Session I: Promoting Healthy Behaviors and Safe Communities

DR. POTSIC: We are going to begin this session. Before we formally begin the commentary period, I was asked to hold this up and remind people that until 1:00 o'clock today, there are flu shots available for $10, and coronary risk assessment as well is available for $22.75.

It is done by a private organization, American Health Services. We thought it was kind of a neat component of prevention in action for the meeting as well.

It is only until 1:00 o'clock. As I mentioned yesterday, by coincidence, it is in the Hong Kong Room.

Again, good morning. I am Steve Potsic, the regional health administrator here in Chicago, covering the six states in the Midwest.

This session is promoting healthy behaviors and healthy and safe communities. We have nine focus areas, nine chapters, that we will hear commentary today.

Those sections are physical activity and fitness, nutrition, tobacco use, educational and community based programs, environmental health, food safety, injury and violence prevention, occupational safety and health, and oral health.

Again, in order to help assure a fair opportunity for everybody to participate, we will be using the same procedures as those used in the opening session.

For those of you who weren't in the opening session, let me briefly state what those procedures are.

First of all, each oral statement will be limited to three minutes. The light will turn yellow when you have one minute left, and red when the time is ended.

Second, each individual and organization will be limited to one oral statement for each chapter, each focus area.

Third, we will allow 20 minutes of comments for each chapter. That means we will hear about six or seven people probably at the most.

However, at the end of the session, if we get through all the chapters on time, and there is time remaining, we will allow comments, people to come back and comment, either to give general comments or give comments on focus areas that you were not able to comment on because of time limitations.

So, keep that in mind, that if we have to go to a next chapter, if there is time at the end, we will be able to take comments, because we will, in fact, stay until 1:00 o'clock, if necessary.

Again, we ask each of you to introduce yourself by name and state of residence. Also, please let us know if you are commenting on behalf of an organization or yourselves as individuals.

One of the very nice features here in these sessions is we have the individuals who had a major role in drafting this document to hear your comments.

Not only will this information be transcribed and be placed on the web site, but you actually have the opportunity for the individuals who have shaped this document and helped draft it, to actually hear your comments in person.

What I would like to do is, I would like to briefly introduce the individuals, so you see who they are.

Also, there might be some opportunity toward the end of the session, to come up and individually talk to them if time permits.

The first focus area -- maybe what I will do is take public commentary and introduce the individuals as we start the commentary.

The first focus area that we are going to begin hearing comments on, again, is physical activity and fitness.

We have two individuals here representing that area, Christine Spain, the President's Council on Physical Fitness and Sports, and Bill Dietz from CDC.

Both of these individuals -- Ms. Spain has been a member of the Healthy People steering committee and a work group coordinator for this area. Bill, obviously, has been much involved in his work at CDC. Those are the two individuals who represent this particular focus area today.

Now, those of you who would wish to comment on this focus area, please come up to the microphones. Anyone with special needs, please raise your hand.

We do have staff here who will be happy to give you a hand microphone, if you would prefer that.

Again, please state your name and state of residence. After the comments, it is very important that you go back to the table in the back to sign in, so that we have the correct name, the correct spelling, the correct organization, so that your comments can be acknowledged appropriately.

Let's begin the first section.

DR. BRIGHAM: Thank you, Dr. Potsic. My name is Dr. Dale Brigham. I am with the University of Missouri in Columbia. I can't say that I speak for all of my colleagues in the area of nutrition and fitness -- my academic area -- but I believe I might be voicing their concerns.

In Missouri, in particular, we are working to try to stop the epidemic of sedentary life style that is affecting the majority of Americans.

You probably all know here that only one in five Americans meets the CDC's guidelines for physical activities.

I believe you know that about, I believe, five of the leading 10 killers of Americans are amendable to, you might say, preventive care by physical activity but also worsened by a sedentary lifestyle.

Thus, I applaud the committee for their good work in providing so many fine objectives and indicators of physical activity and fitness for communities.

I would just like to make two quick comments. In Missouri, we have two major metropolitan areas, but mainly we have a rural population.

In particular, it is hard for people in rural areas, often, to find access to physical activity, since prosaic and seemingly simple things like sidewalk zoning laws or low cost fitness facilities are key to the access of physical activity for people in rural areas.

I encourage the committee, if possible, to come up with objectives or indicators related to local ordinances, or perhaps encouraging in ways beyond just school and work site based activities, indicators and objectives related to community physical activity access.

Secondly, physical activity and sedentary lifestyle, I should say, is more of a problem for people who have less money -- that is, they are poor -- less educated and people of color.

This is, in essence, an access or disparity issue, in addition to being an overall issue of public health.

Finally, I would like to just say that it would be wonderful if we could emphasize physical activity and healthy eating in the training of health professionals -- physicians, nurses, and other folks in the allied health field. I thank you for your time.

DR. POTSIC: Thank you. Please?

MS. PEARSON: Good morning. My name is Barbara Pearson. I happen to be the administrator for the preventive health and health services block grant in Nebraska.

The cardiovascular and physical activities people who are funded with block grant money asked me if I had a chance, to express their concern about the loss of objective number 1.11, about trails and fitness facilities, that were in Healthy People 2000, that don't appear in Healthy People 2010.

They say that they are concerned -- they would like to see it be at least a developmental objective, because there is some small regional data available to show the improvement in accessibility to facilities, particularly trails, in a rural state like Nebraska.

They wanted me to say that behavioral health is important, to talk about encouraging people to be more active, but the environmental aspects, of changing the environment so folks can behave in a healthy way, is equally as important. They would like to see that placed back in the set of physical activity objectives. Thank you.

DR. POTSIC: Thank you very much. Is there anyone else who would like to comment on the first focus area of physical activity and fitness?

MS. SCHROCK: My name is Karen Schrock, and I am with Adult Well-Being Services from Detroit. I would like to see a physical activity and fitness objective for older adults.

