Transcript of the Healthy People 2010 Regional
Meeting
New Orleans, Louisiana
October 21-22, 1998
U.S. Department of Health and Human Services
Office of Disease Prevention and Health Promotion
Session II:
Improving Systems for Personal and Public Health
MS. BOWERS: Let’s get started. I am Mary Bowers and I am in the regional office in Dallas, of U.S. Public Health Service Office of Minority Health.
This is the session on improving systems for personal and public health. We will be hearing your comments on Chapter 10, access to quality health services.
Under that are some subtopics, preventive care, primary care, emergency services, long-term care and rehabilitative services, chapter 11 family planning, chapter 12 maternal, infant and child health, chapter 13 medical product safety, 14 public health infrastructure, and 15, health communication.
First, each oral statement will be limited to three minutes, so that we can hear from the greatest number of participants. There are not a lot of us here, so we should do okay.
The light will turn yellow when one minute remains and red when your time is ended.
Second, each individual or organization will be limited to one oral statement for each focus area.
Third, we will allow for 20 minutes of comments for each focus area. Those are the chapters and subchapters that I have mentioned.
If time permits, at the end of a concurrent session, the floor will be open for general comments.
I will 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 as opposed to yourself as an individual.
Before we get started, I am going to introduce our experts on each of the chapters, and I do have that someplace.
For focus area 10, access to quality health services, we have Paul Nannis, who is with HRSA. He is a member of the Healthy People steering committee.
For focus area 11, family planning, we have Evelyn Kappeler. She is with the Office of Public Health and Science. Evelyn, as well, is a member of the Healthy People steering committee and is a work group coordinator for this focus area for the Healthy People steering committee.
For focus area 12, maternal and infant health, we have Stella Yu, who is with HRSA. Stella Yu is the work group coordinator for this focus area.
Focus area 13, medical product safety. We have a representative from the Food and Drug Administration, and I must admit I don’t have her name.
MS. PARISH: It is Eileen Parish.
MS. BOWERS: Thank you, Eileen. Welcome.
Focus area 14, public health infrastructure, Pom Sinnock, with the Centers for Disease Control and Prevention. Pom is a work group coordinator for this focus area.
Last, for focus area 15, health communication, we have Evelyn Kappeler again, with the Office of Public Health and Science. Again, she is a member of the Healthy People steering committee.
Once you give your comments, please sign in at the back of the room, so we will have a formal list of who made comments. Are we ready to begin?
If we are all here and we are ready to begin, then the mike is open for comments. We are starting with the first chapter, access to quality health care.
MS. RICHARDSON: My name is Dr. Lynn Richardson and I am an emergency physician. I am here today on behalf of the American College of Emergency Physicians.
The emergency department is a unique and important perspective from which to view the public health and health care delivery systems.
From infants to centenarians, male and female, the victims of violence, heart disease, trauma, asthma, poisoning, infection, diabetes, stroke, AIDS, STDs, mental illness, they are all part of my practice as an emergency physician.
As a provider who sees the most critical manifestations of disease and injury, I have a tremendous appreciation for the importance of preventive and primary care.
I am proud of the role that the College of Emergency Physicians has played over the last two years in developing many of the Healthy People 2010 objectives. Nowhere have we worked harder than in the area of access.
We strongly endorse objective 10-A.1. No other single objective will contribute more to the goals of health for all than universal health coverage.
For the disenfranchised, the emergency department is often the only accessible source of health care. We are the providers of last resort, a safety net.
Emergency care has stood alone as being always available until the emergence of managed care. Over the past few years, we have seen attempts to bar the doors to emergency departments.
Those who are being denied access to emergency care, sometimes with disastrous results, are not the uninsured, whom we continue to care for.
It is the unsuspecting clients of managed care companies, who are facing delays and denials of emergency care, as their cost conscious gatekeepers erect financial and administrative barriers.
The American College of Emergency Physicians was instrumental in the development of 10-C.2, which mandates access to emergency care.
Unfortunately, last minute wording changes to objectives 10-A.1 and 10-C.2 obscure the problems of managed care populations and denies the long role of emergency departments in providing access to the uninsured.
We were puzzled and disappointed by these wording changes and dismayed by the unresponsiveness of the access group coordinators to our deep concerns.
We ask that the words, emergency care, be removed from the first sentence of the support statement of objective 10-A.1, as well as by the words, by their insurance status from 10-C.2, and the unsubstantiated and dangerous assertion that the uninsured face barriers in the emergency department be removed from the 10-C.2 support statement.
Thank you. I will be providing written comments with these wording changes in detail.
MS. BOWERS: Thank you. Any further comments on chapter 11?
DR. AIKEN: My name is Dr. James Aiken. I am faculty with LSU Emergency Medicine, and I am also an officer with the local parish medical society.
I echo the comments that my colleague, Dr. Richardson, just spoke about. I would like to also address how some of these changes might be effected.
As I said a couple of times yesterday, I think it is critical, and access, of course, does imply a local response that we remember that it is the local health care providers that will be crucial in effecting any changes that go on.
In fact, outside of the public health arena, there are a number of resources that can be utilized. The private health care providers are here to help you.
It was a little surprising that that was a point that was not brought up very often in the discussions that I was a part of yesterday.
I would like to reiterate that those of us -- while I do operate primarily in a public hospital setting, I do have a great deal of experience in the private sector.
Emergency medicine is a very, very valuable resource in getting to the people that we want to get to.
I would like to congratulate the focus and emphasis that this conference has taken toward the idea that health is the issue and not necessarily disease or sickness.
Again, getting back to the access issue, this is an area of medicine where there can be no disagreement, that everybody has a right to health care, and everybody has a right to health care based on what they feel are their needs. Thank you very much.
MS. BOWERS: Thank you. More comments on chapter 10?
