ecosystem approach, viewing the
basic components air, land, water and biota}in-
cluding humans. and functions of ecosystems in a
broad context, integrating environmental, social
and economic concerns. Such breadth demands
agreed upon ways of monitoring and assessment
which cross disciplinary boundaries and permit
the utilization of scientific findings for manage-
ment and policy purposes. The development of
indicators has been heralded as the way of re-
sponding to these challenges WHO, 1996..
Yet how can the findings of environmental
health scientists be best applied to the develop-
ment of indicators relevant to human health in
particular ecosystems? How can such findings be
linked to the broader concepts of healthy commu-
nities and sustainability? This paper explores
these questions, drawing on our experience in
Ontario, part of the Great Lakes Basin. We start
with definitions of indicators and their potential
purposes. We propose a set of scientific criteria to
select indicators. We set out a range of environ-
mental exposure measurements that have been
used as indicators of risk to human health. Then
we consider measurements of human health sta-
tus and social well-being that we believe reflect,
at least in part, the effects of environmental expo-
sure. We discuss attempts to use these indicators
as measures of sustainability. Throughout we
comment on the extent to which potential indica-
tors meet our scientific criteria. Finally, we reflect
on the challenges for future work in the areas of
indicators.
2. What are indicators?
Indicators are measurements selected to repre-
sent a larger phenomenon of interest, in our case
the relationships between ecosystems or environ-
ments and human health. They are shaped by the
different models that scientists and policy makers
use to understand the links. Indicators therefore
reflect the significance of their conceptual bases.
We shall consider three different bases for discus-
sion of definitions and purposes of indicators:
environmental models, measures of human health
and well-being and sustainability indicators.
The pressure-state-response model is an im-
portant framework for environmental indicators,
developed by Canada and adopted by the Organi-
zation for Economic Cooperation and Develop-
ment OECD, 1993.. Pressures are the underlying
causes of change in environmental states, condi-
tions of the natural and human world at varying
scales. Responses are actions by human organiza-
tions to ameliorate environmental conditions. A
similar approach is provided by Hunsaker and
Carpenter 1990., with an indicator being a char-
acteristic of the environment that, when mea-
sured, quantifies the magnitude of stress, habitat
characteristics, degree of exposure to a stressor,
or degree of ecological response to the exposure.
Underpinning this approach are concepts such as
self-maintenance or self-sustainability of ecologi-
cal systems, sustained use of the ecosystem for
economic or other social purposes and sustained
development to ensure human welfare. Based on
these concepts, the US]Canada International
Joint Commission, which governs the use of
boundary waters between the two countries, has
set out five uses for environmental indicators
Table 1; IJC, 1996.. Historically, compliance has
been the most important from an environmental
regulation perspective but early warning and di-
agnostic purposes have become more salient as
the irreversibility of some ecosystem changes be-
comes more apparent.
For health planners, human health indicators
 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
Table 1
Suggested uses for environmental indicators
Assessing the current condition of the environment in order
to judge its adequacy i.e. a compliance indicator.
Documenting trends in the condition over time, i.e.
degradation or rehabilitation a compliance indicator or
sometimes an early warning indicator.
Anticipating hazardous conditions before adverse impact in
order to prevent damage before the fact i.e. an early warning
indicator.
Identifying causative agents in order to specify appropriate
management action i.e. a diagnostic indicator.
Demonstrating interdependence between indicators to make
the assessment process more cost-effective and to reinforce
political will to make environmentally sound management
decisions i.e. correlations between various indicators.
Source: IJC, 1996, p. 13.
have traditionally drawn on the wide variety of
data routinely collected to document vital statis-
tics or administer health care services Birch and
Eyles, 1993.. Health indicators are then defined
as statistics selected from the larger pool because
they have the power to summarize, to represent a
larger body of statistics, or to serve as indirect or
proxy measures for information that is lacking.
They are chosen because they are efficient, effec-
tive tools for planning, management and evalua-
tion. Murnaghan, 1981.. Stimulated in large part
by national or global strategies such as Health for
All by the Year 2000, a wide range of terms and
definitions for such measures of health status has
been generated Hansluwka, 1985..
