Transcript of the Healthy People 2010 Regional Meeting
Sacramento, California
December 9-10, 1998

U. S. Department of Health and Human Services
Office of Disease Prevention and Health Promotion

Session I:
Promoting Healthy Behaviors and Safe Communities and Improving Systems for Personal and Public Health

DR. BANKS: Thank you for coming to the session. Welcome. In the interests of time and in the interests of fairness we will conduct ourselves in the same manner we conducted ourselves in the Plenary Session this morning with respect to giving our public comments.

We will take comments on the first 13 chapters in the draft document, and let me just go over how we will do this in case someone doesn't remember.

Again, we would like for each person who has a comment to come to the microphone and make that comment, state your name, your residence and again tell whether or not you are representing yourself or you are representing an organization.

Remember that you will have 3 minutes to make your comment, and again, we have a timekeeper here. The yellow light will come on and indicate that 1 minute is left. When the red light comes on your time is up, and I am not embarrassed to stop you because we do want to hear from as many people as possible.

Each focus session will last 20 minutes, and I estimate that we will be able to have comments from six to seven people so that we can conclude by one, and I understand in the other regions where this has taken place they had concluded well before one, if that warms your heart.

(Laughter.)

DR. BANKS: Now, I would, again, at the end of the session if there are questions after we have gone through all of these sessions, all the focus sessions there hopefully will be time, there will be time for any additional comments people want to make at the conclusion of your public comments.

So, at this time I would like to open it up, but first I want to introduce some very important people. We all are important. You are important, very important, but I just want to introduce people who will be specifically listening for each focus area, and we have had some changes. For focus area No. 1, physical activity and fitness we have Michael Pratt from CDC.

Michael?

We will begin now receiving comments on focus area No. 1.

MR. PERRY: Good morning. My name is Jim Perry. I am the Director of Athletics at La Kinta(?) High School in Southern California in Huntington Beach. I am, also, a classroom teacher of physical education and health education.

I am here at the request of the California Association for Health, Physical Education and Recreation which has 1500 members, and we are aligned with the American Alliance of Health, Physical Education and Recreation that has 33,000 members.

Listening to what went on yesterday, 30 minutes of daily physical activity is not a stretch. Thirty minutes of daily activity is a very, very reasonable thing to do, especially since we have the framework of national standards already in place that has been written by the National Association of Sport and Physical Education.

We have the schools in place. We have physical educators who are trained and professionals in their field in place. We are requesting the support of mandatory physical education on a daily basis in the schools across this country from grades K through 12. Currently there is only one state, Illinois that has that mandatory law, K through 12, and in the last 4 years they have gone to block scheduling at the secondary level and that is no longer a daily requirement and has become a 2-or-3-day-a-week requirement.

We are asking that this panel support mandatory physical education on a daily basis across the country K through 12. We think we can eliminate an awful lot of problems. There is no sense in spending billions and billions of dollars to educate our America's youth and have them die of heart attacks and diabetes by the age of 28.

Thank you very much.

DR. BANKS: Thank you.

Sheila, could you be the timekeeper and let me know when 20 minutes are up? I left my watch in the room.

MS. SEELEY: Good morning. My name is Anne Seeley. I am Active Community's Coordinator with the University of California, San Francisco Health and Aging Institute. I reside in Placer County. My goal as Active Community's Coordinator is to make community environments more conducive to routine and incidental physical activity.

I am testifying today on behalf of an ad hoc group of public health, park and recreation, fitness and alternative transportation professionals from across the country. We are concerned with the omission of community indicators for tracking levels of physical activity. Without adequate surveillance systems to track the availability, development and use of public environment for physical activity, including parks, community centers, after school access, trails, bike paths, sidewalks and so on the ability to achieve the comprehensive recommendations for the 1996 Surgeon General's Report on Physical Activity will be difficult, if not impossible to quantify.

These environments are essential to creating access and opportunity for physical activity participation where people live, work and play.

It should be a priority focus of the lead federal agencies to develop, fund and execute acceptable surveillance strategies during the next decade. To diminish this as a priority for Healthy People 2010 will severely limit any measurement of quantifiable growth in leisure time physical activity nationwide and it will jeopardize efforts to select and develop effective interventions in this regard. Therefore, it is essential that a physical activity objective along these lines be restored to Healthy People 2010.

We, also, believe that the inclusion of community data will enable us to reach the Healthy People 2010 goal to eliminate health disparities.

Thank you.

DR. BANKS: Thank you.

Are there additional comments?

MR. FALCON: Adolph Falcon speaking on behalf of COSSMHO. On behalf of our members we would like to ask that a number of the programs under this area call for school-based programs. We ask that the work group working in this area look at community-based programs, particularly since a significant percentage of Hispanic youth are out-of-school youth, and we need to find a way to reach them.

Also, those areas that deal with delivery of messages we would ask that cultural linguistic competency be incorporated into those areas as well.

DR. BANKS: Thank you. Are there additional comments for this focus area?

Ma'am, do you have a comment?

Going once, going twice?

We will move to the next focus area which is nutrition. Dr. Janet McDonald of the FDA is our representative for this focus area.

Step up to the mike?

MS. STERN: I am Judith Stern, professor of nutrition and internal medicine at University of California, Davis. I am representing myself, but I am, also, a past president of the American Society for Clinical Nutrition.

In my comments earlier this morning I emphasized that obesity should be a leading health indicator in a separate chapter. We are in the midst of a global epidemic of obesity certainly in the United States, and it is important that we address this in Healthy People 2010.

I think one of the cornerstones to achieving any objective in the area of obesity meaning prevention and treatment is research, both basic and applied. I think USDA should be commended for their nutrition centers, but we need more competitive grants with USDA and more nutrition research at NIH. Only about $90 million a year is spent for obesity research. That sounds like a lot of money, but over $1 billion for AIDS, over $1 billion for heart disease and over $900 million for diabetes. So, $90 million is hardly enough.

I wanted to comment on a second area, and that is objective 2.9. That is salt and sodium intake. I do not believe that there is justification for limiting salt to 2400 milligrams a day. I don't think we can justify that figure. I think it is better to emphasize foods and being modest in sodium intake.

There is an NHLBI-funded study called the DASH study that had almost 50 percent minorities, meaning African Americans, and their sodium was not restricted. It was about 3000 milligrams a day, and it was a low-fat diet, fruits and veggies and low-fat dairy. There was a highly significant drop in blood pressure, both systolic and diastolic. If you didn't know it was diet, you would say, "What is this new drug?"

There were few side effects. There was no weight loss associated with that. So, it couldn't be attributed. So, again, I think that if we go with these recommendations of 2400 milligrams or less, we will have an effective decreasing consumption of dairy products that would be bad as a nutritionist. So, I think that this objective should be modified.

Thanks.

DR. BANKS: Thank you.

Additional comments in this focus area?

Please remember to sign in as we did this morning after you conclude your comments?

MS. HAYDU: I am Suzanne Haydu. I am with MCH for California, and I am testifying for myself. Objective 19 I think should be revised to address medical nutrition therapy. The suggested wording would be "Increase the proportion of physician office visits which non-medication therapy was provided or referred to a registered dietitian or qualified nutritionist for medical nutrition therapy when appropriate," and I think they could use the MNT definition given out by the American Dietetic Association.

The narrative should be changed to include MNT is an essential component of comprehensive health care services and as a medically necessary cost-effective element of treating disease and nutrition-related medical conditions.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: I am sorry. I have a comment under each area.

DR. BANKS: Don't be sorry.

MR. FALCON: I apologize. Adolph Falcon on behalf of COSSMHO. In this area we would ask that the group look at healthy weight standards, in particular the body mass index and some of the research that indicates that healthy weight standards are not the same for all racial and ethnic groups and incorporate that into the discussion as well as incorporating into the discussion a number of the positive nutritional health practices of racial and ethnic groups, in particular Hispanic women as one of our really positive success stories and it would be a good area to include in the discussion of nutrition.

Thanks.

DR. BANKS: Thank you.

Additional comments for focus area No. 2?

Thank you for those comments. We will move on to focus area No. 3, tobacco use and the representative for this area is Julie Fishman from CDC.