Let’s go on to chapter 11. Let me say this. If others come in and we have time at the end of going through all the chapters, and if you think of something else to say on access in chapter 10, then we can come back to that.
Chapter 11, Family Planning. Comments?
MR. SMITH: Good morning. My name is Donnie Smith. I am with the Arkansas Department of Health, but speaking as an individual today.
I think one of the critical elements for all the chapters is the ability that the data can actually correspond to data that is available at the local level.
In looking at the objectives for family planning, many of those are based on national surveys for which we have national data, but even at the state level, our data is not perhaps that great, particularly in smaller states. Certainly there is no corresponding data at the community level.
If the 2010 objectives are to be more than a bookshelf work plan, but actually to be a tool that is used by the local community to monitor change and to develop progress, I think those objectives have to be considered which allow some sort of local feedback.
MS. BOWERS: Thank you, Donnie. Are there further comments on chapter 11, family planning?
Okay, we are going to chapter 12. Again, if you have comments that come to mind because you are in here, you have some ideas on this area, we will come back, if you think of something. Let’s move on to chapter 12, maternal, infant and child health.
MS. REGAN: Hi, I am Debbie Regan from New Orleans. I am here from the International Lactation Consultant Association. We have 5,000 members, or thereabouts, worldwide.
I was a little disappointed to see one small paragraph about breast-feeding in the yellow pages that we received when we came in.
I think that we have to look at the benefits of breast-feeding and health professionals. When we say the word breast-feeding, a lot of health professionals say, oh, here comes another one, you know, about breast-feeding.
This is so critical when we look at the rates of women who are now in the age group that the rates were low in breast-feeding, are now those women who are so high to develop breast cancers, osteoporosis and so on.
We also know health professionals interchange breast-feeding with artificial feeding so easily, and it is not the same.
We can know that human milk has benefits that enhance the quality of life, whereas artificial baby milk does not enhance the quality of life.
Millions of dollars are spent in the companies that promote artificial baby feeding. It doesn’t do anything to enhance the quality. Certainly, a human can grow on artificial feedings, but it doesn’t do anything to protect their immune system or increase their IQ.
There have also been studies to show that it decreases the rates of childhood cancers, particularly leukemia, and onset of diabetes and other childhood illnesses.
We know that it also enhances the ability to metabolize cholesterol and things that maybe later on we can see decreases the chance of heart disease and the risk of heart disease.
We know that breast-feeding is the first feeding that we should be promoting as health professionals. I think we dismiss that and discard that much too easily.
We also see that the population of women that do have the higher rates of breast cancer is the population of women that have the lowest rates of breast-feeding.
I think we need to go back to day one and start promoting this much more in the hospitals. We have the baby friendly hospital initiative that the World Health Organization started years ago in 1989 and 1990.
We only have nine baby friendly hospitals in the United States. Other countries, much less developed countries, have many, many more hospitals than we do.
I think we need to look at the hazards of artificial feeding paper that was written by Marshall Walker, and we also need to look at the book written by Gabriel Palmer, which is the politics of breast-feeding.
It is very important for health professionals to realign ourselves with breast-feeding now, instead of the large drug companies that produce artificial baby milk. Thank you.
MS. BOWERS: Thank you. We are on chapter 12, maternal, infants and child health. Any more comments? Any thoughts?
MS. MONROE: Good morning. My name is Elsa Monroe. I am a registered nurse and I am working right now for a federally funded program called Great Expectations.
Our primary focus is to decrease the infant mortality rate. Unfortunately for our city, once again, we made it nationwide that we are one of the leading cities in death among the babies.
Our primary focus started with 10 target groups and it was all in the different areas where the ghettoes were and also the projects.
Right now we have been limited to three target groups. Unfortunately for us, we have just now realized that we have made an impact of decreasing at least 30 to 35 percent of the mortality rate among our babies here in New Orleans.
My main plea here is to ask you not to cut out funding for programs like ours. We have just now realized that the important factor in being more effective is to infiltrate the public school systems.
Right now we just infiltrated one high school, where we found 25 documented teenagers who are pregnant. That is not to say that there aren’t some mothers out there who don’t’ realize they are pregnant yet, and some mothers who are afraid to come out of the woodwork to identify themselves as being parents.
We are now implementing a lot more lessons. One of the most things is the Maternal Infant and Child health parenting and prenatal care.
It is not so much the accessibility, but it is pleading with all of you, when you see programs like ours, is to continue funding us and not to curtail us.
We started out with about seven nurses. Now we are down to three nurses and, unfortunately, we are down to just myself. The other two nurses have walked away. Now we have one medical director.
We have some terrific backbone supporters. We have terrific caseworkers, social workers. We are just trying to get it together and to continue being effective.
I feel that we have been doing a lot of things. The teenagers are opening up some dilemmas that they have been hit with.
I feel that if we want to do something for our own safety and to decrease the mortality rate and increase the infant health, to please support us. Thank you so much.
MR. NANNIS: Just a question. Are you at one of the federally funded Healthy Start programs? Is that what you are working on?
MS. MONROE: Yes, sir.
MS. BOWERS: Thank you.
MR. SMITH: Again, Donnie Smith from Arkansas. Probably more of a question than a comment. One of the areas overall, specifically maternal and child health, that I had an interest in coming to the meeting to hear about, was the relationship of the 2010 objectives to GPRA, the federal requirement for performance measures.
Is there a relationship between the 2010 objectives and the movement at both the federal and state level to look at establishing performance measures?
I think it would be helpful to compare those measures that have been identified in the federal programs, where they have already been identified, the different measures, and how that relates to 2010.
Specifically for myself, I guess a worry that I have is that many of these measures are important monitoring measures. Yet, I am not sure, if we were to choose a performance or outcome measure, that these might be what would be chosen as being representative.
