A  Matrix for Disease Prevention
      and Environmental Protection
     "... Clean, safe water is the first line of defense for public health.
     Safe, clean water keeps our communities healthy and thriving."
                                      .  Carol M. Browner, Administrator
                                     U.S. Environmental Protection Agency
 In order to fulfill their mission of "assuring the conditions in which
 people can be healthy," local health officials must understand how
 environmental factors affect health, as well as strategies for protecting
 the public's health and the environment. The purpose of this fact
 sheet is to clarify the relationship between pollution
 prevention, drinking water, and public health, and to promote
 steps local health officials can take to reduce health risks by
 helping to safeguard the nation's water supply.

 Concern about drinking water safety is widespread. An environmental
 health study of local health departments conducted by the National
 Association of County and City Health Officials found that
 contamination of groundwater, private wells, surface water, and public
 water are leading problems in communities nationwide. Moreover, the
 American public ranks water issues at the top of their environmental
 concerns, according to a poll commissioned by the Natural Resource
 Conservation Service, USDA (formerly Soil Conservation Service)1. The
 challenge is to transform concern into action that ensures a safe and
 sufficient drinking water supply. Pollution prevention is one means to
 that end.  Pollution prevention (P2) is any practice that prevents
 or reduces pollution at the source. It is a method for reducing both
-the quantity and toxicity of waste generated, thereby lessening the
 likelihood that such substances will reach the water supply and,
 ultimately, be consumed by humans. Thus, when we prevent pollution,
 we protect human health.


Ninety-sevenpercent (97%) of the earth's
water is saltwater in oceans and seas.
Only one percent is available for drinking
water supplies. The water available for
human consumption (fresh water) is
divided into groundwater and surface
water. Groundwater is water absorbed
into the earth's crust and stored in
underground aquifers (large areas of
permeable rock, gravel or sand that are
saturated with water). Only .5% of all
water is groundwater, butit supplies much
of the world with fresh drinking water.
Approximately 93% of all the public water
systems in the United States are served by
groundwater, and groundwater sources
account for nearly 96% of the small
systems.2 In all, more than 50% of the
people in the United States, including
nearly everyone who lives in rural areas,
use groundwater for drinking and other
household uses.  Groundwateris also used
in some way by about 75% of cities and by
many factories. The largest use of
groundwateris to irrigate crops.
Groundwaterresources are threatened by
contaminationsources such as leaking
storage tanks, septic systems, hazardous
waste sites, landfills, and the widespread
use of chemicals* Available data indicate
that 20-25 percent of groundwater sources
are contaminated with viruses or bacteria.4
Water found on the surface of the earth is
called surface water. About .02% of
water is in the form of surface waters.
Surface water is susceptible to
contaminationfrom animal waste,
pesticides, industrial waste and other
materials and can contain bacteria and
other microorganisms.	
Questions & Answers

How does water quality affect
the public's health?
The safety of water has been a
concern of public health officials
since the recognition of drinking
water as a transmitter of bacteria
and other microorganisms capable
of causing disease and death. Later
discoveries that other contaminants,
such as toxic chemicals, could cause
acute and chronic illnesses
heightened this concern and, along
with it, efforts to safeguard the
nation's drinking water supply.

It is not known how many people
become sick each year from
contaminated water, since the
majority of waterborne disease
cases go unrecognized and
unreported. Symptoms can range
from diarrhea and dehydration
from exposure to natural pathogens
to reproductive disorders and
chronic illnesses, such as cancer,
from exposure to chemicals. Since
1971, the Centers for Disease
Control and Prevention (CDC) and
the U.S. Environmental Protection
Agency (EPA) have maintained a
collaborative surveillance system for
collecting and reporting data
related to occurrences and causes of
(WBDOs). State, territorial, and
local public health departments are
primarily responsible for detecting
and investigating WBDOs and
voluntarily reporting them to CDC
on a standard form. For the two-
year period 1993-1994,30
outbreaks associated with drinking
water were reported, causing an
estimated 405,366persons to
become ill. However, because not
all WBDOs are recognized,
investigated and/or reported to
CDC or EPA,  these data do not

reflect the true incidence of WBDOs,
which is probably significantly
higher.5 Estimates of the number of
annual waterborne microbial
illnesses in the United States are 1-
10million cases.6

What are the sources of water
The four categories of possible
contamination in the public
drinking water supply are:7
• natural (or microbial)
pathogens which occur in the
source water or in the distribution
system: bacteria (eg. E. coli), viruses
(eg. Hepatitis A) and protozoa (eg.
Cryptosporidium. Giardia):
• organic, inorganic, and
radioactive chemicals, naturally
occurring and man-made, which
occur in the source water;
• disinfectants and coagulants
used to treat the water to kill the
pathogens or remove the chemicals;
• chemical byproducts resulting
from the reaction of the
disinfectants with organic or other
materials in the water.