I think we have seen a lot of research lately that indicates there are tremendous benefits. So that I don't have to come up 16 more times, I will just say ditto for the other objectives.

DR. POTSIC: I wonder how that would be transcribed. Thank you. Any other comments?

Seeing no other individuals wishing to comment on this first focus area, we are going to go to focus area number two, or chapter two, which is nutrition.

Van Hubbard from NIH is here. He is a work group coordinator for this focus area. Are there any comments for the nutrition area?

MR. SMITH: Good morning. My name is J.P. Smith. I represent the American Society of Bariatric Physicians, a national medical society of doctors and allied health professionals who offer specialized programs in the medical treatment of obesity and associated conditions go to focus area number two, or chapter two, which is nutrition.

For those of you not familiar with the term, bariatrics is the branch of medicine specializing in the treatment of overweight and obesity.

Yesterday, Surgeon General Satcher told us that the Healthy People 2010's goals are moving in the wrong direction.

Maybe that is because obesity is not being regarded as the chronic disease that it is. From one-third to one-half of the American population is either clinically obese or overweight, and moving toward obesity.

There is a frightening increase in the number of obese children and adolescents, and many of these kids are developing adult-type conditions, such as type II diabetes.

Healthy People 2010's nutrition and diabetes goals and, to a lesser extent, the physical activities goals, address obesity to a limited degree.

Obesity is a multi-factorial chronic disease affecting millions of Americans. Obesity contributes to the development of diabetes, hypertension, cardiovascular disease, some types of cancer, and several other disorders.

Obesity can be debilitating, and often places a social stigma on its victims. The ASBP and other members of the obesity community believe that obesity itself -- not synonyms or the comorbidities -- should be recognized as a major public health problem in the United States.

Secondly, we believe that obesity should be addressed at the same level as smoking, because of its impact on morbidity, mortality, quality of life, cost and stigma.

Prevention of obesity, especially among children and adolescents, should be a national priority.

I am addressing this section and this chapter, because there is no other forum for obesity in Healthy People 2010. Thank you.

DR. POTSIC: Thank you very much. Any other comments on nutrition?

We are going to start focus area number three, tobacco use. I am sorry. Please.

MR. BORS: I am Phil Bors and I am from the North Carolina Department of Health and Human Services, state health department.

My comments really relate to physical activity and nutrition, and echo the previous comments on physical activity.

I would like to see more emphasis paid to environmental and community level objectives, walking trails, land use, planning that relates to sidewalks, bikeways and greenways, also perhaps state level objectives that relate to resource allocation related to these aspects.

For nutrition, I think we need to also consider community level availability objectives, such as foods actually served in schools, in cafeterias, foods served at school functions. The Kansas lean project that was presented yesterday gave some nice examples.

The restaurant environment, restaurants that provide low fat, high fiber menu items, and that market those items to their customers.

Specifically, within work sites, for physical activity and nutrition, I think that work site health promotion programs is too vague and it is probably pulling out the healthy vending machine options for nutrition and for physical activity, facilities for physical activity and time off for physical activity.

DR. POTSIC: Thank you very much. Any other comments on nutrition?

Okay, we are going to go to focus area number three. Theresa Rogers is here, and she is a member of the Healthy People steering committee.

Would anybody like to discuss tobacco use?

DR. OLDS: I am Dr. Scott Olds, from Kent State University, on the faculty of health education. One issue, I guess, that perhaps would be worth considering to include in the tobacco area is the issue of the diffusion of what we know already to be effective tobacco prevention programs for school-aged kids.

Predominantly the NCI has invested, as Carl Sagan used to say, billions but millions of dollars on trying to identify what we know can be helpful to prevent the onset, or delay the onset as well, of the initiation of tobacco use by children.

Yet, when we take a look at what is actually being used in schools around tobacco prevention, there is a tremendous gap between state of the art and state of the practice.

So, it might be worth while considering how we can try to identify an objective to try to encourage school-based programs to adopt those demonstrated effective programs.

DR. POTSIC: Thank you. We are now going to go to focus area number four, educational and community based programs.

Henry Montes and Catherine Hutsell are here. Henry is from HRSA and Ms. Hutsell is from CDC. She is a work group coordinator for this particular focus area.

Are there any public comments on educational and community-based programs?

MS. GILOTH: Hi. My name is Barb Giloth. I am from Chicago, Illinois. I am currently chair of the public health education and health promotion section of APHA, and a member of the Society for Public Health Education.

I would like to make four comments that we will reinforce with our Internet comments.

First, for this chapter, one of the problems and opportunities of this chapter is that it covers a broad array of areas.

We think there needs to be more attention paid to the definitions in the chapter, and to the consistent use of terms, not only in this chapter, but throughout the document.

For example, health education, which is defined early on as focusing on materials and structured activities, is a very limited definition.

We would suggest, for example, Greene and Kreuter’s definition, health education is any combination of learning experiences designed to facilitate voluntary actions conducive to health.

This also brings in the voluntary aspect, which we think is a very important part of the educational component of this chapter, as opposed to some of the health promotion activities, which are less voluntary in their nature.

We also think that linkages with these definitions need to be consistent throughout not only this chapter, but other chapters that have substantial components of health education, including the patient counseling activities in the preventive health chapters, and the health communications activities.

Secondly, in this chapter there is a very nice definition of the elements of the community health promotion program, which we think should be refocused to address all the programs encompassed by this chapter.

For example, patient education programs also need to have the participation of patients in the development of those programs, and that is not emphasized in the current way it is written.

Thirdly, with regard to the school-focused objectives, numbers two and four, we suggest that you include reference to these elements as part of a coordinated school health program, a comprehensive school health program, to maximize health and learning in schools.

There are eight components of a coordinated school health program that I won't reiterate here, but that have been well defined by CDC. I think they should be incorporated into this chapter.