Another approach has been that of public
health surveillance defined as the ongoing syste-
matic collection, analysis and interpretation of
data on specific health events affecting a whumanx
population, closely integrated with the timely dis-
semination of these data to those responsible for
prevention and control Thacker and Stroup,
1994.. An initial focus on disease or injury surveil-
lance approach has been expanded to include
hazards. Hazard surveillance is the assessment of
the occurrence of, distribution of, and the secular
trends in levels of hazards toxic chemical agents,
physical agents, . . . as well as biological agents.
responsible for disease and injury Wegman,
203
1992.. Closely related is exposure surveillance or
the monitoring of individual members of the
population for the presence of an environmental
agent or its clinically unapparent e.g. subclinical
or preclinical. effects Thacker et al., 1996..
Surveillance is thus built on indicators not only of
human disease or injury and its surrogates of
health care utilization but also on relevant mea-
sures of hazards in the environment and expo-
sures to individuals.
In measuring social well-being, social. indica-
tors are defined as statistics which measure social
conditions and changes therein over time for vari-
ous segments of the population Eyles, 1994.. By
social conditions, we mean both the external so-
cial and physical. and the internal subjective and
perceptual. contexts of human existence in a given
society. An indicator is
a statistic of direct normative interest which
facilitates concise, comprehensive and balanced
judgements about the conditions of major as-
pects of society. It is in all cases a direct mea-
sure of welfare and is subject to the interpreta-
tion that, if it changes in the right direction,
while other things remain equal, things have
gotten better or people are better off US
Department of Health, Education and Welfare,
1969, p. 97, cited in Eyles, 1994..
Sustainability indicators build on the environ-
mental, human health and social well-being liter-
ature Gosselin et al., 1993.. Definitions gener-
ated for lay groups working on building healthy
communities are more familiar in style. For exam-
ple, Indicators are signposts of change. Moni-
tored over time, they provide clues to the direc-
tion the community is heading Hellman, 1996.;
and an indicator is a flag, marker or sign that
points to a condition you want to measure . . . we
use indicators to describe conditions or processes
in a community British Columbia Ministry of
Health and Ministry Responsible for Seniors, un-
dated.. As part of the strategy to improve infor-
mation for decision making on sustainability
UNCED, 1992, chapter 40., the World Health
Organization has taken the lead in developing
indicators related to environmental health
204 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
chapter 6 of Agenda 21. which reflect this active
use by lay public Table 2, WHO, 1996.. Indica-
tors are firmly seen as being specified in a model
of some aspect of environment or society which
affects well-being and demonstrates over time,
patterns and variations in the issues of interest to
a wide variety of stakeholders. They are goal-re-
lated. As noted in a World Resources Institute
review, Indicators must be more than just a de-
scription of conditions or trends . . . they must
help to express progress toward attainment of
public policy WRI, 1990.. Clearly, indicators
have a number of socio-political requirements for
their use Eyles et al., 1996, p. 58, for use-based
criteria . but what scientific requirements should
they fulfil?
3. Criteria for indicator selection
Desirable characteristics of indicators have
been dealt with in a variety of ways in different
literature. A report on bioindicators for the vir-
tual elimination of persistent toxic substances
Fox, 1994. suggests four criteria: specificity to
the substances, placement in appropriate scales,
costs of measurement and social relevancerpub-
lic perception. Of initial importance are scientific
issues of data quality. A report on the State of
Lake Ontario used quality criteria for the inclu-
sion of different kinds of data, based on critical
appraisal questions developed for analytic mea-
Table 2
Role of indicators for sustainability
Provide a common currency or language for information
exchange between the many stakeholders concerned with
health, environment and development interactions
Help to quantify the situation and highlight its significance
Help to simplify the data and present it in a form directly
relevant to the question being addressed
Enable decision-makers to be aware of the choices available,
and to evaluate and compare the implications of these choices
Provide the information to the general public, and facilitate
external scrutiny of decisions and policies, thus ensuring
transparency and accountability
Source: WHO, 1996.
surements, toxicologic studies, ecologic studies
and epidemiologic studies Rang et al., 1992.. A
Community Health Profile document Commun-
ity Health Profile Working Group, Ontario Min-
istry of Health, 1994. examined health data in-
tegrity e.g. completion of records, nature of sam-
pling in brief surveys., geographic coding issues
e.g. postal codes vs. census subdivisions. confi-
dentiality and data access, and data gaps.