I guess the question is how is it anticipated that these might be used. If there is not an answer to that question I would certainly offer the comment that that might be an important consideration to the crafters of this plan.
MS. YU: I think that for our particular chapter we will make an effort to align our objectives with the MCHB block grant performance measures. We have not looked at the GPRA measures per se.
Mr. NANNIS: Let me just add to that, we are, in fact, taking the day in early November with the bureau leaders and the executive council of HRSA, and looking at how the HRSA strategic plan lines up with the 2010 objectives and how the GPRA reporting measures feed into that.
We are not there yet, as you suggest, but we really do want to align where we are, what our goals are, how we will measure progress toward those goals. Much of that will be the GPRA related measures and those that are reported through the new electronic reporting system that MCHB is putting in place.
MS. BOWERS: Thank you. Further comments?
MS. FEIG: It is just a quick question. I am not familiar with the GPRA reporting measures.
MR. NANNIS: The GPRA reporting measures are the performance measures that Congress has asked departments to report on as really accountability measures, really.
My simple way of explaining it is simply by saying, we have a program and we have a goal and we have a budget. Tell us how you are spending that money and how those dollars get you toward those goals, measured by what. The performance measures are the measured by what. Does that help?
MS. FEIG: Yes.
MS. PATTERSON: I am Chris Patterson from Arkansas. I am the director of the Office of Minority Health. I was going to keep quiet until you mentioned an imaginary word.
My comment is in reference to MCH, but infant mortality in particular, and the burden of disease on minority communities, in particular, too, African Americans for the state of Arkansas and probably across the board.
These rates have continued year in and year out. For some reason, there has never been an emphasis as far as the MCH dollars in particular, and all the way across the board, of funding streams following the burden of disease.
These communities have been burdened with these rates but we have never had an all-out effort to try to reduce the rates.
One of the things as minority health directors that we have seen and we continue to see it -- and we are kind of excited about eliminating disparities as being one of the two, but the question that communities will ask -- and we represent them -- will be how serious are we, whose objectives are these.
You know, we heard performance measures. We heard Donnie talk about, we have the big yellow book, but the yellow book is not in a language to which communities can relate very well.
I guess I want to go on record and say, as we are looking at this, infant mortality in particular, would you at least be serious about trying to let those dollars follow that particular burden of the disease.
Let’s be able to go to communities and use the lingo that they can understand and use them as resources.
Every meeting that we go to -- and the same thing is present here today -- we see very few of the people that these rates represent. We see it over and over and they can tell their story.
They may not have the lingo for the performance measures, but they could actually tell us how and what we need to try to do to lower the rates.
I didn’t comment on access to quality health, but you said that I could mention it. One of the things that I wanted to mention that ties into this, access many times has nothing to do with having a system of care right next door.
In Arkansas we have 75 counties who have a health unit everywhere, and we still have a problem with women coming into prenatal care.
If you go into the communities, they will tell you some of the reasons why, and it has nothing to do with the transportation. It has to do with the cultural competency of who is providing the care, too.
MS. BOWERS: Thank you. Are there more comments or thoughts on maternal, child and infant health?
Okay, then we will return to that if we have time. It appears that we are going to have a lot of time. Let’s go on to chapter 13, medical product safety.
Let me say, I know most of us have not really examined with fine toothed, the big yellow book. If you have comments or thoughts on this, don’t feel like you have to go by every word of the big yellow book. Leave our experts to figure that out. Please, share your thoughts and comments.
MR. NANNIS: During the lull here, just in thinking about the last comment, I have been now with HRSA for five months, but I came from a local community, Milwaukee.
There is, I think, a perception that there is a disconnection between the yellow book and what actually happens in local community, and there is.
I think we need to remember that there is a staging and a process that needs to happen where folks are putting together the yellow book as guides, but there needs to be the translation of what is in that book to what people hear and understand and can respond to and kind of what resonates locally.
Part of that process is part of what we are doing here, and part of what we will continue as we move forward. So, don’t look at the book as the end of the process. It is really the beginning of the process.
How it translates and how it gets communicated and implemented is not going to be solely a federal responsibility, but I think, at least from what I am hearing and I believe it, a partnership between federal, state and local and communities, and meaningful communities, not the folks that we often say are communities, but folks who are in communities.
That is just a reaction to the last comment that this book is over here. It is, but it is part of a continuum of action that needs to happen kind of universally if we are going to make a difference with any of these objectives.
MS. BOWERS: We appreciate that. You are motivated; good.
MS. (name withheld by request): _________ from Texas. Thank you, Mary, for giving us permission to not have to follow the yellow book.
MS. BOWERS: Your name and your representation?
MS. (name withheld by request): __________ from Texas. I thought I said that; I am sorry.
I don’t know what you can do through this process or with this book, but I just want to share an issue that is going on in our state.
We have some new leadership at the state level that doesn’t fully understand the nature of targeted public health services.
I think there is a great misunderstanding between assessment and assurance as far as targeted services. You can assess all night long, but if you don’t know how to assure, it is kind of pointless to assess.
With regard to family planning, there is idealism that every woman should have a medical home, and we all share that ideal.
We also know -- and I did notice in the yellow book that it is acknowledged that universal health care does not exist, and there are many fractions of vulnerable women who do not have any kind of real health insurance, be it public or private or something.
Therefore, the reality of them having a real, bona fide medical home is just not so.
Trying to get that reality understood at the present time is being very difficult. We are undergoing a tremendous upheaval in Texas where family planning is not being supported at the top because of this misunderstanding.
That women should have comprehensive services, we all agree on that, and most of the family planning targeted efforts do also involve comprehensive services and referral to additional services as things are picked up on screening.