Finally, objective number eight, which is regarding the increase in the percent of health care organizations that provide patient/family education.

With the current joint commission requirements regarding patient and family education, it is unlikely that you would find a health care organization that does not provide patient and family education.

We don't think this is a particularly focused objective. It would be helpful to consult with the joint commission as to what other data they have in an aggregate form regarding their survey visits, and whether or not they could provide information, for example, on the interdisciplinary nature of the patient education programs, the extent to which patient assessments for educational interventions are performed, or the extent to which outcomes are used in the evaluation of the programs. Thank you.

DR. POTSIC: Thank you very much. Would anyone else like to comment on the focus area?

MS. SCHROCK: I am Karen Schrock with Adult Well-Being Services in Detroit. I do want to say that with respect to objective 12, I think it is wonderful that the elderly are mentioned here in terms of participation in community health promotion.

My only reservation here is that the definition seems to focus on community-based, outside of the older person's home or other living setting kinds of activities.

You may want to review that. The reason I say that is that we are starting to do health promotion and health education to seniors in their homes, because many are not able to participate in broad-based community-wide efforts like that. I think those should be counted as well, but I am glad to see an objective for the elderly in here.

DR. POTSIC: Thank you. Any other comments for this focused area?

MS. LAMPERT: Hi. My name is Joan Lampert. I have been a school social worker for 25 years, both here in Illinois, and in Michigan.

I am also on the faculty at Northern Illinois University and National Lewis University, where I teach graduate level classes in teacher education.

I really want to comment -- I actually got this on Monday, so I was actually able to read pieces of it, and looked at the things that have been proposed.

I am delighted to see the decrease in the ratio for school nurses to students, to reduce that. I am also delighted to see that we might actually take our semester level class in the sophomore year and extend that to a full year of health education.

I have two comments I would like to suggest that we look at. One would be to collaboratively work with perhaps the NEA, of which I am a member, and those organizations that certify teacher education organizations, to look at the possibility of making it a requirement for certification in this country, but particularly at the secondary level, that teachers have access, or an opportunity to take a class, on the health risks and resiliency factors for the students whom they are going to teach.

As a social worker, I find often that people in my school don't know what students are dealing with outside of school, don't understand what the risk factors are in their community for drug addiction or early pregnancy or suicide or the other things, as a social worker, that I deal with.

The other thing would be, for a graduation requirement for high school students, to take not only that health class, which I think needs to be a year long, but also to look at taking classes on child development and healthy parenting, so that we can pick up on what was said in the open session about early detection, and how do you know if your child is growing well.

How do you know, when you take them to the doctor at six months, are they doing the kinds of things that they need to do.

If we can teach kids how to drive a car -- and that is what they have to have to graduate here in the state of Illinois -- I think we could teach them how to raise healthy kids. Thank you.

DR. POTSIC: Thank you. Does anybody else wish to comment on this area?

If not, we will go on to focus area number five, environmental health. Chris Kochtitzky from CDC is a work group coordinator for this focus area, and is here with us today to hear comments on environmental health.

It would be helpful if people would remember to go to the back of the room, to make sure that we have the correct spelling and your organization and affiliation, so that when we transcribe it and put it on the net, we have that information.

MS. MURI: I am Diane Muri. I am the public health administrator for the city of Racine, Wisconsin, which is located on Lake Michigan.

I would like to speak to the objective on beach closings, which is on page 5-10, lines 23 through 27, and also the objective related to fish contamination levels, which is on page 5-11, lines 19 through 24.

I have some concerns about both of these objectives, and I will start with the first one.

Basically, for the one related to beach closings, I think that we have poor research to back up current standards for beach closings.

We don't have any consistency in what people are using as measures for beach closings. It could be fecal coliform, it could be e. coli.

Basically, we need a much stronger research background in this area.

Just one general comment about the entire document, is that while we say on page 9 of this document that we are calling for sound scientific data to support all of the objectives, I don't really see any objectives related to research specifically.

I think there should be more of this, just in the document in general, that we do want to be a research, scientifically based discipline, and that we should have more in this document related to research.

The particular objective that is down here for beach closings, another concern is that it says that we want to reduce the number of beach closings.

I would suggest that if we had standards for beach closings that were well enforced throughout the United States, and everyone who should be testing recreational waters was testing recreational waters, we might, in fact, see these increase.

I think that this is not a realistic objective. I can make some more comments, too, on the Internet. But I would like to see some more work done on this objective, because I don't think it is too realistic, considering where we are.

Quickly -- I see the yellow light -- the last objective that I mentioned I wanted to address was reducing the fish contaminant levels.

My concern here is what are we doing in the meantime. If we want to try to reduce the level of toxins in fish, this is going to take us a while.

In the meantime, what is happening to people who are eating fish that is now contaminated? I think we should be, over the next 10 years, addressing that more directly.

I would like to suggest perhaps that we might want to tie this to WIC programs. Sometimes people of lower socioeconomic status are eating more fish that might be toxic.

I would just like to have everybody sort of re-think this objective, too. I think we have an ethical responsibility to do something about the people directly now, because it is going to take a while to reduce the contamination in the fish. Thank you.

DR. POTSIC: Thank you very much. Anyone else wish to comment on environmental health?

MS. FRADKIN: Hi, my name is Jolie Fradkin and I am from the School of Public Health at the University of Michigan.

At the University of Michigan, I am studying environmental health science with a specialization in water. Today I would like to address water quality issues.

Americans generally assume that the water from their faucet is healthy and free of bacterial and chemical contaminants that can cause disease.

Usually, this assumption is correct. The drinking water supplied to cities and towns in the United States rank in quality, on average, among the best in the world.

Nevertheless, there is cause for serious concern. The major findings from a public health service community water supply 20 years ago stated that 46 percent of the 26,000 individual tap water samples contained one or more bacterial constituent exceeding public health limits.