Availability of appropriate data is the first sci-
entific criterion for indicator selection Eyles et
al., 1996., as set out in Table 3. The second
criterion refers to the closely related concepts of
validity and reliability. Questions based on the
types of validity include: after evaluating the ra-
tionale behind indicator selection, is it a reason-
able measure? face validity.; does the measure
behave as expected in relation to other related
variables? construct validity.; does the measure
correctly predict a situation which would be
caused by the phenomenon being measured?
predictive validity.; and do several measures col-
lected or structured in different ways all move
similarly over time? convergent validity.. Reli-
ability is an important component of validity but
more easily ascertained through repeated mea-
sures in different contexts and at different times
provided similar methods are used. The third
criterion is responsiveness or the ability to avoid
ceiling or floor effects which inhibit documenta-
tion of change over time.
Table 3
Scientific criteria for indicator selection
1. Data availability, suitability and representativeness with
respect to sampling of populations.
2. Indicator validity face, construct, predictive and
convergent. and reliability repeatability across times
and sources.
3. Indicator responsiveness to change
4. Indicator disaggregation capability across personal and
community characteristics .
5. Indicator comparability across populations and
jurisdictions.
6. Indicator representativeness }Coverage of important
dimensions of concern
 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
To be informative, indicators should also be
able to be broken down by key variables. The
OECD 1973. identifies three types of desegrega-
tion: by ascribed characteristics e.g. age, sex, race,
region; by well-being characteristics e.g. years of
education, family income; and by contextual char-
acteristics e.g. size of community, type of occupa-
tion. Similarly, indicators should be able to be
compared across communities and jurisdictions to
satisfy the human desire for ranking and to permit
studies to link human health outcomes with envi-
ronmental conditions in different places. Finally,
indicators should cover as broad a range of
concerns as possible in ways that do not unneces-
sarily compromise validity. Such breadth may nec-
essarily involve the inclusion of non-com-
mensurate types of indicators representing dif-
ferent aspects of a phenomena of interest such as
human health related to environment. Keeping in
mind these criteria, we shall now turn to the
options available among indicators of human en-
vironmental exposures, related human health im-
pacts and measures of the sustainability of human
communities.
4. Human exposure indicators
In choosing indicators of human exposures to
toxic agents in the environment, we face a bewil-
dering array of potentially relevant choices, be-
cause of the connectedness of different parts of
the biosphere. Many exposures potentially have
human health consequences Brooks et al., 1995..
Most of these are not as easy to recognize as
environmentally-related accidents included in
the United Nations Environment Programmes
reports on unplanned releases which resulted in
injuries and evacuations e.g. UNEP, 1991, p. 241.
or similar short-term events documented by the
US Agency for Toxic Substances and Disease
Registry in its Hazardous Substances Emergency
Events Surveillance System Hall et al., 1996..
Low-level long-term multiple exposure situations
pose significant challenges. Environmental policy
makers charged with producing State of the Envi-
ronment SOE. reports e.g. Government of
Canada, 1991., environmental scientists trying to
model environmental processes e.g. Hauhs et al.,
205
1996. and environmental epidemiologists trying to
demonstrate relationships between environmental
exposures and adverse human health outcomes
e.g. Armstrong et al., 1992, 1995. have all had to
grapple with this challenge. Among the diverse
approaches used, we can focus on potential expo-
sure indicators from those areas in which credible
exposure]human health effect relationships have
been identified through toxicologically-based risk
assessments or epidemiological studies.
Inventories of emissions to air, discharges to
water or toxic releases to any media can provide
information on the magnitude and apportionment
of sources of contaminants of relevance to human
health e.g. Canadian Chemical Producers Asso-
ciation, 1994.. They are important components of
SOE reports at the national e.g. sulphur dioxide
emissions to air. and municipal levels e.g. sewage
treatment plant discharges of total suspended
solids. Government of Canada, 1991.. Pirrone
and Keeler 1996. examined trends in air emis-
sions of trace elements in the Great Lakes region
and demonstrated corresponding changes in am-
bient air concentrations. Further, sophisticated
dispersion modelling programs have modelled the
transport, movement and concentrations of emit-
ted contaminants in particular media over time,
e.g. contaminants moving by air currents into the
Arctic McKay and Wania, 1995. and toxics in
water]sediment systems of the Great Lakes US
EPA, 1989..