DR. WILLIAMS: Good morning. I am Dr. Seleda Williams with the California Department of Health Services, Maternal and Child Health Branch. I just want to comment on the tobacco use objectives related to pregnancy, Objectives 2 and 7. The Branch is supportive of the inclusion of these objectives. We agree with Objective 7 in terms of increase in smoking cessation during pregnancy so that at least 60 percent of women who are cigarette smokers at the time they become pregnant quit smoking early in pregnancy and maintain abstinence for the remainder of their pregnancy.

We recommend increasing future targets as this would be an important contributor to reducing low birth weight.

DR. BANKS: Thank you for those comments.

Would those persons coming to the microphone to make a comment get just a little closer because I understand people in the back are having difficulty hearing?

MS. KLINK: Good morning. My name is Anne Klink, and I am from Sacramento. I am representing myself today although for the last 8 years I have been working by funds from the tobacco tax here in California on the tobacco initiative. So, my comments do relate to tobacco use.

First, I want to comment and say how positive I feel about the inclusion of secondhand smoke in the discussion of the tobacco section. It was necessary to have that included, I think, in the document. I noted that there are two areas that I think are very positive, No. 16 which is the enacting comprehensive laws throughout the 50 states and they are listed by type of location that become smoke free, such as the work site and public transportation, etc.

I think that is a fine objective, but in addition I would urge you to try to establish some population percentages that are covered by those entirely smoke-free laws. That gives you a very easy idea to quantify when you are reaching a fairly large portion of the population.

Lastly, I am, also, gratified to see that I believe it is No. 25, you do have a statement about reducing to zero the preemptive laws, state preemptive laws. That is extremely important. Local ordinances lead to very strong clean indoor air environments and often can be disabused with preemptive ordinances.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: Adolph Falcon with COSSMHO. We would ask that a section be added calling for international tobacco control standards addressing tobacco use among immigrants to the United States.

We would, also, like to see an objective added that would deal with tobacco industry sponsorship of cultural events.

Thank you.

DR. BANKS: Thank you.

Are there additional comments for focus area No. 3?

Okay, going once, twice, gone.

Now, we are ready for focus area No. 4, educational and community-based programs, and we have two representatives for this focus area, Lyman Van Nostrand from HRSA and Julie Fishman, again, from CDC.

MS. NAHAT: Good morning. I am Emily Nahat, California Department of Education here in Sacramento, and I am representing the department.

The State Superintendent of Public Instrument Delane(?) Easton and the California Department of Education congratulate you for highlighting the connection between strong education programs and young people's health.

The California Department of Education supports the school-related objectives and makes 12 recommendations. I will present eight of the 12.

One, national health and education goals. CDE recommends that the US Department of Health and Human Services and the US Department of Education coordinate national health and education goals to demonstrate the link between student's health and the school success.

Two, comprehensive school health programs. Comprehensive school health programs are supported by the Centers for Disease Control and Prevention and the Institute of Medicine. CDE recommends A, an objective for increasing and improving schools' comprehensive or coordinated school health programs and B, an objective to increase state education agencies' support of those programs through appropriate state level staff.

Three, positive youth development. Specific protective factors and resilience traits increase the likelihood that young people will make healthier decisions as youth and grow up to be healthier adults. CDE recommends adding a positive youth development objective.

Four, school-linked services. California's Healthy Start, the Colmar(?) Projects and the Beacon(?) Schools improve learning, health and family functioning. School-community partnerships are vital for reducing education and health disparities. CDE recommends adding a school-linked services objective.

Five, student support services. Student support services staff promote high school graduation, address mental health problems early and intervene in school violence. CDE recommends adding objectives 2A, increase the number of schools that provide a comprehensive guidance program and B, improve the ratio of school counselors, school psychologists and school social workers to K-12 students.

Six, teacher training. Classroom teachers must be prepared to teach health education and physical education and to promote a confidential school health program. CDE recommends adding an objective to increase the percentage of states that require candidates for multiple subject teaching credentials to take a course or meet rigorous content standards in comprehensive school health. I am going to add a couple on nutrition so you don't hear me more than once.

School meals and snacks. CDE recommends Objective 2.13 read, "Increase to at least 70 percent the numbers of children and adolescents whose dietary intake at school from all sources averages a score of at least 80 points using the healthy eating index and meets age-appropriate calorie levels."

No. 8, we propose the adding an objective to increase the number of school districts that have school nutrition policies in effect which promote the dietary guidelines for Americans and ensure healthy food choices.

In conclusion, CDE will continue to work with you on the Healthy People objective. We do ask for your support in expanding and stabilizing the resources to states and local education agencies to deliver the services designed to meet these objectives.

Thanks for the opportunity to participate and for being in Sacramento today.

DR. BANKS: Thank you.

MS. GONZALES-BALEY: My name is Gina Gonzales-Baley. I am a health education consultant with the Department of Health Services Maternal and Child Health.

DR. BANKS: Could you speak a little louder, please?

MS. GONZALES-BALEY: However, I am here today speaking at this moment on behalf of myself. I wish to encourage the inclusion in this area of community-based activities that would increase the interest of young people in schools and at the community level in health professions because I believe that the increased number of ethnically and culturally competent health professionals would be a great assistance in all the other activities that are in this giant document that you have worked so well with to decrease the disparities in the health indicators.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: Adolph Falcon with COSSMHO. Under this area we would call for the addition of an objective which links health to high school completion rate and seeks to decrease the disparity in school drop-out rates.

Under the terminology section we would ask that community be more broadly defined so that it is not only geographic boundaries. Under the settings definition we would ask that community-based organizations be added as a setting for educational and community-based programs and under Objective 11 culturally appropriate community health promotion we support increasing that to read that at least 98 percent of the proportion of local health departments have culturally appropriate and linguistically competent health promotion and disease prevention programs.

Thanks.

DR. BANKS: Thank you.

Anyone else?

That being the case there doesn't seem to be anyone else, we will move to focus area No. 5, environmental health. Our expert representative for this area is David Evans, CDC.

MR. EVANS: ATSDR.

DR. BANKS: ATSDR? We have to make that distinction, right?

Are there any takers?

MR. FALCON: I will take. Folks who know me are used to this. Adolph Falcon for COSSMHO. Under the section of environmental health we would support reformatting the objectives. Instead of reading as reduce by X percentage, reformat those to reduce to 0 percentage.

As the objectives are currently stated they are at the best unambitious. The amount of percentage decrease is very minimal and of negligible impact. We instead would call for reformatting these objectives to read, "To reduce to 0 percentage," and then the area stated. Under Objective 1, we would ask that a subobjective be added mandating the improvement of the air quality in Hispanic communities, given that data show that with regard to ambient air quality Hispanics are much more likely to live in areas that fail to meet those standards.

Thank you.

DR. BANKS: Thank you.

DR. MOBED: Good morning. My name is Dr. Ketty Mobed. I am Chief Epidemiologist for Sacramento County, California, but these comments are personally my own, and as I read the chapter yesterday something really hit me, and I would like to have these comments added to the objectives of Healthy People 2010, to promote and maintain health care standards in prisons as it relates to infectious diseases such as STDs, hepatitis C, HIV-AIDS and TB as these are a public health risk to the whole community.

I, also, would like that another clause be added to promote collaboration and data exchange between public health entities and law enforcement agencies.

Thank you.

DR. BANKS: Thank you.

Anyone else? We are moving fairly quickly. We might be able to go skiing this afternoon.

(Laughter.)

DR. BANKS: We will move to focus area No. 6, food safety. Dr. Janet McDonald is our representative.

You have another comment on food safety or back to the environment?

DR. MOBED: No, on food safety and again the same comments are true for prisons. Food safety standards need to be monitored in prisons. We recently had an outbreak in one of our local jails in Sacramento County, and it actually came from food handling within the prison, and I think that needs to be included in the objectives.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: I have one. Adolph Falcon with COSSMHO.

Under the area of food safety under Objective 1, food-borne infections we would ask that a subobjective be added including farm workers in the target group for reducing infections caused by parasitic pathogens.

Thank you.

DR. BANKS: Thank you.

Any other comments on food safety?