This study was done 20 years ago, but has water quality improved greatly enough to cause this research to be invalid today?

More recently, a study has shown that in 1994 the drinking water supply to 90 percent of the populations served by community water systems violated health-based standards at least once in a year.

Violations occur from coliform bacteria, radiologic contaminants, metals and other sources.

In 1998, according to USA Today, about 40,000 of the 170,000 water systems serving about 58 million people violated POT standards last year.

There are 11 states that have yet to implement all the safe drinking water act contamination limits.

With increased water regulations, the water system is gradually improving. Still, it is far from perfect, especially in rural areas.

These risks, as growth of the world population, accompanied by industrial and agricultural development, is creating heavy demands on our water systems everywhere, and forces us to continuously improve our water quality.

In addition, water quality demands on drinking water, deep or shallow well, or surface water, the water supplier, private and community wells, small or large municipal water systems, and what happens as the water travels from the source to a distribution system to a faucet should be a concern.

Recently, a growing awareness of the link between water borne pathogens, chemicals and disease outbreaks led to municipal entities in North America to institute various methods of drinking water primary filtration and chlorination, which largely succeeded in eliminating serious water related problems in the past.

Nevertheless, the organisms, chemicals and particles that caused problems earlier are still a threat to our society.

Drinking water treatment, theoretically, should remove all contaminants in water, or at least reduce them to acceptable limits.

In order to purify water, new systems are necessary to reduce chemicals and solids that could potentially harm or pollute our environment.

To accomplish this goal, the EPA along with other agencies had to set up parameters that will help us to identify water systems to become cleaner for human consumption.

The EPA has established a series of indicators to measure our progress in improving our water systems. To reach these goals, we must indicate the source of problems that cause our waters to be contaminated.

To do this, we must map out what contributes to the impurity of our drinking water and how these elements can be changed. This is not a simple process, by any means.

As the 20^th Century draws to a close, enormous water quality challenges confront societies worldwide. Around the globe, in developed and developing countries alike, unrelenting human pressures on the environment have created unprecedented water quality challenges.

Confronting these challenges will be expensive and will require the government, consumers and water management teams to work together to accomplish better drinking water for all.

This will require us to educate the public about safe drinking water and have water officials who have experience in the area of water treatment.

It will also require stiffer regulations on water quality with consequences for those who violate the standard limits set up by the EPA.

Nevertheless, the importance of clean water to all human well being is crucial. So, we have no other choice but to make this effort.

DR. POTSIC: Thank you very much. I appreciate that. I was going to ask a question -- who is going to win the Penn State game?

Would anybody else like to comment on environmental health? Maybe before you start, sir, we do have a number of people standing in the back and there are a number of seats in the front. Why don't we take a minute and people who would like to sit down -- this is potentially a long session -- can come up and be more comfortable. Please.

MR. ERICKSON: Keith Erickson, director of the Lynne County Health Department, Cedar Rapids, Iowa. I want to direct objective 20, which has to do with reducing deaths and non-fatal poisonings from carbon monoxide.

I would like to see suggested in this objective perhaps a strategy for doing that. What I am suggesting as one possibility would be carboxyhemoglobin screenings at trauma centers.

I am suggesting that the elderly that present themselves to trauma centers, particularly in the morning, be routinely screened for carboxyhemoglobin. I am not talking about blood tests. I am talking about a Breathalyzer, and then a protocol that would trigger a blood test depending upon the level.

We instituted such a program in our county. Both hospitals agreed to do this without charge. I can tell you, the second person who was screened, we determined a high carboxyhemoglobin.

We had a protocol that called for the hospitals to notify the utility that went into the home, found a plugged hot water heater, collected same. This same person would have been sent home before.

Another example, we had a farmer who was found lying on the ground outside a shed. He was able to dial 911, was taken to the ER. They thought he had a stroke, were treating him for same.

Because of the protocol, they did screen him. He had a carboxyhemoglobin of 50 percent. He was removed to the hyperbaric unit in Iowa City, but this would not have been caught, had it not been for this screening.

So, it is not enough just to say we are going to reduce something 15 percent. We ought to suggest within that objective how we might accomplish that.

I also think that the number is greatly understated, about 5,000 non-fatal cases in 1994, when I have seen the dozens and dozens of cases in a small jurisdiction like mine, and the same with deaths.

Again, I have seen in my jurisdiction six deaths in the last year from carbon monoxide in car washes.

You know, all these car washes have signs posted, close the door when you wash your car. We have had several people go down. Why don't they say, open the door.

DR. POTSIC: Any other comments on environmental health?

MR. ROBERTS: Daryl Roberts, Missouri Department of Health, Jefferson City, Missouri. I would like to talk about the objectives on page 521 on infrastructure.

They predominantly relate to various types of chemical exposures and compounds. Unfortunately, many states and even fewer localities have the ability to assess for the compounds that are listed here.

The CDC, although they have got the capacity, the capacity is extremely limited right now. Even to the 2010, I don't see that capacity increasing greatly.

I think what you need to do is either consider a capacity development objective, and reduce these down to other types of strategies, or take these out altogether.

I don't see any state in the nation, or anywhere, being able to assess acute dioxins. The cost of dioxin at CDC is $1,200 a sample, and there are 22 variables that are listed under item 23.

To have that done like by Midwest Research Institute in Kansas City is $5,000. Unless you can come up with capacity development -- these are very important; don't get me wrong.

I think they are very important. I think they are needed. But I think a capacity development strategy is necessary. Thank you.

DR. POTSIC: Thank you very much. Anyone else wish to present comments on environmental health? Okay, we will go to the next focus area, which is food safety. Darlene Bailey from the FDA is here to hear your comments. Any comments on food safety?

Did you all enjoy the food quality that was here? [Laughter.] It is not quite lunchtime yet.