Most models rely on measurements of contami-
nant levels in different media and biota for initial
estimation and subsequent calibration. For the
Great Lakes Basin, considerable work went into
the synthesis of data and reporting on the pres-
ence and potential impacts of toxic chemicals
Environment Canada et al., 1991. with foci on
contaminant levels in water and sediments,
aquatic biota mainly fish. and wildlife species
mainly birds. by lake or river e.g. Lake Superior,
Niagara River.. For human contaminants, the ap-
proach involved first examining contaminants in
all the media which form pathways for human
exposure food, drinking water, air and soil. and
then setting out data on contaminants in different
human tissues adipose, blood, breast milk and so
on.. In some sense this reflects the luxury of
206 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
focusing on a single species but it also reflects the
wider range of locations in which humans spend
time and the importance of various types of expo-
sure e.g. workplace, ambient air, consumable
food.. Multiple routes of exposure are particu-
larly important for radionuclides, with consider-
able external sources and potential pathways
through fish consumption for which little current
monitoring data are readily available Joshi, 1991..
Exceedances of established international, fed-
eral, provincial and state standards of contamina-
tion in different media have also been proposed
as major environmental indicators relevant to
health Ecosystem Objectives Work Group, 1992..
However, two potential problems emerge. First,
as newer compounds are documented and their
health effects gradually elucidated, no such stan-
dards may exist for some time, e.g. alkyl phenolic
compounds Bennie et al., 1997.. Secondly, what
were thought to be protective levels at one time
may no longer be perceived or demonstrated as
such over time, e.g. small particles in air Dockery
and Pope III, 1994..
Another important consideration for human
exposure is the activities that bring people into
contact with a contaminated medium or biota.
The distributions of time]activity patterns based
on diaries e.g. Leech et al., 1996. have made
important contributions to the risk assessment
process for exposure to airborne contaminants.
Similarly, dietary surveys combined with measure-
ment of contaminant levels in foods have permit-
ted estimates of contaminant intakes among
populations for a limited number of metals and
pesticides e.g. Dabeka and McKenzie, 1995.. For
fishing and the subsequent consumption of poten-
tially contaminated fish Stow et al., 1995., a
variety of methods have been developed to obtain
data US EPA, 1992. and relate consumption to
contaminant intakes e.g. Kearney et al., 1995..
Related to human activity is the perceived use
to which various aspects of the natural environ-
ment can be put. For example, bathing beaches
are frequently posted due to either measured via
bacterial counts in water. or presumed biological
contamination at levels which would be most likely
to cause swimming-related illnesses Rang et al.,
1992.. Relevant human activity information has
often been lacking except when special studies
are undertaken Seyfried et al., 1985a, 1985b..
The IJC Indicators for Evaluation Task Force
IJC, 1996. recommended that Swimmability and
Fishability both be used as indicators. Fishability
requires ongoing assessment of contamination in
species-size-location mixes and consumption by
people living in the Basin e.g. Sheeshka et al.,
1996.. Hence indicators which characterize the
environment as a place for human activity must
confront the need for the critical information on
human use.
Biological measures of absorption often pro-
vide summary measures of exposure for contami-
nants with long half-lives in the human body
Environmental Health Directorate, 1996.. Blood
lead is the classic biological measure of immense
importance in large US cities Agency for Toxic
Substances and Disease Registry, 1988.. Although
national surveys have been done for persistent
organochlorines using adipose tissue Lordo et
al., 1996. or breast milk, plasma or serum have
been more commonly used among those with
potentially higher exposures such as anglers
Kearney et al., 1995. and First Nations peoples.
Such measurements are often linked to risk as-
sessment-based predictions of potential human
morbidity e.g. Forti et al., 1995..
These different approaches to quantifying hu-
man exposure only partially meet the scientific
criteria for indicators. Although much of the data
has demonstrated validity and can be responsive
to change, there is a lack of systematic, repeated,
representative data across jurisdictions and over
time. Air pollutants and food contaminants show
the most promise partly as a result of internatio-
nal attempts to standardize profiles and methods
e.g. UNEP, 1991., yet they must be linked with
human activity and morbidity and mortality data
to be useful as indicators of human health in
ecosystems.