If not, we will move to focus area No. 7, injury/violence prevention. Tim Groza, CDC is our expert representative.

DR. WILLIAMS: This is Dr. Seleda Williams again speaking for the California Department of Health Services. Can you hear me?

DR. BANKS: Move closer, please?

DR. WILLIAMS: Speaking for the California Department of Health Service, Maternal and Child Health Branch, Section 7, injury and violence prevention, a couple of comments on Objective 35 which is reduce physical abuse by current or former intimate partners to less than blank per 1000. The Branch recommends adding a selected objective to include and demonstrate the significance of pregnant women.

According to the March of Dimes between 7 and 20 percent of women report experiencing physical abuse or sexual violence during pregnancy. Research has shown that physical abuse during pregnancy can lead to maternal-infant complications such as low birth weight, low maternal weight gain, infections and substance abuse.

We suggest possibly a subobjective 35A, reduce physical abuse by current or former intimate partners of pregnant women to less than 7 percent or 70 per 1000

I must say we are coming from a California focus here. We understand there may not be national mechanisms for tapping this. Some potential data sources that we use are EPIC which is Epidemiology and Prevention for Injury Control her at the California Department of Health Services and, also, the March of Dimes.

Objective 37, reduce to less than blank percent the proportion of battered women and their children turned away from emergency housing due to lack of space. Consider setting a target at 15 percent. Again, we are coming from a California perspective here. That may not be appropriate for the nation. A potential data source for that is the shelter information system commonly known as SIS in California.

Thank you.

DR. BANKS: Thank you.

MS. BEGLEY: My name is Doreen Begley. I am here representing the Emergency Nurses Association. I would be remiss in my duty is I did not speak up to something regarding injury prevention since that is one of our major focuses. As one of our missions, No. 41, under injury prevention and violence, to reduce to less than 15 percent the prevalence of weapons carrying by adolescents in grades 9 through 12. Boy, I would really like to see this be a lot lower, like zero tolerance for carrying weapons to school. Gun safety, It Is No Accident, programs like that really do need to set the standard for children that school is not the place for guns.

DR. BANKS: Thank you.

DR. JOHNSON: Loren Johnson, California Chapter, American College of Emergency Physicians. One of the apparent deficits that appears to be in the entire structure of our public health and EMS systems is the lack of integral representation of emergency medical services at the federal level in any agency except the National Highway Traffic Safety Administration.

We see, for example, that emergency medical services systems can be a very important element in injury and illness prevention, and that this is manifest in the EMS agenda for the future just published by NHTSA, and one of the most important comments, statements in their vision statement is the incorporation of injury and illness prevention into EMS activities.

I recommend to this panel that the NHTSA EMS agenda vision statement be reviewed and possibly incorporated and integrated into your work and that EMS be given a higher profile with respect to being a community public service that is most important from the standpoint of prevention as well as the provision of quality health services.

DR. BANKS: Thank you.

MR. FALCON: Adolph Falcon with COSSMHO and this area we would ask that the group review the behavioral risk factor surveillance system to try to call additional data on Hispanic populations. We would ask for a subobjective ensuring that across the objectives cultural and linguistically appropriate educational programs are developed.

Under Objective 7, injury prevention education we would ask that information about the implementation of culturally appropriate injury prevention education be added.

Under Objective 14, pedestrian injuries we would ask that a subobjective be added targeting the elderly.

Objective 15, safety belts, we would ask that the inclusion of surveillance of adults be added since children are more likely to buckle up if adults use their seat belts and under Objective 32 injury prevention counseling would ask the addition of culturally and linguistically appropriate to that counseling objective.

DR. BANKS: Thank you.

MS. OMAN: Sharon Oman from the Department of Health Services in Sonoma County, and I am representing myself. I am a maternal-child-adolescent health coordinator. I would like to address the area of domestic violence and ask that you think about changing the wording of the objective of reducing the number of battered women and children turned away from shelters to include men. I think that I know we are finding more and more men being victims of violence, and they are part of a family. So, I think that I would like to see more, I would like to see more gender neutral language in terms of any of your objectives around domestic violence.

Also, around child abuse one might consider an activity or objective making more parenting skills classes available to parents, and I noticed in another maternal child health section you recommended that all parents receive childbirth classes. I think maybe even more important will be parenting skills development to prevent child abuse.

Thank you.

DR. BANKS: Thank you.

Other additional comments?

MS. CHAN: My name is Alice Chan, and I am representing from California Department of Health Services, Refugee Health Section. In addressing domestic violence and, also, child abuse in 17, lack of skill, in our refugee community in the United States especially they have such a transitional period to understand about the culture and they have the priority which is not really how to raise their children. They have been struggling with how to deal with financial system, their housing and feeding the family. Those are the basic needs. So, a lot of those like the domestic violence being the male is the dominant in most of those foreign-born immigrants and refugee communities and the woman is the victim a lot of times. There are some anecdotal statistics out there being for the battered women, and also they don't have a shelter to go to because of the cultural and linguistic barriers, the obstacles, and the trust issue, too because they are new to the country, and they don't know how to navigate the system, and for refugees especially they come to this country because of the persecution, of human terror and reason, and so the distrust to the government is another issue that I would say, and so I would like to see the objectives paying a lot of attention to the refugee domestic violence and child parenting skills.

Thank you.

DR. BANKS: Is there another?

If not, we will move to focus area No. 8, occupational safety and health and Chuck Gollmar, CDC is our expert representative.

DR. KHANNA: My name is Dr. Mona Khanna, Director, Occupational Health Services for the County of San Bernardino. I would like to refer specifically to draft objective No. 4 which addresses repetitive motion injuries. It is more of a work absence targeted model and due to the high number and the increasing number of cumulative trauma disorders that we see because of computers and other automation I would like to see a more aggressive approach to this problem through our productivity and prevention model instead which includes increasing awareness, education and the inclusion of ergonomically appropriate interventions and job training and the engineering hierarchy of controls.

DR. BANKS: Thank you.

MR. FALCON: Aldoph Falcon with COSSMHO. In this area we would like to see an objective added regarding collection of baseline data on work-related injuries by race and ethnicity.

Under Objective 3, workplace injury and illness surveillance we would like to see that increased as a goal to all states and under Objective 10 blood levels exposure we would like to see that target increased to elimination of exposure.

DR. BANKS: Thank you.

Any other comments on occupational safety and health?

I guess everybody has a secure, safe workplace here.

We will move on to the next focus area, Oral Health and Dr. Henry Montes from HRSA is our expert representative for this area.

MS. STEPHEN: Hi, Samantha Stephen from San Francisco Health Department. I am the dental director and I am, also, representing nine Bay Area counties for the Child Health and Disability Program Oral Health Subcommittee.

C. Everett Koop stated that we do not have overall health unless you have oral health. Too often dentistry is ignored in federal health care and other health-related legislation. Notable examples include Medicare which provides virtually no dental care coverage and community migrant homeless health centers which have only minimal requirements for preventive dental services.

Given the disparities in oral health in adults that are cited in Healthy People 2010 the goal to reduce the large amounts of dental disease experienced by minority groups, it makes sense to try to reduce some of these disparities by recognizing that oral health is an essential and integral component of health. Therefore, I suggest an additional objective, something like all new legislation would establish publicly funded health care programs, facilities or delivery systems intended to serve poor and near-poor families will include a provision for dental care.

Dollars spent on health services should include between 5 and 20 percent for oral health services.

Thank you.

DR. BANKS: Thank you.

MR. GALL: Good morning. Teran Gall, with the California Dental Association. I am sorry, could I have the name of the gentleman from HRSA again?

DR. BANKS: Henry Montes.

MR. GALL: Okay, thanks. I would like to speak to several objectives. First of all I would like to say that all of the objectives seem to be appropriate and that we in dentistry anxiously await the Surgeon General's report on oral health forthcoming in 1999.

I would like to speak to Objective 3, the prevalence of root caries in adults ages 65 to 74 with six or more teeth from 13 to 19 percent. Having been involved in geriatric dentistry for a good bulk of my professional practice, believe me root caries does not stop magically at age 74. I think it should be all adults over age 65, especially due to our aging population demographics.

