Developing environmental health indicators as policy tools for endemic fluorosis management in the People's Republic of China.

Drinking groundwater containing naturally occurring elevated concentrations of fluoride has given rise to extensive dental and skeletal fluorosis affecting many millions of people in China. This paper describes three sets of indicators useful for environmental and human fluorosis management purposes, namely, descriptive indicators (the past), response indicators (the present) and performance indicators (the future). Each of the sets of indicators was further detailed following the Organisation for Economic Co-operation and Development (OECD) pressure-state-response model modified to include an impact parameter. But as managers need more aggregated information to summarise monitoring data, two indices were constructed from identified indicators, namely, a four component (indicators) 'health impact index', and a three component (indicators) 'management capability index'. Data from 14 provinces and autonomous regions were used to illustrate the application of the two indices. Results showed major differences in the values for the indices for management actions and human health outcomes at the provincial level. Provinces with a low management capability index, for example, Inner Mongolia, had a high health impact index, while provinces with a high management capability index, for example, Shandong had a low health impact index. It was concluded that a greater emphasis should be given in China, not just to monitoring fluorosis occurrence, but to the development of indicators and indices that empower decision-makers to initiate strategies to more effectively manage this major endemic disease.