Okay, seeing no one who wants to testify on food safety, we will go to the next focus area, which is injury/violence prevention. Tim Groza is here from CDC, and he is a work group coordinator for this particular focus area, injury/violence prevention.

MS. STONIS: Hi. My name is Nancy Stonis. I am from Park Ridge, Illinois. I am from the Emergency Nurses Association and am currently employed there, and I am representing them. I am also an emergency nurse.

During the construction of the initiative, the Emergency Nurses Association was asked to look at violence and abuse, and they had proposed several different goals.

One goal has not made it in there, and I just wanted to read what that goal was, and make a recommendation to include that goal.

First of all, I would like to start with, ENA commends the work that the Healthy People 2010 consortium has done thus far.

As an organization acutely aware of the violence and abuse issues in the United States, ENA supports the Healthy People 2010 goals to review the effects violence and abuse have on the United States population.

ENA strongly supports wording in goal seven to include the need for forensic evidence collection for victims, both male and female, of sexual assaults.

ENA would like to see the following goal added to the objectives, and to the goals already listed.

That would be: Increase the number of victims of abuse, sexual assault, and/or intimate partner abuse who receive forensic evidence collection by trained professionals.

MR. PICKARD: Steve Pickard. I am an epidemiologist with the Kansas Department of Health and Environment.

I was a little disappointed. Maybe I should start by saying that, I am not sure -- I normally judge the quality of a book by its index, and I don't think I found the index in this. So, if I missed it, I am sorry.

I was a little disappointed that there was no youth violence objective about bullying, not that I know that it is proven that it is an antecedent of more serious violence, but more because it is a substantial hit on the esteem, the safety of children, the enjoyment of children of school.

When I hear about physical activity in school, I shiver, because that brings up the images of bullying in school that I am familiar with, as a young person.

I know it is very difficult to define the area, but because of the quality of life of children, I would like it to be considered by itself as an issue, and certainly with the possibility that it may yet prove to be a very substantial indicator of more violent events that develop in schools. Thanks.

DR. POTSIC: Thanks, Steve.

DR. ORSAY: Good morning. My name is Elizabeth Orsay. I am an emergency physician. I am with the University of Illinois. I am here today representing the Society of Academic Emergency Medicine.

This society is an organization that represents the teachers of our future emergency physicians, as well as the researchers, trainers and faculty who are interested in the pursuit of knowledge and the promotion of emergency medicine.

I would like to commend the panel on the work that has already been done on this draft. I know it was a Herculean effort to put this all together.

My comments specifically refer to objectives number 25 and number 26 in chapter 7, and that is regarding bicycle helmet use.

For goals of that objective, I would recommend adding the verbiage that would increase the proportion of public and private school districts that require bicycle helmet use for children who ride to and from school, and the same for the 9^th through 12^th graders riding to and from school.

The reason I ask is that schools teach much more than reading, writing and arithmetic. Rules of conduct, ethics, morals and healthy behaviors are lessons for life that are learned in school and last throughout life.

Schools can set a standard in the community, and by enlisting the active support of the schools, we get the community participation that is so desperately needed when trying to implement injury reduction measures.

This helmet requirement for school travel represents a little bit more palatable approach than the mandated helmet legislation.

In this particular state, I have worked hard to try to get motorcycle helmet legislation for motorcyclists, and it is a tough order.

This is a much more grass roots oriented approach. It conveys a message of concern in safety for our children who are traveling to and from school, and less of a government order.

It is also limited to school travel. These same habits for helmet use may be continued in other recreational bicycle use and as they grow older.

In general, for all these violence and injury reduction objectives, the use and participation of churches, schools and other community organizations would help ensure the success and active participation of the community. Thank you.

DR. POTSIC: Thank you.

MR. AMUWO: Good morning. My name is Shaffdeen Amuwo. I am associated with UIC School of Public Health. I wear many hats, but this morning my hat is professor of community health sciences.

I teach the only course that focuses on the public health context of family violence. I really appreciate the efforts that were put into the preparation of this document regarding the area of violence.

However, I noted that on, I believe, objective number 41, in which that states reduce the rate to 15 percent the prevalence of weapons carried by adolescents nine through 12, what I have noted in my study -- I am also a principal investigator of a fairly large prevention project called African American Youth Behavior Project.

What I noted in my research is that the number of kids that are actually carrying weapons increased substantially in lower grades, lower than nine years old.

If you look at some of the more dramatized incidents in the past couple of years, you have noted that many kids under age nine do carry weapons.

I am appalled that in this document there is not one objective that intends to reduce the number of weapons being carried by children below grade nine. That needs to be addressed.

The other area has to do with spousal abuse. Throughout this document, there is no mention of spousal abuse of familial partners.

Quite a number of data quite substantiate the fact that this is really on the rise. Somehow the recognition of that has to be made, and objectives relative to that need to be developed. Thank you.

DR. POTSIC: Thank you.

DR. KIRSCH: I am Dr. Tom Kirsch with the American College of Emergency Physicians. We represent 18,000 emergency physicians nationwide.

On a personal note, I would like to further emphasize the importance of Dr. Orsay's recommendation regarding the use of bicycle helmets.

The comments I would like to make are two-fold.
One of them is in reference to recommendation number nine, which is to reduce emergency department visits caused by unintentional injuries to no more than 111 per 1,000 people. Our college is firmly in support of this recommendation

The addition that I would like to add to this is that the DEEDS project, or the data elements for emergency departments, be used as a potential data source.

This is a project that was developed jointly with the CDC and the American College of Emergency Physicians and the Society of Academic Emergency Medicine to collect better data.

As I am sure most people are aware, there are more than 100 million visits to emergency departments annually. Almost 25 percent of these are related to injuries.

Clearly, delivering this much care to 25 million victims of injuries annually would provide an excellent data source for meeting this specific target, as well as some of your other targets in the recommendation. Thank you.