There should be another objective to avail dental health coverage to all adults over age 65. Currently Medicare doesn't cover routine dental and Medicaid is not available in all states.

Objective 10, I would like to see an increase, where it says, "Increase to 85 percent the proportion of the population served by community water systems, with optimally fluoridated water," I think in order to accomplish this, especially in California there needs to be some consideration for federal matching funds.

Currently in California we have submitted a private request through a foundation, the California Endowment to receive funding for fluoridation. There is o funding available from the federal level or from the state level, and I think it is a crying shame that we have to go to private resources to get funding for this objective.

Objective 12, increase to blank percent the proportion of 2 year olds who receive caries screening should read 6 months, and that is clearly stated by the American Academy of Pediatric Dentists that screening should begin at age 6 months.

Objective 17, increase to blank percent proportion of long-term care facilities that provide oral examinations and initiate necessary prevention, education in oral health treatment services no later than 30 days after entry into these facilities.

To me this is a "no-brainer." When you consider over regulations, the percentage should be 100 percent.

Objective 20, ensure that all state health agencies and local health agencies serving jurisdictions of 250,000 or more persons have an identifiable dental public health program in place that is directed by a dental professional, I think that you should consider withholding federal funding for a dental program if a state dental health director and/or a paid dental consultant is not in place. Currently in California we do not have a state dental health director.

I see that my time has expired. Thank you for listening.

DR. BANKS: Thank you.

DR. NOEL: My name is David Noel. I serve as the Chief Dental Program Consultant for the California Department of Health Services. I am a dentist, and I want to speak to oral health.

There is a particular viewpoint these days that has come out of quite a bit of current research that some people aren't aware of, and that is that dental decay is an infectious disease. A child is born without the critical Strep mutans bacteria that cause tooth decay, and the child is therefore infected by the child's mother, father, peer group or whatever very early on with Strep mutans. These particular strains of bacteria, if they are not present no tooth decay is caused, and the intervention at the level of maternal and child health, Ob-Gyn, what might be called the medical side of the body as opposed to the oral health and dental side of the body could be of great service when a pregnant mother comes in for early counseling for that mother to know that if she and her circle of people around her do not infect that child with tooth decay that this disease very likely will not occur in that child. Most of us know that 80 percent of tooth decay occurs in 25 percent of the population, and this is borne out with this research.

So, I would like to suggest some kind of category which encourages Ob-Gyn, maternal and child health folks who deal with expectant families to intervene based on this research, and that would involve training in medical schools, nurse practitioners, etc., to let folks know that if they get the Strep mutans cleaned out of their mouths and the child develops an oral flora without Strep mutans it is extremely difficult to create tooth decay in that person.

There are a number of reference folks around on this, John Featherstone, the Chair of Oral Health at UCSF School of Dentistry, Dr. Rory Hume, of UCLA Dental School who is still at UCLA, and Dr. Max Anderson, the head of dentistry at Washington Dental Service. All are out on the circuit discussing these materials.

So, I am certainly available for discussion about this, and those three reference folks are available, and thank you.

DR. BANKS: Thank you.

I understand we have a gentleman in the back who wants to testify using a hand-held mike.

MR. DAVENPORT: My name is Bob Davenport, and I work for the Department of Health Services in Sacramento, but I am representing myself. I would just like to say that I agree with the ex-Surgeon General C. Everett Koop that you don't have health unless you have oral health and that a child in school that has a toothache who has pain or infection in the face is not likely to be learning very much.

With that in mind, I would like to advocate for a new evaluation for public health infrastructure and an addition that monitors the percentage of states that have a full-time dental public health director that is either a dentist or a dental hygienist, and that is the conclusion of my comments.

Thank you.

DR. BANKS: Thank you.

MS. SKOURN: Hi, my name is Sharon Skourn, and I am from the Community Health Center in Reno, Nevada. We currently opened a dental project. I am speaking for myself and for our center. We are working with hygienists and no dentist on staff. We refer out. That is extremely difficult. We are currently providing cleanings, screenings, exams and sealants to Medicaid children and are hoping to open that up to sliding-fee children.

We currently have seven dentists in the Northern Nevada area that accept Medicaid. I would advocate for expanding reimbursement so that Medicaid is more readily acceptable by the dentists, and I would advocate education through our low-income populations so that they have less dental problems, and it is true, children who have dental problems don't do well, and it breaks your heart to see a 2 year old with baby bottle tooth decay that you cannot get into a dentist. Nobody will see this child. So, I would advocate for more dentists that accept Medicaid. I would advocate for more dentists in the pediatric field alone, and I would certainly advocate for more funding for community health centers across our nation so that they can provide public health dental services to our children, and the other thing that I would advocate is including dental programs and dental benefits to Medicaid and Medicare beneficiaries.

Adult Medicaid recipients in the State of Nevada receive no dental benefits.

Thank you.

DR. BANKS: Thank you.

DR. COOK: Good morning. My name is Dr. Tracey Cook. I am the dental director of the Sacramento Urban Indian Health Project located here in Sacramento. My comments are my own. I would like to see added to objective No. 13, a statement that involves completion of necessary dental treatment within a specified time. I noticed that local programs often get children started with referrals and screening, but there is a lack of follow-up, and so nothing ever occurs until there is an emergency later on. So, if we could include some type of follow-up of a completion date to see some of these documented problems being taken care of so that they are not an emergency later on throughout the year I think we will end up with less cost involved and less pain to the child.

Thank you.

DR. BANKS: Thank you.

MS. CHAN: Alice Chan, from California, Department of Health Services, Refugee Health Section and, also, speaking for myself, being an immigrant here years ago. When I look at the objective, let me see, No. 16, talking about the community migrant health center I think it is very important to have a highly establishment expressly on, not only on services but, also, health education because as a foreign-born person and, also, with refugees there is not a kind of official statistics show being working for the refugee health program. Ninety percent of the refugees come in this country for our initial health screening we detect they have dental problems, and 50 percent out of that 90 percent need treatment regarding whatever because dental hygiene, oral hygiene is not enforced in most of the foreign countries where we come from, where I come from anyway. So, even though for myself, for those years and for my Ob-Gyn, the only thing that I had the detected problem and I was enforced that I really need to keep up, and, also, regarding my friends and family around me has to be keep up with the oral, you know, routine hygiene. So, I would like to enforce for the cultural and linguistic part of it for health education for oral health.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: Adolph Falcon with COSSMHO. Under this area I would like to see a subobjective added increasing the number of Hispanic dentists to a level of no less than 12 percent.

DR. BANKS: Thank you.

Additional comments for this focus area?

DR. WILLIAMS: Seleda Williams, California. I think I would just like to add a personal comment although this is not my area of expertise. I noticed that in the oral health objectives there is really no specific mention of baby bottle tooth decay, and actually they mention in one of the first objectives reducing caries starting at age 2, but actually baby bottle tooth decay can start before that age. So, it might be a consideration to add an objective maybe more of a developmental objective in terms of increasing knowledge of expectant mothers about baby bottle tooth decay so that it can be prevented from a very early age, and one other final comment for the department regarding the objective on dental sealants, as you know, the Title V Maternal and Child Health National Performance Measures include dental sealants. The 70 percent rate, I believe that is set as the target goal is actually very high compared to what we are seeing here in terms of dental sealants in the State of California. I don't have the exact figure with me today, but I do know that it is much lower than that, so that the better than the best method may be a very ambitious target although I think it is a noble one, and we need to strive for that.

Thank you.

DR. BANKS: Thank you.

Additional comments?

MR. OLANO: My name is Victor Olano from Stockton, California. I am the senior health educator for the Public Health Service in San Joaquin County, but I am speaking for myself.

We have a dental diseases prevention program in California, and we would like to see that expanded, and when we say the Objective 1, reduce dental cavities in primary and permanent teeth we are talking about children, but we don't say how, and prevention and health education is one of the most effective ways to do it. So, I would like to see an objective that addressed that, education in primary and secondary schools.

Thank you.

DR. BANKS: Thank you.

Other comments?

We will move now to focus area No. 10, access to quality health services. Our expert representative from HRSA is Lyman Van Nostrand.