Pollutants enter waterfront many
sources. Some come through
specific points, such as the
discharges of factories, which can
contain untreated waste. This type
of pollution, called point source
pollution, is easier to monitor and
control. Nonpoint source pollution
is contamination from non-specific
sources and is harder to control.
Examples include farm and lawn
nutrients that move through the soil
into the ground water or enter local
waters directly through runoff
during heavy rains; uncontrolled
stormwater runoff from
construction sites; forestry
operations; animal wastes; and
pollutants released directly into the

What are the main strategies
for assuring a safe drinking
water supply?
Pollution prevention is the preferred
strategy. Once water is
contaminated, clean-up may be
technologically or economically
impossible. A recent study by the
National Research Council found it
could cost as much as $1 trillion
Over the next 30 years to clean up
the estimated 300,000 to 400,000
contaminated ground water sites in
the United States.9 Moreover,
treatment carries with it other risks
— the chemicals used to clean up the
water. The cleaner the source water
the less disinfectant needed and,
thus, the less chemical

Pollution prevention, or "source
reduction," is any practice that
prevents or reduces pollution at the
source. By minimizing the use and
production of pollutants, we can
prevent those substances from
entering the air, water, soil and
food chain and reduce human
exposure to them. Examples
include product substitution and
educating consumers and
businesses about proper disposal of
hazardous or toxic substances.

Milwaukee, WI
The largest ever documented
waterborne disease outbreak in US
history occurred in Milwaukee, WI in
April 1993. Over 400,000 areas
residents were sickened by the
parasite, Cryptosporidium. The
"silver lining" is that the outbreak led
to many changes in water-related
policies in Milwaukee and
representatives from the local health
department are still sharing "lesson's
learned" with other public health
officials.  Key among them are:
Existing water quality standards were
inadequate even though they were
within regulatory limits—
communities need to set their own
monitoring standards; public health
agencies and water utilities must re-
form old partnerships; municipalities
must invest in their infrastructure;
and there cannot be complacency
about source water. Although the
health department may never know
the exact cause of the outbreak, it was
believed to be a confluence of events
including agricultural runoff after
heavy snow-melt and spring rains;
sewage overflow due to the water
volume in the metropolitan system;
and possible aggravation by meat and;
bide processing practices along the
rivers, which empty into the lake,
upstream from the treatmentplant.
The local health department has taken
steps to improve source water quality
by moving the treatment plant intake
farther from the river mouth,        :
improving disinfection with the
addition of ozone, and optimizing
What protections are in place
to safeguard the nation's water
Responsibility for the quality of the
water supply is shared by many.
Public water system owners are
accountable for the quality and
availability of drinking water from
its source to the consumer. More
than 13 million households drink
from their own private wells, and
they are responsible for protecting
their water supply.

Several federal statutes include
provisions for protection of
groundwater, surface water and
drinking water supplies.  Chief
among them is the Safe Drinking
Water Act (SDWA), passed by
Congress in 1974 and revised most
recently in 1996, with amendments
that include new guidelines for EPA
to use in developing rules to protect
public water supplies, public
notification requirements and funds
for upgrading local infrastructure..
States also set standards for
contaminant levels and take
additional steps to safeguard their
water supplies.

Local level activities, such as land
use laws, homeowner and business
education programs, water
conservation standards, operation
of used oil or hazardous waste
collection sites, community and
business stewardship programs,
groundwater protection policies,
and public/private partner ships
can greatly influence the quality of
our nation's drinking water supply.