DR. POTSIC: Thank you very much.

MS. LAMPERT: Again, I am Joan Lampert. I have been a school social worker for a while. I didn't mention before, because it wasn't germane there, but my research area of interest is that of gender and bullying.

In the spring I will be a post-doctoral student at Harvard's post-graduate, continuing the work that I began for my dissertation.

I really want to comment on two things that have been discussed here. One is to support the idea that school bullying is absolutely a precursor to a number of other issues that students need to deal with.

Dan Alvais(?), who is a professor of psychology at the University of Bergen, has found that for two-thirds of the young people who have been labeled as school bullies in elementary school, by the time they are 23, have a felony conviction.

I think it is very important to extend the work to look at school aged bullying, if that is possible.

Second, I want to ask why, when we are looking at sexual assault or forced sexual intercourse, we are limiting it to children aged 12 and older.

When we are talking later on in the document about physical assault, why are we limiting it to children aged 12 and older, when it is my impression that a number of young people, particularly girls who experience incest, it is when they are eight or nine.

That doesn't seem to be addressed in the document. I would ask you to take a look at that and extend it to children who are younger than the age of 12. Thank you.

DR. POTSIC: Thank you. Anyone else wish to comment on injury/violence prevention?

DR. RHODES: Hi. I am Karen Rhodes. I am an emergency room physician at the University of Chicago. I have been working in emergency medicine for 15 years.

I am concerned that in terms of objectives 34 through 38, which are excellent objectives, which target reduction in family violence, that there has been left out a process-related objective that was in the Healthy People 2000.

It read: Extend protocols for routinely identifying, treating and properly referring suicide attempters, victims of sexual assault, victims of spouse and partner violence, elder and child abuse, to at least 90 percent of hospital emergency departments.

It is my understanding from reading the document that this was left out of Healthy People 2010 because it lacked measurable data sources.

This is a real concern. It is true that levels of emergency department identification of intimate partner abuse remain without baselines or consistent tracking systems.

However, I would like to request that it be reinstated as a developmental objective, and give us another chance to look for some potential data sources.

I would like to propose that the joint commission on accreditation of health care organization routinely reviews protocols in this area, both hospital-wide and emergency department, which I think are both necessary.

The primary care provider survey could be expanded to include emergency physicians, and put in elements finding out if they have a representative survey, and targets could be set for that.

In addition, the DEEDS data base, which was mentioned earlier, would be a possibility, and even screening consumers, I understand there are some data bases screening consumers, about whether or not they have been asked about healthy behaviors.

This could also include whether or not they have been screened for family violence. That would be my recommendation, and thanks for all your hard work. You guys do a great job.

DR. POTSIC: Thank you. Any other comments on injury and violence prevention? Okay, we are going to go to the next area of occupational safety and health. Theresa Rogers is also here representing this area from CDC. She is a member of the Healthy People steering committee.

MS. CLARK: Hi, we are addressing occupational safety and health, because that is the only place in the document we found latex allergy.

It is impacted with environmental health, preventable unintentional injuries, and food safety and oral health.

MR. CLARK: My name is James Clark from Illinois. I am nine years old and I have food and latex allergies.

Last summer, I took one bite of a salad at a restaurant and I started to have an anaphylactic reaction. My throat started to close and I could not breathe well. We discovered the salad had been made using latex gloves.

Almost every ambulance and emergency room in America uses powdered latex gloves, which could kill me if I am touched by latex or breathe latex protein that is carried on glove powder.

Even if emergency services have non-latex gloves available, if their glove of first choice is latex, they may injure me, because they may not know that I have latex allergies until it is too late.

Many people do not know that they have latex allergies. That is why emergency services nationally should be completely latex safe.

Biomedical providers should only use low allergen, powder-free latex gloves, or powder free non-latex gloves throughout their facilities.

Food services and housekeeping should never use latex gloves.

I need your help receiving access to safe medical care. When my parents have asked hospitals to switch gloves, we have been told that the cost is too much and that doctors like the feel of their latex gloves.

That doesn't seem fair to me. What are my rights as a patient? Please help those of us with this disease and help stop others from getting this disease, by making medical care providers switch to safe gloves. Thank you.

[Applause.]

MS. CLARK: Good morning. My name is Ann Clark. I am from Illinois. My son, James, is nine years old and has food and latex allergy. We do not have access to safe medical care.

The American College of Allergy Immunology has declared latex allergy to be at epidemic proportions. Researchers estimate 2.8 to 18 million Americans suffer from latex allergy.

Our family supports the recommendation of Healthy People 2010's draft concerning latex allergy. We would like to see 100 percent compliance of health care facilities using low allergen, powder-free latex gloves and powder-free non-latex gloves.

Medical research has shown that latex protein aerosolizes when powdered latex gloves are used. Anaphylactic reactions have occurred from breathing air contaminated from powdered latex gloves.

Because of the danger imposed by air-borne latex allergens, we would like to see the recommendation expanded to include 100 percent of emergency medical service providers and 100 percent of emergency departments be latex safe, meaning that only non-latex gloves and non-latex medical supplies be used in this area.

We would also like the draft to include the recommendation that food service and housekeeping never use latex gloves.

Up until now, the thrust of latex allergy education and changing the medical community has been driven by workers' health and occupational issues.

Attention must now be paid to the needs of consumers as well. Patients and workers are protected by the Americans with Disability Act, or the ADA.

On October 23, 1997, the civil rights division of the U.S. Department of Justice obtained an ADA settlement and consent agreement from the La Petite Academy, Inc.

La Petite Academy, Inc., which operates more than 750 day cares nationwide, changed its policies to require day care staff to administer epinephrine to those children who experienced life-threatening allergic reactions.

This set a precedent that life threatening IGE mediated allergies are a disability. Legal challenges from consumers will establish that under the ADA, the only option that medical facilities have is to safely accommodate persons with latex allergies.