DR. JOHNSON: Once again Dr. Loren Johnson, California Chapter, American College of Emergency Physicians. I would like to reiterate that we treat all of the failures, if you will that occur in every one of these focus areas and all those in the other room. So, we believe that there should be some better integration of emergency medical services into the entire process.

The specific area that I want to represent is to commend the body for the recognition of the importance of access to emergency care and to recommend that objective C2 increase to, should be 100 percent; it is blank here, the proportion of patients whose access to emergency services when and where they need them is unimpeded by their insurance status or by their health plan's coverage or payment policies.

You, also, want to speak to that statement. The American College of Emergency Physicians objects to the inclusion of this term "by their emergency status" but favors the continuation of the term "by their health plan's coverage or payment policies."

Let me explain? Federal law and the ethics of emergency medicine dictate that we see everybody who presents and requests emergency care. There certainly was a tremendous amount of confusion in the health care environment with respect to managed care prior authorization for access to emergency services, but this has long since dissipated, and there is no such thing as a patient who doesn't have access to emergency care because of insurance status. It is difficult for me to make such a blanket statement, but I would say that that is virtually true in California with respect to access to the emergency department itself.

The problem continues to be insurance barriers to coverage and payment practices, and so we would support the statement without the insurance status words in there.

Secondly, I want to focus on a new area that is a grave threat to the emergency chain of survival. I speak for myself.

Most hospital emergency departments in urban and suburban areas are staffed by qualified emergency specialists who must, also, rely on consultants in other specialties to provide on-call back-up coverage for complicated emergencies. In many regions the reorganization of our health care system under managed care has resulted in a major reduction of availability of physician specialists and their willingness to serve on these on-call panels.

Serious deficits in specialty back-up threaten to compromise patient care and the integrity of local emergency medical services systems. This problem must be addressed at regional and national levels if the chain of survival is to be maintained.

I recommend that as an objective that we have 100 percent availability of physician specialty coverage when a request for immediate back up for the provision of emergency care is made by the physician on duty. This is a serious problem in California and several other regions of the country in which managed care is prevalent. We are working on a task force for the California Health Care Association, CMA, CALASEP(?) etc., to try to solve this problem.

DR. BANKS: Time.

DR. JOHNSON: We need attention at the public level.

DR. BANKS: Thank you.

MS. SUSSMAN: My name is Carole Sussman. I am from Torrance, California. I am a physical therapist, and I represent a consortium member, the National Pressure Ulcer Advisory Panel or NPUAP, and I would like to speak on two aspects of the access to quality health services, both preventive care and long-term care and rehabilitative services. I wonder if I might have a little extra time so I can cover both topics, more than the 3 minutes?

DR. BANKS: No, you are allowed 3 minutes. If we have time within the 20 minutes we can come back to you.

MS. SUSSMAN: All right, thank you. I just wanted to clarify that. All right, then let me tell you a little bit about pressure ulcers are a problem in long-term care, but they are a problem, also, in acute care and the National Pressure Ulcer Advisory Panel would like to see an added objective to add pressure ulcer prevention and education to your list of objectives under preventive care. We are, also addressing the goals to improve quality of long-term care services to reduce to no more than X per 1000 the proportion of nursing home residents with pressure ulcers at stage 2 or greater.

NPUAP proposes a target goal of 5 percent or 50 per 1000 cases. Multiple studies show that the average prevalence rate for pressure ulcers even in good long-term care facilities is about 5 percent or 50 per 1000. This is based on studies where guidelines based practice was implemented and showed that prevalence was reduced to approximately 5 per hundred or 50 per 1000. There are those who would argue that this figure should be lower, but that implies we have knowledge and technology to lower this figure.

At the present time prevention studies have not shown this to be achievable with current knowledge. Some studies currently show a prevalence as low as 8 percent. Our target of 5 percent or 50 per 1000 seems to be realistic. However, we, also, propose research and testing of quality of care indicators that have been derived from HCPR pressure ulcer prediction and prevention guidelines and which have been further refined by a national expert panel.

What I would like to come back to talk to you about is the quality of care indicators that we would like to have included.

Thank you very much.

DR. BANKS: Thank you.

MR. TOLERAN: My name is Daniel Toleran. I am the coordinator, policy and planning for the Association of Asian Pacific Community Health Organizations better known as AAPCHO. We are based in Oakland, and I am a California resident in Oakland specifically.

My comment is one to acknowledge the working group in terms of including in its overview the very concepts of culturally competent settings, and the language states high-quality culturally competent settings by culturally linguistically competent health care providers.

I did want to point out an oversight. Given that there is tremendous interest, nationally on cultural competency and the standards that are being established by the Health and Human Services Interdepartmental Working Group to put out cultural linguistic access to service standards we would like to see some objective in all the sections under preventive care, primary care, emergency services, long-term care and rehabilitative services the very notion that cultural competence is something that we need to strive for. At minimum we would like to see language that would incorporate the class standards that are being developed by HHS. I think it is going to be put out already in a second draft review at this point.

So, thank you.

DR. BANKS: Thank you. Would you sign up?

MS. CHEN: Alice Chen, from Department of Health Services, representing the Refugee Health Section, myself, as an immigrant and, also, as an allied health professional registered nurse and I want to address about the cultural and linguistic equal access to health care services and, also, the quality of services provided to all the consumers out there, and that is regarding the medical interpreters, and all the medical staffing no matter where you are in the clinic, at a hospital and a lot of, and I have professional and medical doctors that have been utilizing medical interpreters to do interpretation for the non-English-speaking or limited English-speaking patients, and at this time there is no national standard or any national reimbursement for the local health you know to reimburse, to hire qualified and train medical interpreters to do the medical interpretation, and there is a lot of concern out there throughout from the medical professionals, allied health professionals and, also, any health provider or related interpreting services regarding the training and certification and qualifications of the medical interpreters.

There are some local and, also, national and state non-profit organizations that have been working to set up standards for medical interpreters. The one I recommend would like to see in the federal document to put the strength, you know, to look into this issue, and ensure to have adopt you know, like the Massachusetts, California and also, Washington State and, also, there is a national organization, American Society for Testing and Materials that we are working so hard to set up the standards, but right now the key is to put into the legislature into the bill and finally get it all standardized, uniform and consistent among all the states and the nation, and this is what I am advocating for medical interpreter standards, and the other thing is to train all the medical interpreting service providers how to utilize medical interpreters because they need to be recognized as a skilled profession.

Even though I am bilingual by culture when I was a nurse working and I still don't understand the code of ethics, you know; so, I violate a lot of rules that when I look back I don't see this. I say, "Why should I do that?" So, even though you know medical terminology and know the procedures so well, but the ethics issue is the main part. It requires skilled training, and thank you.

DR. BANKS: Thank you.

DR. KALLSEN: Dr. Gene Kallsen, clinical professor of emergency medicine from UCSF, Fresno, and I am speaking today on behalf of the Society for Academic and Emergency Medicine not on behalf of the university.

I would like to speak in favor of your access objectives in general and 10A1 and C2 in particular. I would like to point out as Dr. Johnson did that in fact access to emergency departments, there is not a major barrier in access to emergency departments because of insurance. In fact, there is federal and state legislation that clears up that problem fairly nicely.

The problems continues to be though the problem of follow-up, and in fact, this section coming right after the oral health section reminds me of a very recent example where a local emergency department was cited by the state because a patient with a toothache waited 4 hours before being seen by an emergency physician.

The disparity between what an emergency department is expected to do when a patient presents with a condition and what the rest of the -- and the access that the patient has to much of the rest of the health care delivery system is really a remarkable disparity.

Finally, I would like to add that in California SB1973 was passed and signed into law within the last several months. It offers a data opportunity where there will now be both a mandate and funding for better information about emergency department visits. I think this will make your access objectives more measurable at least in California.

Thank you.

DR. BANKS: Thank you.

MS. BEGLEY: Doreen Begley, from Emergency Nurses Association. I would like to concur with my esteemed colleagues from ASEP and SAM(?) regarding access and follow-up, and although I laud all of our efforts to include the prudent lay person terminology in access to health care, my fear as a health care provider and a hands-on caregiver is that insurance companies not only will tell you don't have an emergency but that you are not prudent, also.