5. Human mortality and morbidity indicators
Data collected through vital statistics systems
at provincialrstate and national levels have tradi-
tionally formed the bases of indicators of human
 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
mortality Peron and Strohmenger, 1994.. Infor-
mation on rates of death mortality. by disease,
age and sex may prove useful for comparisons
across regions when environmental exposures are
sufficiently high and regionalised to cause major
effects. For example, after adjusting for district
measures of mean income, mean car ownership,
proportion of illegitimate sic. births and abortion
rates, Hertzman 1994. and colleagues found that
the rates of low birth weight, postneonatal moral-
ity and infant mortality were all significantly
higher in former Czechoslovakia districts with the
highest levels of air pollution compared with those
with the lowest. Similarly, the declining propor-
tion of live births that are male has been advo-
cated as a measure of the reproductive health of
large populations, linked to environmental expo-
sures in Canada Allan et al., 1997..
Hospital utilization rates by age, sex and dis-
ease may also prove useful. A recent Canadian
Atlas of Hospital Morbidity in the Great Lakes
Region Bureau of Chronic Disease Epidemi-
ology, 1993. noted areas with higher rates for
some diseases which facilitate the generation of
hypotheses as to environmental and social causes.
Such data have been used to demonstrate associ-
ations between levels of aluminum in drinking
water and admissions for Alzheimers disease e.g.
Neri and Hewitt, 1991.. Utilization rates are,
however, subject to considerable variation based
on facility availability and health professional uti-
lization practices in different settings Roos and
Roos, 1989.. For example, among Manitobas el-
derly patients reporting good or excellent health,
the probability of being hospitalized could vary
twofold depending on the practice style of their
physician Roos and Roos, 1989.. Further, Bur-
nett et al. 1994. using sophisticated time series
analyses to link air pollution and hospital admis-
sions, showed the proportion of all hospital
admissions attributable to air pollution among
those 65 or older was 4.3%. Such a small percent-
age change could be easily masked by non-ran-
dom distributions in practice style among physi-
cians in any particular community. Conversely, a
large increase in hospital admissions in a commu-
nity could be inappropriately attributed to pollu-
tion effects when the source of variation was
207
physician practice style. One means of over-
coming such interpretation problems is to predict
the proportion of hospital admissions that would
be due to air pollution in a community, based on
existing coefficients of relationships in the litera-
ture and measured levels of air pollution. For
example, a multidisciplinary group estimated that
for Hamilton-Wentworth, about 1% of all non-
traumatic admissions could be attributed to acute
changes in ground level ozone, NO 2 , carbon
monoxide, particles or sulphates Pengelly et al.,
1997.. Such attributable risk estimates may be the
best way to predict the potential of environmental
exposures to produce human health effects.
Registries of birth defects usually are derived
from hospital discharge diagnoses and vital statis-
tics data Johnson et al., 1992.. Increased rates
can spuriously come from differences in ascer-
tainment by physicians and coders in hospitals,
random variation, combinations of the two, or
true differences. Nevertheless in rural Minnesota,
the highest rate was found in the major wheat,
sugar beet and potato growing region where
phenoxy herbicide and fungicide use are greatest
and higher rates were only found at the time
when the heaviest applications occurred, the
spring Garry et al., 1996.. In two heavily polluted
industrial cities of Ukraine, average rates of con-
genital anomalies were 11.7 and 8.8 per thousand
live births compared to 3.8 in a less polluted city
Hertzman, 1994.. Similar gradients for rates of
multiple, dominant and x-linked anomalies but
not recessive anomalies. were documented, indi-
cating that new mutations may be occurring. Such
an analysis is relevant to potential effects of envi-
ronmental pollution yet it is best done by chart
review, a time consuming exercise used to compile
the British Columbia congenital anomalies data-
base Darrell Tomkins, personal communication..