Anne Arundel County, MD:
Aime Arundel County, MD is
participatmgin the U.S.
Environmental Protection Agency's :
National Onsite Demonstration :
Project (NODP). The NODP, a four-
year project, isassisting^
communities in developing strategies
to treat wastewater and ensure that it
does not contaminate the drinking
water supply.  The chief
environmental consideration in Anne
Arundel County is controlling and
preventing pollution of the
Chesapeake Bay and its shoreline.
This can be done by treating    *;
wastewater to reduce the amount of
nitrogen, phosphorus, and pathogens
in it.  Through NODP, the Anne
Arundel County Health Department'
has installed several alternative '     *
wastewater treatment systems in the
community, including recirculating
sand filters, a peat filter," a trickling
filter designed for use with a septic
tank, filtering pump basin-and
expanded filter. The health" ?
department is working with EPA to
evaluate theselsystems.1 TheJiealth
department has also developed^  }
public education program targeting
public health sanitarians and  *  f
contractors from the region. -   ;   f
What is the role of local health
departments in safeguarding
our drinking water supply?
While many entities play important
roles in drinking water protection,
local health departments are
uniquely positioned because they
are responsible for protecting both
the health of the community and
the environment. They are also the
first place the public turns for
information about water safety and
health concerns. This sets health
departments apart from other local
agencies or organizations that focus
on one or the other.  Local health
officials use their expertise in
population-based health and their
understanding of community
environmental health issues to
develop pollution prevention and
other policies to protect human

How do the core public health
functions relate to P2 and
drinking water?
The core public health functions-
assessment,policy development
and assurance — capture the range
of activities local health
departments can undertake around
drinking water and public health.

ASSESSMENT: Identifying local
level water issues, community
concerns, populations at-risk and
available resources

> Identify the main contaminants
in the water supply through a
Contaminant Source Inventory or
similar process.

> Determine the sources of
identified water contaminants, such
as businesses, industry, agriculture,
government and consumers, so that
steps can be taken to help them
reduce their use of those
contaminants that affect water

 Thurstpn County, WA
 This community relies on
 approximately 5,000 public and
 private wells for 100% of its drinking
 water. The "Groundwater Guardian
 Team" has been formed to serve as an
 advisory board on groundwater
 protection and includes citizens and
 representatives from business,
 agriculture, and government. Its
 regional program involves 3 cities and
 the county. Activities include data
 collection, education and regional
 wellhead policy  development.
 Education is done through National
 "Drinking- Water Week and by
 incorporatingthe message about the
 importance of groundwater into all
 pollution prevention activities. The
 wellhead protection program focuses
 on developing uniform, regional
 policies so that businesses and
 consumers are not plagued by a
 patchwork of requirements. A local
 land use ordinance is in effect that
 establishes more stringent protection
 measures for facilities locating in
 sensitive groundwater areas. A
 comprehensive hazardous waste
 prevention program was begun in  ..
 1991 that offers a mix of education,
 technical assistance, waste collection
 and enforcement programs for local  ;
 businesses and residents.
>• Identify groups in the community
working on water issues (i.e. utility
companies, water quality agencies,
advocacy organizations, etc.) and
explore ways to collaborate with

> Measure the community's
perceptions, attitudes and needs to
determine the best way to address
 water-related issues and the best
 avenues for conveying your

 > Identify practices within the
 health department (in both business
 offices and clinics) that threaten to
pollute water so you can practice
 what you preach.

 > Develop a water-related disease
 surveillance system to track the
prevalence in your community.

Developing responsive and
proactive programs, policies and
outreach strategies to minimize
health threats and support and
promote safe drinking water,

 > Use information gained through
the assessment process to determine
how water issues can be
incorporated into the local health
department's environmental health

 > Draft local ordinances or best
management practices standards
defining steps to prevent pollution.

> Work with policymakers to
develop incentives for local
businesses and government
operations to become engaged in
pollution prevention and water
protection efforts.

>> Develop campaigns and ongoing
public information about steps
consumers, business and
government can take to reduce

threats to the drinking water

> Incorporate pollution prevention
into the land use and planning
process, (i.e. protection of water
supplies at the source using buffers
or other protection).

> Set up a task force of
stakeholders, including citizens, to
study issues affecting wellhead
protection areas.

> Develop programs to recognize
and publicize the work of
individuals or businesses involved
in protectinggroundwater above
and beyond normal expectations.

ASSURANCE: Assuring that
communities have services that
protect their water supplies, such as
pollution prevention strategies and
resources, and that responsive
strategies are in place for instances
in which  water quality is found to
be unsatisfactory.

> Take steps to ensure that local
health department staff are trained
to respond to public inquiries about
drinking water and health.