So, I don't think we should have a false sense of security that the prudent lay person is going to clear up a lot of the gray areas.

The second issue I would like to address is the objective C6 to increase to 75 percent the number of hospital emergency departments that provide or arrange for follow-up for mental health services. It goes on in the notes to say that the reason this isn't done is because the services don't exist. So, as opposed to having a goal for an emergency department to do yet one more thing with a system that isn't in place, perhaps we need to buff up mental health so we have people to refer people to.

Thank you.

DR. BANKS: Thank you.

MS. FRENCH: My name is Susan French, and I am representing the California State Emergency Medical Services Authority, and we are very pleased that the Healthy People 2010 will have a specific goal for emergency medical services. We are disappointed, however, that except for EMS for children Healthy People 2010 lacks specific objectives for the completion of the infrastructure of EMS systems and subsystems and for the improvement of those systems and subsystems.

We will be submitting written comments and suggesting additional objectives that address our concerns.

DR. BANKS: Thank you.

MS. SKOURN: Hi. Again, I am Sharon Skourn, from Reno, Nevada, and I am speaking on behalf of myself. I was reading through the access to primary preventative health care and I agree wholeheartedly that we need to have a medical home for everyone and that it should be zero percent.

It has been a pleasure to be part of this this week, and I have to tell you that access for us is a real issue. We have bilingual people in our clinic, and we see a large proportion of Hispanics, but we see a large proportion of uninsured, and it is a shame to see how many uninsured people there are.

It would be nice that everyone had equal access to health care regardless of where they reside.

Thanks.

DR. BANKS: Thank you.

MS. WALLACE: Good morning. My name is Ann Marie Wallace. I am a federal legislative director for Planned Parenthood Affiliates of California.

Under the emergency services objectives, C2, where you are increasing access to emergency services and trying to prevent impediment based on health plans, we would like to see that expanded to also prevent impeded access due to the provider or entities' limitations. For example, we find women seeking emergency care in cases of rape and incest are sometimes denied access to emergency contraception due to the religious beliefs of some religiously based health care entities that object to contraception.

This refusal of care is during the critical period of 72 hours when emergency contraception is effective in preventing conception. That is just one example, and we appreciate your expanding that goal.

Thank you.

DR. BANKS: Thank you.

Is there anyone else?

MR. FALCON: Adolph Falcon with COSSMHO. Under this area, Objective A5, training to address health disparities we ask that language be added concerning cultural competency training for all health professionals and, also, certification and cultural competency for the health professions and under Objective B5, racial and ethnic minority representation in the health professions this is truly one of the most glaring areas where the objectives are not ambitious and not bold.

Rather than 6.4 percent being the target for Hispanics in the health professions we would call that the target should be set at no less than 12 percent which is the current representation of Hispanics in the population as the goal for 2010.

DR. BANKS: Thank you.

MR. VAN NOSTRAND: Could I just ask a question on that, whether you have a recommendation on the nursing section, too or whether you are going to have one on that?

MR. FALCON: Yes, actually that, also, refers to the nursing section.

MR. VAN NOSTRAND: Okay.

DR. BANKS: We will now move to focus area No. 11, family planning. Tom Kring, Office of Population Affairs is our expert representative in this area. Are there comments?

MS. SINGER: Hello. I am Jade Singer from the Women's Health Care Nurse Practitioner Training Program at Harbor UCLA in Torrance, California.

For those of us working in the area of family planning, we face the same obstacles discussed here, such as need for culturally and linguistically appropriate care access problems and of course the bigger picture of health concerns, hunger, housing, violence and so on.

However, it is critical to recognize the additional battles that family planning advocates face, and that is of a well-organized, well-funded vocal minority who are against the use of contraceptive methods including IUDs, emergency contraceptives and dare I mention a word, "abortion."

I listened to a congressman some months ago who is, also, a physician stand on the House floor opposing a bill that had a family planning funding addendum on it convincing his colleagues that IUDs are abortifacients and given that he is a physician we must know that he has the right information. However, that is incorrect. The commitment by DHS to view family planning as a public health issue, not as a political or religious issue must be strong and it must be continuous.

The goals of Healthy People 2010 in the area of family planning cannot be dependent on the political party in the White House. Method availability needs to be equal to that of what it is in other countries and our focus and energy needs to be toward the delivery of services including the very important component of education and not in fighting these political battles on an ongoing basis.

Thank you.

DR. BANKS: Thank you.

MR. FALCON: Adolph Falcon, with COSSMHO. In the area of family planning we would ask that we include HIV, STD prevention, treatment and outreach and education along with the family planning language. We would, also, ask that the youth risk behavior surveillance system be looked at to identify more areas for Hispanic data reporting under Healthy People 2010.

Under Objective 11, the language about safe sex we would call to be changed to safer sex in terms of terminology and under Objective 12, the school requirement for classes on human sexuality and pregnancy prevention would, also, ask that this area include community-based programs to reach out-of-school Hispanic youth.

Thanks.

DR. BANKS: Thank you.

MR. WENGER: Hello, Steve Wenger, Saint Joseph, Missouri. I am representing the Saint Joseph Youth Alliance. I am Chair of the Board, as well as the Youth Health Partnership which is a collaborative between the health system and the school.

I am going to quickly represent a thought that actually came up yesterday by Peter Abbott and that is that we really aren't measuring teen pregnancy. We are measuring teen births, and I know the data collection issue is a hot one, and if we can just have the wherewithal to actually collect the relevant information so that we can monitor teen pregnancy rather than just teen births that would be a help.

DR. BANKS: Thank you.

Are there additional comments?

MS. WALLACE: Again, my name is Anne Marie Wallace, federal legislative director for Planned Parenthood Affiliates of California. Under Objective 1 we laud the goal of 70 percent for a new rate of unintended pregnancy. Currently half of all the pregnancies in the United States are unintended and that same rate is true here in California, and we applaud that goal and we do think that that is very doable.

Under Objective 4 with contraceptive failure a recent study found that contraceptive failure is the No. 1 reason why women use emergency contraception. We believe that greater access and dispensing of emergency contraception through programs like Title X will go a long way towards preventing unintended pregnancy but, also, making sure that women are using the right form of contraception for them personally.

Many times women may opt for a method of contraception and later find that it is not working for them. This would be a great tool, I think, in order to identify that problem.

Under Objective 6 under male involvement I would like to see, Planned Parenthood would like to see this goal to include more preparation for the day when reversible form of male contraception becomes available. It will become available in the foreseeable future. We believe this new form of contraception will be in very high demand when it becomes available, as you saw recently with Viagra and we need to prepare for that day and particularly here in California the Title X program is the only source for male contraception in this state through the public health system, and that is critically important. So, again, when that contraceptive form becomes available the first place we want to be able to turn to is the Title X program and other related programs.

Under Objective 11, pregnancy prevention education the goal that comprehensive health education for students, we would like to add language that requires that health education information be medically accurate. Unfortunately, our health educators report to us that a number of programs here in this state and I understand throughout the country use grossly inaccurate medical data on the effectiveness of contraception and even the effectiveness of condoms in preventing HIV.

We really need to set standards and make sure people are using the CDC statistics on the effectiveness. It is critically important if we want to prevent sexually transmitted disease, HIV AIDS and unintended pregnancy across the board.

Thank you.

DR. BANKS: Thank you.

Any other comments for this focus area?

If not, we will turn to focus area No. 12, maternal and infant health. The expert representatives for this focus area are Lyman Van Nostrand, HRSA and Chris Kochtitzky. He is from CDC.

MR. WENGER: My name is Steve Wenger, Saint Joseph, Missouri, again, representing the Saint Joseph Youth Alliance and the Youth Health Partnership of Saint Joseph, Missouri.

I took a little different strategy than Adolph, and rather than popping up every time my comments are actually quite broad, and they didn't get limited just to maternal and infant, but it is really children's care. The first thing I would ask is that this body challenge itself to meet with its education brethren at a national level so that when these objectives are reviewed we aren't setting ourselves up for conflict with our educators. We have found that there are policies when we go to work together through schools, some of our health and school and education objectives end up conflicting. So that there would be some sort of a way to make sure we aren't setting ourselves up for conflict down the road. Earlier today I mentioned developing asset indicators, and this is the best opportunity that I know to develop that, and my challenge is that the youth health behavior survey system folks take a look at balancing their risk indicators with asset indicators.