Patients and workers have the civil right to reasonable accommodations in all public facilities. In the documentation I submit to you today, are many recommendations calling for the use of low allergen powder-free gloves, and powder-free non-latex gloves, from such esteemed organizations as NIOSH, the CDC, Emergency Nurses Association, the American Nurses Association.

These calls are not being implemented in a timely, thorough fashion. Latex allergy is a serious public health issue. Thank you.

DR. POTSIC: Thank you. Are there other comments on occupational safety and health?

MS. LEX: I am Louise Lex and I am the coordinator for Healthy Iowans 2010. I have no comments about the content of the health objectives in this chapter, but only a commendation to Janice Klink.

We discovered, when we were pulling together the teams for Healthy Iowans 2010, that there had not been any coordination with the Labor Department.

That presented a multiple problem because evidently the Labor Department had asked the various states to comply with the GPRA regulations that conflicted, in effect, with the proposed plan for the Healthy People 2010.

As I understand it, that has been resolved. As a result, at the state level, we have been able to work very effectively with our labor division and, of course, the OSHA requirements that they have to comply with.

I did want to say publicly how much I appreciated that amount of work that put together that coordination and collaboration at the federal level.

DR. POTSIC: Thank you. Any other comments on occupational safety and health?

Okay, we will go to the next focus area, focus area nine, oral health. Delores Malvitz is here from NIH to hear the comments.

DR. CRAWFORD: Thank you. My name is John Crawford. I am at the University of Illinois College of Dentistry.

Firstly, I would like to compliment the team that prepared the oral health objectives. I have nothing to say about most of them, but I would like to make a comment about number six, which is the gingivitis objective.

I assume that this objective, handling gingivitis, is on the assumption that gingivitis leads to the more destructive disease, periodontitis.

This relationship is actually very complex, and the complication is illustrated by the progress made since the last set of objectives, in which it is stated that progress toward reducing gingivitis is going the other way, i.e., mouths are getting dirtier, but the progress toward reducing destructive periodontitis is actually improving.

It illustrates the two objectives which presumably are toward more healthy people are moving in opposite directions, and if they are linked, this is inconsistent.

The other thing I would like to say is that I think our objectives need to be more emphatic in the area of elderly oral health.

In one of the objectives, we allude to the number of people who have visited a dental health provider in the last year. One of the objectives is to increase the number of people having oral screening exams.

With the oral screening exam to reduce the incidence of oral cancer, we are going to have trouble in reaching the elderly population.

The elderly population sometimes are edentulous. The assumption is that if you don't have teeth, you don't need to go visit a dentist.

Obviously, if we are going to be increasing oral screening for cancer, this is the one group that is the most susceptible to that problem that we have to reach.

It is a public health access problem and it is an elderly problem, and I think the objectives need to include a more strict emphasis on the elderly patient. Thank you.

MS. DAVIS: Margaret Davis of the Southside Health Consortium, Healthy Start Southeast, as well as the Chicago Chapter of the National Black Nurses Association.

Under oral health, we are concerned about periodontal disease as it relates to low birth weight infants.

In our state, as in many states, Medicaid does not pay for dental care beyond the age of 29. That is a severe barrier to the quality of oral health for people of color and other immigrant populations in our states.

In addition, we would advocate for dental sealant programs for our children. Right now, many communities are implementing that. It is not a statewide initiative.

That will do a lot of good at reducing decays and caries in our young population. Hopefully, if that is implemented, we will see people living longer with a better quality of life with a full set of teeth, as they reach their geriatric status.

DR. POTSIC: Thank you.

DR. LAMPIRIS: I am Dr. Lew Lampiris. I am chief of the division of oral health for the Illinois Department of Public Health.

I would like to recommend that a new developmental objective be created, to increase the proportion of community-based dental sealant programs by a certain percent. I think I just had a lead-in into this actually.

Community based dental sealant programs assure access to preventive oral health services for those children for whom we are most concerned.

This population-based intervention allows services to be provided through a dental delivery system that overcomes many of the access barriers encountered by those children most at risk for dental decay -- finances, manpower distribution, transportation to the dental office, and lack of education among care givers.

Such programs have been shown to be effective, and support of such programs as an objective can positively impact several of the other Healthy People 2010 oral health objectives.

This new objective may be more realistic than the proposed oral health objective number 15 on page 918, which reads: to increase to a blank percent the proportion of school-based health centers with an oral health component.

Community based dental sealant programs, by their very nature, can be quite mobile, and multiple schools may be served by one such community-based program.

Proposed objective number 15 limits you to just one geographic site, one school. That is my first recommendation.

I also propose that we re-institute Healthy People 2000 objective number 13-11, to increase to at least 75 percent the proportion of parents and care givers who use feeding practices that prevent baby bottle tooth decay, or perhaps create a new developmental objective, to decrease the number of infants and children by a certain percentage diagnosed with early childhood caries, formerly known as baby bottle tooth decay.

To deny the disproportionate and profound that early childhood caries has on children, due to the controversies regarding its etiology, is paramount to throwing the baby out with the bath water, even if that water is fluoridated.

Several prevalence studies in our state indicate that 11 to 17 percent of our Head Start children suffer from what has been called baby bottle tooth decay.

The name of the disease may be controversial. The causes may be uncertain. Nevertheless, the severity and the damage it causes, and the cost -- both financial and emotional -- associated with its treatment can be profound.

Data needs to be collected regarding prevalence, and interventions need to be encouraged that have been shown to be effective.

Finally, as oral health is integral to health, the following chapters of Healthy People 2010 need to have a linkage. Currently, they do not mention oral health as a linked focus area: nutrition regarding caries experience, untreated dental decay, root caries, tooth loss, screening and counseling of children, exams for those in long-term facilities.