Anything you could do to help, people understand that, while there is the ideal that we should all have medical insurance and that, once you have it, that you know how to access it correctly and that it be accessible, that is certainly an ideal.
We have a great deal of non-documented individuals in Texas who are not eligible for any system, public or private. We have a great number of people who fall within that gray zone, who are not eligible for any public system.
These are oftentimes women who don’t even know how to boil vegetables or that you can eat certain vegetables. So, there is a great educational issue.
We see the family planning targeted initiatives as a way of getting access to them and into their families and link them to other services, and to try to find a way to begin educating these women, to free them from having unintended pregnancies, and to be culturally sensitive in doing that.
Some women come to us because they want Depo-Provera because they can’t take birth control pills or Norplant because their husbands, depending on the culture, will not tolerate this, yet they don’t want to be saddled with unintended pregnancies.
I don’t know what you can do. I want to be nameless in this.
But if we can get certain people to understand that yes, we all share that ideal, that public health looks at vulnerable populations and focused targeted initiatives to those populations in order to reduce undesirable health status. Thank you.
MS. BOWERS: Thank you, ________. Our group is a little bit untraditional here. We are skipping. Medical product safety. Any comments on medical product safety?
We can come back. Chapter 14. Is there a comment? Good.
MS. KENNAMER: I am making a comment on chapter 14. I am Frances Kennamer with the Alabama Department of Public Health and I am speaking on behalf of the department.
Chapter 14 is some of the best news that we have seen in a long, long time and we are delighted to see that it is included in Healthy People 2010.
The things that are in that chapter are what mold the future for public in the community, at the state and the federal level.
What I would like to do is take an opportunity to encourage ways to increase funding opportunities and coordination of funding at all levels.
It is the responsibility of the federal, state and local levels to be able to fund the things that are in Healthy People 2010, chapter 14.
For example, with the MCH block now, the funding source for MCH block has enabled the states to use that grant in some very innovative ways, to begin to encourage community and population based services.
I would like to encourage other funding sources from the federal government to look at that type of model.
Further than that, I would like to also just say that if there is some way for the law makers to also see the value in this type of funding, I am afraid there is still a desire on their part to see the numbers that show what we have done to people in their particular constituency; for instance, increase or decrease morbidity and disease, which of course, is very important, but to see that there is value in funding and making money available for these things that are more developmental and a little bit harder to place numbers on.
MS. BOWERS: Thank you. Remember to sign your name in the back.
MS. GRAY: Good afternoon. My name is Avis Gray and I am with the Office of Public Health in Louisiana, and I am over quality management.
I went in the big yellow book and I was excited to see that there is something under number 10 on public health infrastructure, that looks at performance standards and quality improvement.
My role has been to look at developing systems to monitor and evaluate public health systems. I have been talking with Pat Montoya, who is the director of region VI, and we have also been talking with the other states in region VI.
A big problem that we are finding is what types of tools, what models can we utilize to effectively monitor and evaluate systems.
We have looked at the TQM model, the total quality management model. Knowing that to evaluate a decentralized system like public health can sometimes be really difficult, some of the things that got pulled out of that particular component was, I liked the statement that says, what gets measured gets done.
Looking at -- they have also stated and alluded to something that I have already found that is not being done in the public health system.
We don’t have a comprehensive and systematic evaluation of public health performance. So, it kind of refocused on something that we have found and it is in the developmental stage, which is great.
Hopefully there can be a lot more dialogue about developing, monitoring and evaluating systems for public health, and I am very glad to see that is in there. Thank you.
MS. BOWERS: Thank you. Further comments on chapter 14, public health infrastructure?
MS. FERNANDEZ: I am Rosa Vivian Fernandez, and I represent First Nations Community Health Source, which is an urban Indian clinic located in Albuquerque, New Mexico.
The comment that I have is more of a general one. It has to do with the interface of the U.S. public health system with the Indian Health Service, which is a public health system that serves American Indians throughout this nation and with what are becoming more common, which are the 638 compact and contracting tribal programs, which will take place or there are a number of them already.
They will be increasing within these sovereign nations and they will be public health systems. How does the mainstream public health system nationally, statewide and locally interface with the sovereign nations in looking at the overall health of communities, noting that the citizens of sovereign nations are many times citizens of the state.
The other is that 60 percent of the American Indian population are considered urban Indians. Only two percent of the funding from IHS is allocated for the provision of services to urban Indians through the urban Indian programs. There are 34 of them nationally.
Urban Indians can one day be a member of or a resident of their sovereign nation and the next day they can be in Albuquerque and be considered an urban Indian.
Following that individual from the state laws and regulations to their sovereign nation can be complicated. The state has no authority to dictate what happens within the sovereign nations.
That alliance and bridging is of critical importance to the system.
The other is that we need to have a common language in public health. I know there has been a controversy over who can do public health.
The reality is that if we do not have a common language and training in public health, we will continue to have these systems that cannot interface with each other because we are talking about different things.
To some people, public health is delivering immunizations to people and to someone else it may mean something completely different.
MS. BOWERS: You look familiar.
MR. SMITH: Thanks to the crowd for letting me. Donnie Smith from Arkansas. I would like to applaud the inclusion of infrastructure as a component of the objectives. I think it is a greatly needed objective.
I have not specifically digested that section, so I may make comments that are already in there. If so, hopefully that would just reinforce what is there.
I think the issue of communication and data, which are certainly two components of infrastructure, the 2010 objectives, really allow an opportunity to zero in on those areas.
I guess specifically a question -- this is probably a gripe. Working at the state level, it is a massive endeavor to find a way to find all the data sources to determine where your state is at year by year for 300-plus objectives.
Is there the possibility that in terms of the federal infrastructure and support for this process, that there might be a web site set up where the variety of data sources could be pulled together to provide that sort of updated information in a readily accessible manner.