It is a good survey, but it is only measuring the negative. It is only measuring the deficits and in fact the reduction of deficits is best done by increasing the assets of a kid, and for those who haven't followed that, it does measure things like is there a positive adult in one's life, the school atmosphere, essentially issues of faith, hope, a compelling future, and in the long run if we want to reduce the deficits of children we are going to build on their assets and I have no stake in this monetarily but Peter Benson and the Search(?) Institute has done a lot of work as have McKnight and Kretzman(?) of Northwestern university, if you can use that and in the future youth behavior risk surveys if we balance the risk part with the asset part and then again just from a very local level, even the notion of identifying children as youth at risk has a certain stigmatizing behavior setting negativity to it that I think we need to be careful about.

DR. BANKS: Thank you.

MS. HAYDU: Suzanne Haydu, again, with MCH, California Department of Health Services speaking as a nutrition consultant.

I have two objectives I wanted to address. One is the one on folate Objective 27. I wanted to go along with the Institute of Medicine, the CDC and the MCH Bureau recommendations.

So, with that in mind, I would suggest stating it as increase to at least 80 percent the proportion of women of childbearing age that take 400 micrograms of synthetic folic acid each day from fortified foods or vitamin supplements in addition to the folate they obtain naturally from a varied diet. Increase to at least 90 percent the proportion of pregnant women who consume 600 micrograms per day of dietary folate equivalence and then when determining dietary folate equivalence include folate intake from food and synthetic folic acid in planning and assessing diet. So that adds food to the vitamin supplement in that recommendation.

The other one is in regard to breast feeding. There are now two objectives recommended. I recommend that we combine those two objectives and instead of stating that 75 percent of the women should breast feed that that portion of Objective 29 should state, "Increase to at least 75 percent the proportion of mothers who exclusively breast feed their babies in the early postpartum period, including premature babies who receive human milk fortifier," and then I would define exclusive as they do in the Title V performance objective. I think what we really want is hospitals to be discharging the majority of the babies exclusively breast feeding. We don't want a high portion of the babies, also, having formula, and then there are three areas that I would like some related developmental objectives and that is to increase workplaces with breast-feeding friendly workplace policies, for hospitals to implement model hospital policy and practices that support breast feeding like in the 10 steps to successful breast feeding and finally, that we increase the perinatal and pediatric medical providers who routinely provide or refer to breast feeding support services.

Thank you.

DR. BANKS: Thank you.

DR. HEINIG: I am Dr. Jane Heinig. I am a research scientist at UC, Davis, and, also, the editor in chief of the Journal of Human Lactation, and I am here representing International Lactation Consultants Association, and we are very pleased to see an objective which includes breast feeding rates out to 1 year of age. We are all very, very, very pleased about that addition. However, we did have some concern about the definitions being used for breast feeding for the objective as a whole.

Right now it says that it is either exclusive breast feeding or the use of breast milk with a supplemental bottle of formula, and our concern would be how the use of a supplementary formula in that definition is very vague and at the very least we hope that that would be clarified whether that "a supplementary bottle of formula" is once a day or once a feed or once a week or something, but prefer as Suzanne Haydu just suggested to have the objective for discharge to be exclusive breast feeding but at the very least I know that many of the surveys that are currently conducted to assess breast feeding rates ask first, "Do you breast feed at all?" and then ask, "Do you provide anything else?" and I don't know of any surveys that specifically ask, "Do you provide a supplemental bottle of formula?" Also, while there is a suggestion in the comments related to the objectives regarding the need to increase social support for women and maternal education, we noted a gap that we think is very important that there was a lack of a need to educate health care providers in support and management of breast feeding and, also, to improve access to all women to skilled lactation professionals.

Thank you

DR. BANKS: Thank you.

DR. WILLIAMS: Dr. Seleda Williams. I am a public health officer with the California Department of Health Services, and I am here to comment for the Maternal and Child Health Branch of California.

First of all, I would like to say that the narrative section in the MCH section on the discussion on infant mortality and prematurity and low birth weight was very well written.

I would like to say that we would recommend that the US Department of Health and Human Services consider incorporating all of the Title V block grant program national performance measures as developed by the MCH Bureau in HRSA.

We would, also, suggest that you might want to additional MCH-related objectives in the last section of the chapter, for example, Section 7 could include additional injury violence prevention objectives such as No. 35 and No. 37. The list could be expanded a little bit.

There is a couple I would like to deal with in terms of specific objectives. I will hit the most important ones first since there is a time constraint.

Objective 15, increase the proportion of very low birth weight infants born at level 3 hospitals and in brackets facilities for high-risk deliveries in neonates. This terminology level 3 is tending to become obsolete. We encourage the inclusion of this developmental objective into the revised 2010 objectives. However, we recommend using the most recent definitions of the level of prenatal care or levels of prenatal care as defined by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists of Guidelines for Perinatal Care, Fourth Edition, and also, we recommend a short narrative section clarifying some of the issues related to the various definitions of levels of prenatal care as they relate to high-risk facilities. We will be submitting some of these additional comments in writing.

Another objective I would like to make comment on is Objective 32, increase to 100 percent the proportion of newborns who are screened for hearing loss by 1 month of age, have diagnostic follow-up by 3 months of age and are enrolled in appropriate intervention services.

We recommend that each component of this developmental objective have its own 2010 target. One hundred percent is a rather ambitious target. We recommend decreasing the targets to be more realistic. We will be submitting comments on some suggested revisions for that.

It is important to realize that the nominators for the second part of those objectives related to follow-up and diagnostic services might be a little different from the first part.

So, the wording should be worked on a little further. Also, we suggest with regard to Title V NCH bureau performance measures the incorporation of those performance measures that relate to children with special health care needs. Upon reviewing the 2010 objectives there do not appear to be any identifiable objectives there, for example, increase the percent of state SSI beneficiaries less than 16 years old receiving rehabilitative services from state children with special health care needs programs and increase the degree to which the state children with special health care needs programs provide or pay for specialty and subspecialty services including care coordination not otherwise accessible and affordable and finally increase the percent of children with special health care needs in the state who have a medical health home.

DR. BANKS: Time.

DR. WILLIAMS: Thank you.

MR. FALCON: Adolph Falcon. It is just me popping up. In this area in particular we would like to call on the group to look at generational data. In this area perhaps more than any other we have information that the first generation does much better than the second and succeeding generations, and that is something we really need to start tracking and putting a lot more attention to.

Those objectives that deal with counseling and educational services in particular, Objective 9 which deals with preconception counseling and Objective 13 with the childbirth classes we would ask that culturally and linguistically competent language be added to those objectives, in particular Objective 26 which deals with genetic testing. It is important that informed consent language deal with the issue of culturally and linguistically competent information about the consent being provided.

Also, under Objective 37, primary care services and Objective 38, screening we would call for those objectives to reach 100 percent finally under this area.

Thanks.

DR. BANKS: Thank you.

MS. SHELTON: Hi, Shirley Shelton, with the Department of Health Services, and my comments are personal. Two areas, one, I think that it is critical that this section talks about cultural and appropriate services, and I think that in this context it needs to go beyond cultural and linguistic.

I implore you to take it further because it is not enough for agencies to provide pamphlets and brochures that they deem linguistically appropriate. It is much deeper than that, and so, I implore you to include language that directs agencies to provide culturally appropriate services.

Second of all, what this process feels like even though I applaud it, I think it is very, very relevant, and I appreciate the opportunity to be here, but it feels like we are planning a wedding, and in the planning stage we are going through the list. We are getting all things in order, but it doesn't feel like we have consulted the bride or the groom, and in this context if we are really about eliminating disparities, what I advocate for is that we involve the bride and the groom, the people that we need to serve.

They need to be involved. We need to have their cooperation. We need to have their support. So, while this form was important for health care providers and community-based organizations to attend and to provide our input, it is, also, important for us to have the support and the cooperation from the folks that we need to impact. So, I would like to see the same kind of effort taken down a step lower.