Tobacco needs to be linked to oral health objective number seven, periodontal disease, adult use of the oral health care system, school-based health centers, community-based health centers, screening for oral pharyngeal cancer, maternal, infant and child health -- again, I was just fed into this one -- needs to be linked to periodontal disease and to adult use of the health care system.

Arthritis, osteoporosis, chronic back pain can be linked to no tooth loss and to the adult use of the oral health system.

Diabetes should be linked to oral health objective seven, periodontal disease. Heart disease and stroke should also be linked to periodontal disease.

HIV disease should be linked to periodontal disease, adult use of the oral health care system, and screening for oral and pharyngeal cancer. Thank you.

DR. POTSIC: Thank you very much. Any other comments on oral health?

Okay, that is the last of our focus areas. So, I would like to open up the session for anyone who has any other general comments that they would like to make in this process. Feel free to do so at this time.

MR. PICKARD: Steve Pickard, Kansas, Department of Health and Environment. Just a couple of general comments.

One, in writing Healthy Kansans 2000, one of the problems that came up over and over again was the lack of data systems in the state which were the same as those at the federal level.

This meant that basically many objectives had to be rewritten because the questions and surveys were asked differently, and there is no comparable data from the state to the federal level.

Some of this is unavoidable. I think that, where possible, choosing things that can be reduced down to the state level is helpful.

The other place it might work is that there needed to be some work done by HHS on model standardization for healthy states.

Not only is it not comparable from state to federal, there is not much comparability from state to state.

No state has access to all however many there are healthy state 2000 documents, or 2010. So, finding some level of standardization or recommended best practice or whatever, and helping states put together their own objectives and what they might monitor in common might be a very helpful process.

While Healthy People 2000 was very helpful, and I am sure 2010 will be, too, there just are too many differences in state data systems.

The other thing relates to the age adjustment issue, and I am not sure what the final result is going to be.

I understand that all the values will be re-calculated for a year 2000 age adjustment once the Census data is in; is that correct?

I hope there will also be some consideration for also at least including some tables that give a comparison to the old values, since there is no census data yet.

It is going to kind of slow down the process. It is also going to mean a lot of work for the states to go back and also do all their recalculations using the 2000 model.

If possible, if you could give tables that include what was it, 1940 was the old reference standard, including that as well would be helpful for those states who wish to retain it. Thanks.

DR. POTSIC: Thank you.

DR. OLDS: Good morning. I am Scott Olds from Kent State University. I have a comment that probably would be best directed toward the educational community based programs, although it is certainly open for discussion, perhaps even beyond this room.

NIH, as you know, is investing huge sums of money in the human genome project. Specifically, one area of interest to me is the COGA initiative, which is looking at the genetic relationship of alcoholism.

That then begins to raise issues about screening issues, particularly around genetic screening for alcoholism.

There really has been very, very little -- in fact, in the review of the literature, we couldn't find anything that has been done that has taken a look at some of the psychosocial implications of genetic screening around these kinds of issues, particularly specifically around alcoholism.

It seems as though the engine is moving down the track, that this COGA initiative and human genome project is going to happen; there is no doubt.

I don't know that enough thought has been given, how do we translate that information? Should those markers be identified for alcoholism and the genetic screening test get created. I think that will happen, as we look into our crystal ball.

What implications does that have for communicating that information to, I would suspect, a populous that is probably not much interested.

So, here is this huge investment. A genetic screening protocol might get created for people who aren't really interested.

So, what implication does that have for us as public health professionals? Whose obligation is it to communicate that information? How do we best communicate that information? I think there are lots of implications.

DR. POTSIC: Thank you.

DR. STIDWILL: I am Barbara Stidwill, a board member for Suicide Prevention Services in Aurora, Illinois.

In regard to the objectives on the educational and community based programs, I believe there needs to be an objective added to provide suicide awareness and prevention programs within schools and communities.

Many of our young people -- most of them see their teachers for more hours per day than they see their parents.

Many, many educators are very unaware of indicators that they could flag. I am not suggesting that educators be de facto clinicians. I do believe that there needs to be a much greater awareness, and much more programming in the public school.

The current rate of suicide among young people is at least 13.5, 14 per 100,000 per year. Then we are talking about at least six of what we call survivors, family members and friends who are affected for the rest of their lives by this suicide.

We are also not including the suicide attempts that occur and, for young people, it is at least 25 to one, probably more, for young people's attempts.

That is a tremendous problem. It is a growing problem and I think that we need a special objective to address it. Thank you.

DR. POTSIC: Thank you very much. Are there any other general comments?

MS. LEX: I am Louise Lex with Iowa, the Healthy Iowans 2010 coordinator. I would like to just underline what Steve Pickard said this morning.

We are going to have to make some major adjustments in 2000. It would be immensely helpful if we did have some help on that. Run down by state, I would really appreciate that.

DR. POTSIC: Good suggestion. Any other comments?

I would like to first of all thank all of you for the comments that you have presented. These have been very helpful and I am sure they will be given great consideration as far as the continuation of the development of this draft.

I would also like to thank all the representatives here today, who are representing all the different focus areas, and your time and your energies on this.

I not only heard the public comments of appreciation, but I have heard many private comments as well, about all your effort and help in delivering a document that will take us into the next century. I appreciate all of you.

The comments, as we have said, are going to be recorded, and a transcript of this session will be posted on the Healthy People web site.

In addition, there will be public hearings held in two other locations, on December 2 and 3 in Seattle and December 9 and 10 in Sacramento.

Comments received today in other hearings, along with the written comments will be reviewed and used to finalize the national health objectives for the year 2010.

I invite all of you to continue participation in this process by submitting additional written comments and by communicating with those responsible for the areas of interest. Those names are in the draft document.

With that, the session is closed, and I thank you much for your participation.

[Whereupon, the session was adjourned.]

Chicago Transcripts and Summaries