It would seem in terms of data, communicating to states as partners in the process, and feeding the process for the states to share the information with community, that such a web site and data base site, pulling that together, what many times states receive is, they feed the information up, but sometimes we have a hard time finding the information coming back down.
It seems like this would fit very well within the infrastructure function, perhaps at the federal level.
MS. BOWERS: Thank you, Donnie. Further comments, public health infrastructure?
MS. GRAY: Avis Gray, the Office of Public Health again. I am going to pose a question to the public health infrastructure on the component with quality improvement.
Because it is in the developmental stage, how often will that be kept up to date. Will that be on the web, to look at developing information on looking at models for evaluating and monitoring public health systems, and how much input on an ongoing basis can we do after today.
MR. SINNOCK: I think these are developmental. I think kind of the way that the process is unfolding is that roughly by the year 2004, we have to have data collection systems in place to really generate the information.
My intent is to continue to involve people as we develop and implement these systems. They are really yours as much as they are at the federal level.
I think it is very important, the point you make, to really continue to evolve, and it is incumbent upon us to do that, and I think we have to make a commitment to do that.
MR. ESPINOZA: My name is Renato Espinoza and I am the director of the Office of Minority Health at the Texas Department of Health.
My comment has to do with the following. In this process that we are engaged in, we are setting up goals for the nation which eventually will be measured in terms of individual events -- deaths, morbidity, disability or whatever it is.
In between those two huge things, the national goals and the individual in my state, in a community, in a family, there are structures in between.
The main one to me is, at this point, the community. We are trying, in the Texas Department of Health, to change the way we do things and focus.
We know that we have to affect individual behavior, but it has to be done at the community level, in the community context.
Therefore, setting up the infrastructure in communities to do these critical tasks -- and I hope, nationally as well as in the states and at the local level -- there are resources allocated in order to accomplish this.
We need good data at the community level. Right now in Texas, we have excellent data at the state level. We can tell the indicators and do all that stuff.
Until that is translated into something that can be used by communities to identify their own goals and objectives, because the national objectives are great, but in the individual communities people will put their energies on the things that they consider more important.
We need to have the capacity to take the data that we have and get the data that we do not have and put it at the service of the communities.
That is a critical task that I hope there will be funding and commitment on the part of the public agencies to fund and promote. I think that is a critical part of the infrastructure; not so much the buildings, but that kind of assistance to the communities. Thank you.
MS. BOWERS: Thank you, Renato. Further comments on public health infrastructure? Let's go on to chapter 15, health communication.
MS. MC PARTLAND: Hi. I am Patricia McPartland and I am the executive director of the Southeastern Massachusetts Health Education Center.
I am delighted to see that you have a chapter devoted to health communication. Let's face it, it is essential to have good communication if we are going to reach any of the goals that are outlined in the Healthy People 2010.
Let me add -- it is my adult education background -- let me add a few things for your consideration. First, I really think learning styles should be added to this section, and you could really add it in a couple of sections, the reading or language level and format, including multimedia, are appropriate for certain audiences, and perhaps add learning style there, or under the understandable sections.
People's learning styles differ. Some people learn by audio, visual, et cetera. It really determines whether or not a message is going to be understood.
Also, if you really want to change behavior, our communication and educational strategies really need to go beyond the cognitive domain to include other learning domains, such as the affective domain.
Finally, our communication and educational strategies must be interactive and participatory. We have really got to get people involved, because they will remember and change, hopefully, what they do rather than what is said to them. Thank you very much.
MS. BOWERS: Thank you. Other comments about chapter 15, health communications; thoughts?
MS. RIFF: Hi. I am Gardenia Riff, director of the Office of Minority Health in South Carolina, speaking as an individual this morning.
I applaud your efforts also in terms of having a section on health communication. While health communication is not my area of expertise, we did feel it was important enough in our Office of Minority Health, to have one of our components of our strategic initiatives focusing on that.
I have a question, first of all, in terms of the format of the book, so that it will be as user friendly as possible. Will all the text that supports some of the objectives be included, the text as we see it now? Will that be included in the final draft?
MS. KAPPELER: That is my understanding, that the final document will include all the background discussion, both the discussion that comes at the front of each focus area, and then the discussion on each individual objective.
MS. RIFF: My reason for saying that is that I think, even though it is included in another section, education and community based, programs as far as cultural competence and the development of culturally sensitive material, I think it is also very important to have an objective that includes culturally competent health communication, even though there is a related area in there.
There are some other words, like underserved populations, that I think it is important enough to be included in the objective itself, even though it is included in the text.
MS. BOWERS: Thank you, Gardenia. Are there other comments on chapter 15?
MS. MONROE: Thank you once again for this opportunity. Once again, my name is Elsa Monroe. I am with Great Expectations.
As one of the first Hispanic nurses to be hired here, in the public setting, I just want to share with the panel that there is a great concern with the health communication as being communicated here.
Our main concern is the lack of translators. For some reason here, in the United States, we are ignoring the fact that many generations have come in from other countries and have not picked up the English language, even though English is considered to be the primary international language, the universal language.
I want to address this to you because, as a nurse, and being out there in the community, I have experienced and observed many negligent acts and many who were horrible.
One example, very quickly, this is very minor, little Hispanic babies are being injected, being examined three or four times because the mother doesn't know that when she is being asked, did your baby receive your PKU before getting discharged, she will say yes, yes or no.
Then sometimes the nurses forget to document. So, when she goes to the clinic, the little baby gets injected again, gets examined.
There are discharge orders. We have our Hispanic mothers who do not understand, but they are saying yes to the doctors. One example is of the C- section sutures--the mother ended up pulling out the steristrips, thinking that was part of her routine at home, to take off her dressing, when the doctor told her, I want you to remove the dressing before you take a shower.