> Work with other entities involved
in drinking water and pollution
prevention activities, such as: soil
and water conservationists,
planning departments, extension
services, waste disposal utilities or
companies, recycling centers, real
estate/financial institutions,
 Lincoln-Lancaster County, NE
 In 1994, th.6 Lincoln-Lancaster County
 Health Department published a  ;
 Contaminant Source Inventory Report
 that identifies groundwater related
 concerns and problems in the
 community^ Recommendations for
 ensuring a safe water supply were
 developed from that report and are
 being implemented with the help of a
' groundwater guardian team
 comprised of citizens, business,
 agriculture, education, and
 government representatives. They
 include the development of a
 "Groundwater and Environmental
'Pollution Self-Help Checklist" that
 farmers can use to-evaluate their use
 of water.- As an incentive, the health
 department will provide a1 free water
 inspection for all who complete the
^checklist; and the involvement of high
.school students in contaminant source
 inventories in an effort to educate '
 them about the importance of a sound
 w.ater supply. That checklist was so -
 successful that the liealth"department >
- developed a similar one for acreage  Jj
 •and xural home owners.,} f-  *  ;   f
 agriculture workers, public utilities,
 developers, consumers/advocates,
 local well drillers, state health
 departments, industry, large and
 small businesses,public health
 laboratories, local elected officials
 and advocacy groups.

 > Engage in ongoing outreach and
 education activities regarding safe
 drinking water, including
 campaigns targeted at communities
 that are disproportionately at-risk
 for unsafe drinking water.

              > Use regulatory and non-regulatory
              strategies, such as permitting,
              zoning, advocacy and interagency
              collaboration to safeguard drinking water.
                                    RESOURCES FOR ADDITIONAL INFORM ATION
League of Women Voters Education Fund
1 730 M Street, NW, Washington, DC 20036
202/429- 1 965. www.lwv.org\~lwvus

National Association of Counties,
440 First Street, N W,
Washington, DC 20001, 202/393-6226

The Groundwater Foundation
P.O. Box 22558, Lincoln,NE 68502-0558
402/434-2740, www.groundwater.org

National Drinking Water Clearinghouse,
West Virginia University, P.O. Box 6064,
Morgantown,WV 26506-6064,
800/624-83 0 1 . www.ndwc.wvu.edu
                                                                 U.S. Environmental Protection Agency
                                                               Office of Ground-water and Drinking Water
                                                        40 1 M Street, S W, (4602), Washington, DC 20460,
                                                               202/260-7077. www.epa.gov/owow/ogwdr

                                                                 U.S. Environmental Protection Agency
                                                           Pollution Prevention Information Clearinghouse
                                                              401 M Street, SW, Washington, DC  20460

                                                                                U.S. Geological Survey
                                                                      .            Branch of Distribution
                                                                     P.O. Box 25286, Denver, CO  80225
                                                                        800/426-9000 (Water Information

                                                                        Water Environment Federation
                                                           601 Wythe Street, Alexandria, VA 22314-1994
                                                                            703/684-2492. www.wef.org
   This factsheet and the National Association of County and City Health Official's (NACCHO's) Pollution Prevention
  Project are made possible through a cooperative agreement with the U.S. Environmental Protection Agency, Office of
 Pollution Prevention and Toxics. More information about NACCHO and local health departments is available, contact
     NACCHO, 440First Street, NW, Suite 450, Washington,DC 20001. Phone: 202/783-5550;Fax/202-783-1583
                                 Visit NACCHO's website at www.naccho.org            .
February 1997

       1 The Aquifer: Journal of the Groundwater Foundation. Vol. 10, No. 1. June 1995.
       2 The Aquifer. September 1995.
       3 U.S. EPA. Protecting Our Groundwater. May 1995.
       * The Aquifer. September 1995.
       5 Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Vol. 45, No. SS-1, April 12,1996.
       * The Aquifer: Journal of the Groundwater Foundation. Vol. 10, No. 2. September 1995.
       7 U.S Environmental Protection Agency. Technical and Economic Capacity of States and Public Water Systems to Implement
       Drinking Water Regulations: Report to Congress. September 1993.
       8 Water Environment Federation. "Nonpoint Source Pollution: You are the Key to the Cleanup." 1992.
       9 The Aquifer: Journal of the Groundwater Foundation. Vol. 9, No. 3. December 1994.