Cancer registries must rely on more varied
sources and methods of reporting to build as
complete a picture as possible of the numbers of
new cases occurring each year incidence. e.g.
for Ontario, Mills and Semenciw, 1992.. Although
data quality across regions in Ontario has been
shown to be good and spatial aggregation oc-
curred for about one-third of the site-sex combi-
nations, considerable work remains to be done on
208 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
the wide range of exposures that may be impli-
cated Walter et al., 1994.. Linkages with existing
environmental data are possible but usually only
as specific case control studies such as those
linking chlorination of drinking water with colon
and bladder cancer occurrence e.g. King et al.,
1996.. Methods for building up detailed exposure
histories for population-based case-control stud-
ies of cancer have been considerably advanced for
occupational exposures to a range of potential
carcinogens using expert hygienist coders e.g.
Siemiatycki, 1992.. These methods remain to be
developed across the range of carcinogens pre-
sent in the ambient environment, likely due the
high cost involved in generating adequate data.
Water-borne infectious diseases have a long
history of mandatory reporting to public health
authorities. Outbreaks due to parasites and other
less commonly controlled organisms like crypto
sporidium MacKenzie et al., 1994. are of particu-
lar importance. Surveillance for these infectious
diseases andror the environmental conditions
which promote them high runoff with high water
intake turbidity. provide examples of conditions
for which indicators can be useful. In keeping
with public health criteria for the appropriateness
of surveillance, they are relatively simple, specific,
feasible, timely and reasonably cheap given the
resulting public health benefits Thacker et al.,
1996..
Surveys of determinants of health, health con-
ditions and health care utilization can also pro-
vide indicators of health status of a population,
though not usually on a regular basis. They may
be entirely questionnaire-based, as in the first
wave of the Canadian National Population Health
Survey Montano, 1994., or they may include
physical examinations and biological samples as
in the US NHANES III survey US National
Center for Health Statistics, 1994.. Such survey
data are based on self-reporting with resulting
lack of specificity of diagnoses but they are good
for general health concerns and are usually repre-
sentative of the entire population. Primary data
collection on environmental exposures is possible,
as in the inclusion of a question on consumption
of freshwater fish from Alberta in Albertas Heart
Health survey Elizabeth Hasselborg, pers.
comm... Respiratory morbidity and health profes-
sional visits reported over a specified period of
time have been shown to vary with local air
pollution levels in Ontario Pengelly et al., 1993,
1995..
Considerable work has been done aggregating
health data and devising indices that provide a
better picture of the overall impact of the con-
stituent conditions on the health of a population
Peron and Strohmenger, 1994.. The World Bank
1993. has estimated environmental burden of
illness using disability adjusted life years
DALYs., which incorporate morbidity and pre-
mature mortality, adjusted for severity of illness
and stage of life, and converted to monetary
units. Community health profiles are another way
of summarizing health indicators and their de-
terminants. For example, relevant categories in
the version from the US Institute of Medicines
Committee on Using Performance Monitoring to
Improve Community Health Institute of
Medicine, 1997. included exposure risk factors
such as air quality standards, health status indica-
tors such as age-adjusted mortality rates and
functional status measures such as general health.
Prime considerations for indicator selection were
similar to our proposed scientific indicators.
Hence those chosen by the committee have avail-
able and representative data, demonstrate validity
and reliability, have differential time lines for
responsiveness to change, can be desegregated
and are comparable across US jurisdictions
though some would not be internationally ..
Social indicators may document public percep-
tions, show particularly vulnerable groups or re-
flect indirect results of ecosystem changes. Public
concern about environmental exposures may gen-
erate stress with health consequences as reported
in the growing literature on psychosocial effects
of waste disposal siting and environmental disas-
ters Cole and Eyles, 1997.. Impacts on the qual-
ity of life were one of the major concerns voiced
by residents of Hamilton-Wentworth in consider-
ing indicators of air quality Pengelly et al., 1996..
Soiling by black soot and the need to clean chil-
dren, pets, clothes and outdoor furniture were as
important as the need to stay indoors on high
pollution days because of breathing difficulties. A
 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
striking example of vulnerable groups suffering
indirect effects has been the reduction of self-
supporting status of the Akwesasne First Nation
consequent to the decline of agriculture due to
fluoride pollution and fishing due to PCB con-
tamination Forti et al., 1995..