So, she removed her steristrips. So, consequently she had a horrible infection and she lost two months of work.
Anyway, these are just a couple of illustrations that I want to just interject that if we are going to have accessibility for public health, we have to consider the fact that because we are a country with wonderful people from different countries -- and this is what makes us a legacy and a role model to the world -- that we have to acknowledge that, being diverse, we have to respect other languages.
Just because you are here in America, doesn't mean that you have to speak English. That is my main thing here with you all, please consider that we have to have translators for all the public hospitals.
It is so embarrassing for me to see that two private hospitals here in New Orleans, and in Jefferson Parish, are charging our Hispanic mothers -- primarily I am saying Hispanic, because that is what I am and that is what I am dealing with.
They are charging our mothers $35 an hour to translate. It could be just a translation of a simple surgical procedure. I don't think that is right.
If the moneys are coming from the government, then those institutions are obligated, in my opinion, to service the public with a language that they can understand. Thank you.
MS. GRAY: My name is Avis Gray and I am with the Office of Public Health. What I was very glad to see was specifying that we need to have funded programs to look at public access to health.
Historically, in public health, social marketing and media have been something that you did on the side or you didn't have funding for.
So, I really liked where they listed funding to promote and enhance public access to public health information.
I think it is so important that we get the message out about what public health does. When it comes to funding and when it comes to the population at large, they know that we are important but they don't know what we are about.
I think that could help us. If the communities know what we are about, that would help us with trying to get increased funding also, because they know that we are essential.
The other part that I felt good about is that monitoring and evaluation is my realm, and that there was a component that talked about incorporating appropriate evaluation activities and other components recognized as contributing to quality and effectiveness.
I think it is important that we also put in the media about the effectiveness of a lot of our service, the quality of our care. Not just that we are public health and we are out there, but that we also show some measurements of the effectiveness of what we are doing.
Another big one, I remember when I went to school, especially nursing, there was not a huge emphasis on public health and health communication and education.
I like the piece that looks at increasing professional schools to include health education, communication and media technology, and also World Wide Web access.
I feel that this component is very comprehensive, and it is in the development stage, and I hope that we continue to dialogue on this, because this is very important.
MR. SMITH: Hi, Donnie Smith from Arkansas. This is the last time. In terms of the area of communication, I would like to reiterate one of the thoughts that the previous presenters made.
That is that I would hope that each section of the book could be seen as a stand-alone section. Because cultural competence might be in a prior section, not to take for granted that it does not need to be repeated in a section later on.
I guess the reality in mind is on how the book is used. I look around the room and everyone here has a copy. We all got it at the meeting.
Only about half the people actually brought it to this meeting, simply because of the size to carry it around.
When we actually meet with communities, or when we meet with interest groups around issues, my guess is that those sections of the book in which they have interest be copied for them.
If that is the case, and we assume that because cultural competence is in a prior chapter, we may lose completely how that is considered in that unit.
The other area that I think is very important is the discussion with the key indicators.
From my perspective -- and this is simply a hunch -- but I would think that the key indicators, when they are developed, is actually what is going to be shared.
That is going to be the two or three page synopsis. Except for the person whose job it is to do this, probably that is going to be the most meaningful part of 2010.
I think great care needs to be taken in developing those indicators, and that may be the true message in terms of communication of what most people in the community see with the 2010 objectives.
MS. BOWERS: Thanks, Donnie. Further comments on health communication?
MR. KLAASSEN: I am Perry Klaassen. I work in a community health center in Oklahoma City. I am not representing any particular organization.
I have not formulated my thoughts real well on this, but I noticed the particular goal in regard to medical curricula in professional schools teaching or adding to their curriculum something about health communication.
I am a physician who deals with patients every day. I really am highly motivated to try to deal with all the things that we are encouraged to deal with -- physical activity, weight loss, nutrition, smoking cessation, all those things. I try to deal with them.
I have a very brief time to try to deal with people in regard to those things. I know there are other professionals that deal with them, there are classes, and so forth.
At least those people who have access to health professionals or mid-level practitioners, we have those moments to communicate these things to people.
I have never really been taught how to do that well. I have learned over the years to find what is effective. The same thing is not effective for all people. Then we have the kind of cross cultural, multicoloured kinds of patients that we deal with and we try to be sensitive to them.
I try to be sensitive to them, too, maybe not even speaking to them in their language, but trying to communicate with them in other ways.
I think that that particular thing needs to be emphasized within our professional schools, primary care, people who deal with primary care particularly.
Maybe there needs to be research on how best to communicate these things in very quick moments of time, because again, people learn in different ways.
You can give them -- I understand giving brochures, written literature, is not very effective for almost anyone. Studies have been done in regard to that.
The words that come out of our mouths to people are sometimes the most effective way to communicate with them. We need to learn how to do that very quickly, but say it in the most effective way.
Just saying, you have to lose weight, you have to stop smoking, you have to eat right is not very effective. Thank you.
MS. BOWERS: Thank you.
MR. BUD: I am Dr. Buu from Harris County, Texas. I have a question, then a comment. This, I don’t know if it is related to the health communication or access to quality health services, or maybe related to infrastructure.
The issue is, we are talking about what of the criteria for leading health indicators, talking about audience interpretability.
The confusion about the terminology involving the preventive care and primary care, I have taken an example.
A child is coming in to a physician’s office for immunization and that child has never received any total physical examination.
Should the physician provide total care, comprehensive care for that child, giving that child a complete examination, instead of giving only the shot.
I have never seen any terms saying comprehensive care or total care at all. The public is very confused between the preventive care and primary care.
I have asked the question so many times to my colleague, please define me, what means primary care. I got so many different definitions, because some say primary care is including preventive care, too.
So, how do you differentiate between preventive care and primary care. That is my concern. Thank you.
MS. BOWERS: Thank you, Dr. Buu.
MR. NANNIS: Just a comment. I don’t know if you have seen an Institute of Medicine on the future of primary care. It is actually called Primary Care in a New Era.
It is about two-and-a-half-years old and it does try to take a little bit of time in clarification of the interface between the two, and tie that definition of primary care to comprehensive care.
Don’t quote me here, because I am doing this by memory, but primary care in the context of the community and family and in the context of prevention.
If you haven’t seen it, it is a very thorough, well done project from the Institute of Medicine. That may not answer your question but it may be a source that you want to take a peek at.
MS. BOWERS: Joan, please.
MS. SMITH: Hi. I am Joan Smith from the Office of Public Health here in Louisiana, regional administrator responsible for more of a local level than at the state level.
As far as health communication is concerned, I guess my concern is that health communication, once you get a person to health care, is one thing.
Health communication also involves having persons understand enough to know that they need to get to health care.
I think a part of inaccessibility has nothing to do with whether or not there is a building but whether or not the person understands, whether or not we have communicated, somebody has communicated to the person that they need to have health care.
In one of my other roles, I am the director of health in my church, and there are not a whole lot of churches with directors of health.
At any rate, I see many people who have no primary source of health care, who only learn from me that they need to have their blood sugar tested, that they need to have their blood sugar read, and that they have got to go to somebody to have that taken care of.
If I don’t ever educate them to get them there, then there is no health communication that you can do for them once they are there. It is just those groups that get there for which you provide health communication.
My concern is that all of us should be health communicators, every one of us, from mama on up should be health communicators.
What is our role, as persons who are in the health care profession? To assure that all of these people are capable of being health communicators.
As I said in the last meeting, there are pastors of churches who pastor 11,000, 20,000, 30,000 people. If those people could learn how to be health communicators, look how many people we could get to understand that they need to do something about their health.
MS. BOWERS: Thank you, Joan. Further comments?
MS. FEIG: I am Jill Feig. I am from Tulane University’s preventive medicine residency. Something I had said yesterday that I would like to say again about educating the health professionals and the educators, is that I think that we have to hold preventive medicine more accountable in that education role.
We are a good resource and I think that maybe some of the lack of physician and nursing education is because maybe we are not so proactive at getting with some of the more traditional primary care specialties.
I would just like to comment that perhaps that should be added to the language in the book, too, is that we should be held as part of the responsible parties for disseminating the information.
MS. BOWERS: Thank you, Jill.
What we are going to do now is give you a second chance. We have time. If you don’t need to speak, then we will say that our work has been done.
Again, we started off with chapter 10, access to quality health services. That included preventive care, primary care, emergency services, long-term care and rehabilitative services.
Last chance; are there any comments, speakers?
MS. BOURGEOIS: Good morning. I am Nancy Bourgeois. I am the director of the Bureau of Emergency Medical Services for the Office of Public Health here in Louisiana, and I do have some comments.
When we look at the objective C.1, we are using the definition of EMS as emergency medical services.
I just think we all ought to be aware of the fact that that is a tiered response. When we talk about EMS we are talking about probably a bystander who is first on the scene, then perhaps a fire department or police department responding, and then we are talking about ambulances and transport to an emergency department and appropriate care.
When we are talking about the nine minutes, I am under the impression that we are talking about ambulance transport. Perhaps that could be reflected in our document, in our planning document.
When we talk about in the rural communities being 40 miles away from EMS, are we 40 miles from the nearest trained first responder in a fire department or 40 miles away from an ambulance itself. The transportation time is going to be of essence to us, and it is in our rural communities.
The National Association of EMS directors is meeting next week. We will be addressing these issues again formally for you. I just want to bring that out as we are talking about it, that nine minutes response time by an ambulance is, we believe, adequate, but not nine-minute response by the first responder or bystander who is trying to provide care on the scene.
When we look at C.2, unfortunately, HCFA reimbursements affect the availability of appropriate EMS care. As HCFA’s reimbursements change and as reimbursements are denied for advanced level care, then services are having to cut back from an ALS service –- advanced life support service –- to a basic life support service, because they can’t maintain the paramedic level trucks and the equipment and the supplies that they will need. I think we are making a step backward in that respect.
For 30 years we have been training and developing what we call the pre-hospital care provider, or the paramedics and the emergency medical technicians.
Now we are seeing large companies who are down sizing and staffing their more rural communities with basic life support trucks. That is sort of a reversal of our philosophy in terms of having the services there when they are needed.
I think we might want to look at that. I know that is certainly not necessarily under our jurisdiction for this meeting, but it is something of grave concern to us.
Also, as long as reimbursements are tied to transport, then we will continue to have the problems in the area of mis-utilization of EMS and also mis-utilization of hospital emergency departments. There is no reimbursement for first responders at the scene.
In terms of access to time sensitive care, that requires that a system be in place with medical control at all levels, that we have a system from first response all the way up through the more sophisticated medical procedures of TPA or blood clot dissolving medications.
We need funding for pre-hospital care personnel and we need the support of this group to convene all key players, who have an interest in early defibrillation, so that we can support a coordinated public access to the defibrillation program.
MS. BOWERS: Thank you.
DR. AIKEN: Dr. James Aiken, again. I presume your rules allow for a repeat comment. When I went through the book, I overlooked the fact that in 10-C.2 there is a blank where it says percent.
I think there should be no question that blanks should be filled in with 100 percent. As you well know, we are legislated, those of us who practice emergency medicine, to provide a medical screening for anyone who presents themselves to an emergency department.
We take this responsibility gladly. However, that responsibility, of course, has costs involved, has staffing issues involved.