6. Sustainability indicators
Such outcomes link with the literature on sus-
tainable and healthy communities. Often the
terms are used interchangeably or actually com-
bined Hellman, 1996.. Early proposals to moni-
tor progress towards healthy cities set out com-
ponents for every aspect of municipal activity
including both the built and natural environment
York University Centre for Health Studies, 1990,
1991.. Municipal SOE reports in Canada were the
first step towards a sustainability perspective. In a
series of case studies, Campbell and Maclaren
1995. and Campbell et al. 1996. noted a pre-
dominant focus on what they term biophysical
indicators n s 226. which included land use e.g.
open space., media e.g. air quality. and stresses
and responses e.g. waste generation and recy-
cling.. Social indicators were next n s 35. fol-
lowed by economic indicators n s 21.. Few mu-
nicipalities included morbidity or mortality vari-
ables as SOE indicators. Those that did had gen-
eral health indicators 5r290. and measures for
poisonings, motor vehicle accidents and air pollu-
tion effects.
Canadian sustainability indicator development
for local communities has built on experience
with SOE reports, with a strong emphasis on
land-use and ecological integrityrheritage. Initia-
tives have focused on development of sustainable
regions and incorporated planning approaches to
documentation of Quality of Life Dilks, 1996..
For example, Hamilton-Wentworth initiated a
community visioning process in 1989 to move
toward Vision 2020: the Sustainable Region
Bekkering, 1995.. A working group involved both
area specialists and community members to de-
velop a set of sustainability indicators or Sig-
nposts on the Trail to Vision 2020 Regional
Municipality of Hamilton Wentworth, Environ-
ment Department, 1995.. The 29 indicators in 11
209
theme areas draw on existing information and
graphically present both current status in relation
to goals and trends. In addition to measures of
contamination in media are indicators such as per
capita residential electricity consumption, low
birthweight babies as a percentage of total births
and a rate of meaningful employment. Well-being
per se was not included because of concerns that
it can quickly include almost all human activity,
rendering it inappropriate for comparative pur-
poses.
Yet when trying to assemble information other
than morbidityrmortality data, those developing
sustainability indicators often face issues of data
availability and comparability, because much de-
pends on local government reporting systems and
requirements. Validity, reliability and representa-
tiveness of the indicators can be more important
issues, since routinely collected data often do not
match models of sustainability nor the publics
major areas of concern about ecosystem]human
links.
Nor do ecosystem boundaries often match po-
litical boundaries. Responsiveness to change may
as yet be uncertain because systematic reporting
and implementation of community planning
changes are only beginning.
7. Conclusions
We have reviewed a wide variety of perspec-
tives and relevant data on indicators relevant to
human health and ecosystemsrenvironments.
Human health is clearly multidimensional and
our task is to be explicit about the dimensions
being measured and devote attention to the sci-
entific issues involved in indicator selection.
Overall, natural scientists have made strong con-
tributions in the area of exposure measurement
but the links of environmental exposures and
ecosystem conditions to human health need to be
strengthened for indicator purposes. Human
health scientists and practitioners have done well
on documenting morbidity and mortality but need
to work on adapting the usual systems of health
service information and health survey design and
reporting to include a broader range of determi-
nants, including exposures. Social scientists and
210 D.C. Cole et al. r The Science of the Total En ironment 224 (1998) 201]213
planners also need to link back to documentation
of human activity and exposures to make their
work more usable as indicators of human health
in ecosystems.
In order to meet the needs of decision-makers
at the local, national and international levels for
information at the appropriate scale, potential
indicators will have to be tested over time among
scientists, policy makers and the public Wills and
Briggs, 1995.. Environmental health professionals
must play an active role in the process of develop-
ment, testing and eventual reporting of indicators.
We understand this process will be arduous at
times, particularly as the indicators we advocate
are buffeted in the policy and political arenas. We
would argue, however, that unless our scientific
work appropriately contributes to such arenas, we
may eventually lack resources to continue our
contributions and decision-makers may un-
knowingly pay inadequate attention to the com-
plex interplay of ecosystems and human health.
Acknowledgements
We wish to acknowledge the research assis-
tance of Nancy Ross, Jenny James and Adele
Iannantuono. We also wish to acknowledge the
advice and financial support given by the Great
Lakes Science Advisory Board Working Group on
Ecosystem Health, International Joint Commis-
sion. Eyles and Cole were supported by the
EcoResearch Program in Environmental Health
funded through Canadas Green Plan, the On-
tario Ministry of Health and the Hamilton-
Wentworth Regional Department of Public
Health Services.
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