We need to, again, be firm in our resolute that 100 percent of everybody in this country deserves access to emergency medical services.
Again, the issues as to whether the outcome reflects an emergency or not is irrelevant. The issue is that everybody in this country needs to know that, no matter where they are, if they can get to the place that they wish to be treated, whether it is through their own or through an ambulance service, they need to know, and the government needs to ensure, that that possibility will, in fact, come about.
Again, on behalf of those of us in emergency medicine, I urge that that blank be filled with 100 percent.
MS. BOWERS: Thank you.
MS. FERNANDEZ: Rosa Fernandez with First Nation again. I am concerned on how these measures will be assessed. An example that I can give is related to the implementation of managed care in the state of New Mexico.
Individuals got assigned. We began managed care in July of 1997. Individuals got assigned to HMOs. The HMOs were sometimes 75 miles to sometimes four-hour drives from where the person lived.
The public health system in New Mexico did not have jurisdiction over the human services, which had jurisdiction over the HMOs.
It made it a very complicated system, although public health would advocate for access and human services would advocate for access, the data systems weren't in place and people kept spinning their wheels as to where they were supposed to go.
These are the realities that we face. How do you measure access on an individual who never entered the system because they would have to call an 800 number in order to enter the system, and they may not have a phone.
They may call the number and they may have language issues and so forth. So, how are you going to go about looking at true accessibility.
Also, how do you measure the impairment of accessibility once the individual is within the system, that they may be seeing a practitioner, but they may not be seeing the specialist when they need to, and so forth.
We see some serious disparities. Unless a person is very vocal or the person has direct communication to certain channels, they receive no services at all.
I have seen the cases of a waiting list for developmentally disabled individuals. All of a sudden the son of the friend of a Senator calls up the Governor's office and the Governor provides a directive to skip this person 100 to 200 people up the chain. Meanwhile, the other individuals are not served.
So, we need to be careful as to the complexities of measuring access.
Another example, I could give one humorous. This took place some years ago, in which a lady goes into labor. She goes into one hospital and they tell her, well, we can't provide you service here.
She gets sent to another hospital. On the way, a hospital stops by a sidewalk, a lady runs out of a house and delivers the baby at the sidewalk.
She finally makes it to the second hospital with her baby. They checked her, sent her home. She received two hospital bills for labor and delivery and emergency services.
Those things are happening. Those are the things that we miss in the data. Those are the serious issues of access in this country.
MS. BOWERS: Thank you.
MS. GRAY: My name is Avis Gray and I am with the Office of Public Health for Louisiana. What I like very much that was listed under assure access to appropriate services was the clinical prevention service piece under A.3.
Looking at 80 percent routinely screened about major lifestyle risk factors -- diet, tobacco, use of alcohol, drug use, exercise and sexual practices.
In my other life, right now I am with the Office of Public Health, but I worked 10 years at the Medical Center of Louisiana in New Orleans, which is a large public health hospital in New Orleans.
We were overwhelmed with tertiary outcomes from diseases that were outcomes. We had a lot of strokes, lower limb amputations because of diabetes.
I worked on dialysis for a lot of years, and we had a lot of people on dialysis. I also worked in the ambulatory care system. Part of our screening was not lifestyle. That was not part of our screening and it was not part of our education.
I am very happy to see that it is listed here as a clinical preventive screening measure, and is also listed as something that we need to be -- once again, I said before, we need to be educating in our nursing and our medical schools about the importance of screening for these components and looking at the behavioral lifestyle implications of some of these diseases. Thank you.
MS. BOWERS: Thank you. Would you sign again?
Any thoughts, comments, family planning, chapter 11? Okay, you are sure?
Moving on, chapter 12, maternal, infant and child health; second opportunity.
Chapter 13, medical product safety.
Chapter 14, public health infrastructure.
Chapter 15, health communication.
MR. JOURNIGAN: Good morning. I am Kim Journigan, a student at Tulane University School of Public Health, as well as an intern for the American Diabetes Association. A comment about 14 and 15.
One, I notice in the book that they said they were going to make a goal or an objective of applying to the public health schools to have better health education communication programs.
I would like to say, as I have looked and gazed at most of the school curricula, they have them already. What we lack is, within the public health infrastructure, actually continuing education courses about health communication and education.
We are in a particular society of public health where we lack communicating to each other about particular health issues. We do not know how to talk to each other about different issues. We do not know if we are asking the right questions or not.
As I am looking at different surveys that are put out from federal, state and local levels, we are lacking asking the right actual question, as well as looking at subsegments in the communities.
In health education they tell us that we are supposed to look at these big, broad target populations. What we also are taught is that there are subsegments within those communities that we need to communicate to.
We are lacking that within our own infrastructure, to actually come up to par with communicating with each other. That is one of the things that I wanted to say about, that we need to learn how to communicate to each other; not necessarily that the curricula lack that in the schools of public health, but we lack that curriculum for ourselves.
MS. BOWERS: We have new instructions. We are reconvening in the big room at 10:15.
I guess none of us were that familiar with the book. Let me say that you have opportunity to make comment via e-mail and in writing.
I think there is an address in your information that was given to you at registration, where you can write in your comments or e-mail your comments.
Don't feel that this is your last opportunity. We are going to adjourn this session. I appreciate your comments. I thank the panel of experts and now we can -- is there a comment?
MR. POMEROY: Can I make one quick comment?
MS. BOWERS: Yes.
MR. POMEROY: I just, speaking on behalf of public health infrastructure, very much appreciate the positive comments. Too many times we get negative comments. There were some positive ones, and I think that is very valuable.
It reflects, I think, a lot of hard work that people have done and I, for one, appreciate it. Thank you for all your thoughts, though.
MS. BOWERS: Thank you.
[Whereupon, the session was adjourned.]