We have to have their input if we truly are going to make a difference. We not only have to partner with our sister agencies, we, also have to partner with communities, with individuals. They need to know that we care. We need to know that they support what we are doing. We cannot plan the party and leave them out, else they won't participate.

(Applause.)

DR. BANKS: Let me just make one comment? This forum for the last day and one-half was an attempt. It might be considered a feeble attempt by some, but it was an effort in each region to be inclusive, not only for health providers and state and local and federal officials, but, also, for community-based organizations and for private citizens to participate, and we had an extraordinarily long mailing list of individuals, private individuals, community-based organizations and so forth, but I think your comments are well taken, and perhaps we need to do a better job of including private citizens, but an attempt was made. It may be considered a feeble attempt, but an attempt was made to include everybody in the country because this is what this is about, and we realize that everyone must be included, but your comments are well taken.

Are there any other comments for this focus area?

If not, we will turn our attention to the last focus area, medical product safety and again, Dr. Janet McDonald from FDA is our expert representative for this area.

MR. FALCON: My last pop-up. For the recording, Adolph Falcon from COSSMHO. Under this area I would ask that Objective 1, monitoring of adverse drug reactions, specifically analyze and report adverse drug reaction information for Hispanics and while we have been calling for culturally and linguistically appropriate information and services across all the objectives would ask for specific attention to Objective 10 in this area, patient information about prescriptions, language being added to ensure that information is provided in a culturally and linguistically appropriate manner.

On the comment about inclusion of community-based organizations and their comments in this process I think it is important as a wrap-up to recognize how difficult it was for community-based organizations really to participate in this process, and if we are serious about including racial and ethnic groups in this process and eliminating the disparity when we finally look at the comments that are received, we need to make sure that there is a way that the comments received from community-based organizations aren't lost in really what are going to be a sea of comments from much better funded entities that have a vested economic interest in the results of the deliberations of Healthy People 2010 and really find a way to ensure that the voices of community-based organizations that have made it to the process of comment aren't lost in the wave of other comments.

DR. BANKS: Thank you, for that comment.

Any other comments for this focus area?

People want to go skiing, I assume.

We are finishing this segment early. For those people who had additional comments from this morning's session and those people who did not finish making their comments in this session, you are welcome to come to the mike and do that now.

MS. SUSSMAN: Thank you for the second opportunity. My name is Carole Sussman. Again, I represent the National Pressure Ulcer Advisory Panel, and I did not get to address the fact that one of the comments under objective No. D4, Item D4 under developmental was to use pressure ulcers as a proxy for long-term care quality care. However, since pressure ulcers occur in the acute hospital, that is where the incidence of pressure ulcers occurs, and then patients are transferred to long-term care settings, prevalence will always be higher in long-term care. Therefore a long-term care setting will not be able to correct prevalence without a reduction in acute care hospital incidence rates.

Pressure ulcer development incidence is definitely one proxy of quality of care in both the acute care and the long-term care facilities, but pressure ulcer prevalence alone is not the correct measure of quality of care in long-term care facilities and is never an indicator of total quality of care.

It is known that patients with multiple or serious comorbidities are more likely to develop pressure ulcers and those may be unavoidable. Persons with pressure ulcers have indeed increased mortality. Therefore we are proposing that you add the prevention objective for pressure ulcer prevention and education to your list of objectives, and we would indicate that there are proposed research and testing of quality of care indicators which are derived from AHRQ, pressure ulcer prevention guidelines.

While these quality of care indicators have not been tested for their efficacy, further testing is needed. Preliminary studies indicate that comprehensive patient assessments are needed to possibly prevent pressure ulcer development.

There is, for example, evidence to show that nutritional assessments followed by intervention and pressure-relieving support surfaces may be significant in prevention.

Recent analysis of compliance rates, however, using quality indicators in acute care facilities shows that there is a very low compliance with quality indicators. Therefore, testing and development of quality indicators and research which will probably require, and in fact, does require and compels funding of these preventive resources is an advocacy position of our organization.

Therefore we would recommend adding the prevention objective for pressure ulcers as well as using a different measure, other measures in addition to pressure ulcers are proxies for quality care and long-term care.

Thank you.

DR. BANKS: Thank you.

DR. WILLIAMS: Some final comments from Seleda Williams from the California Department of Health Services.

I want to speak personally now. One comment I had to make is it would be recommended in general terms that the definitions of better than the best possibly be further elaborated upon in the introductory section.

When reviewing the objectives I found it a little confusing. I wasn't sure exactly what was meant by that definition. So, I would recommend a clarification of that.

I would, also, like to say in general I would like to see the goal of decreasing health disparities really be evaluated thoroughly and I think that the committee has done that.

I would, also, like to say that with regard to the African-American community we have a health care crisis. With regard to maternal and child health we know that infant mortality is double the rate in African Americans than it is in Caucasians.

This is just one example of a real travesty. We see significantly higher rates of disease and morbidity in almost all areas, including cancer. Prostate cancer in African-American males is considerably higher than Caucasians.

We, also, have problems with diabetes and heart disease. So, in terms of target-setting method from my understanding of better than the best I do really think we have to strive for better than the best in that realm, and I just wanted to say that.

I had a couple of final comments on the maternal and child health section which I couldn't get to previously. With regard to Objective 3, reduce sudden infant death syndrome mortality to .3 per 1000 live births, the target-setting method was a 60 percent improvement.

In California the rate of death associated with SIDS has decreased significantly over the last 5 years, and while the overall statewide SIDS rate has decreased by over 52 percent since 1989, the SIDS rate for African Americans has remained largely unchanged.

The Back to Sleep Campaign has played a significant and dramatic role in the reduction of SIDS in California. We support a significant reduction in the SIDS rate. Sixty percent may be appropriate in states where improving knowledge about infant sleeping patterns is still low, but may be too ambitious in those where the impact of programs such as the Back to Sleep Campaign here in California have already occurred.

We, also, recommend including targets for select populations as indicated. Oh, also, with regard to Objectives 8 and 9, these are developmental objectives related to disease morbidity and mortality for pregnant women.

We recommend, and I am assuming the Committee will further define some of these areas. They mentioned complications and eclampsia and ectopic pregnancies and routine care. It would be important for an objective to further define these types of objectives.

DR. BANKS: Thank you.

MS. STRATTON: Terri Stratton, California Department of Health Services, Domestic Violence Section. I am representing myself. Specifically I would like to address the violence and abuse chapter and the specific item No. 37 which was alluded to before. It talks about indicators of women and children who are turned away from shelters. There was a comment before about making that gender neutral, and I would like to recommend that you do not do that, that you leave it as is for the following reasons: One, California data which is consistent with national data still indicate that approximately 95 percent of all victims of domestic violence are women. So, by far they are the largest component of that. Although men are in fact, victims, as well, they generally utilize services related to legal resources, counseling, etc., and not in-home shelter services which that specific indicator addresses.

Men are, also, more likely to have other economic resources to not avail shelter services and frankly, they aren't available in this state as well as others that we are aware of, and there has been no demand for that.

To change this to gender neutral would, also, dilute the specific issues that women and children do have around domestic violence and in-home or in-shelter services.

Thank you.

MS. HAYDU: Suzanne Haydu with California Department of Health Services, MCH Branch, and I am, also, a consultant to the California Diabetes and Pregnancy Program, and I am suggesting two new objectives that could be either in MCH or in the diabetes section, and one is to increase to at least 90 percent the at-risk women who are screened for diabetes within 1 month of their first prenatal visit, and in 1998, we came out with guidelines for care for diabetes in pregnancy, and we defined at risk at age 25 or over obesity greater than 120 percent desirable body weight, having a history of diabetes in the family, had gestational diabetes in a previous pregnancy, are Latino, African American, Native American, Asian and from the Indian Subcontinent.

Also, the other new objective would be increase to at least 90 percent the pregnant women who are screened for diabetes at 24 to 28 weeks of gestation. Unfortunately not all our women are being screened, and it is hoped you could be monitoring that.

Thank you.

DR. BANKS: Thank you.

MS. SALINAS: Hi, Lisa Salinas from Community Resource Project. I am from a non-profit, and we serve five counties in Northern California, and we have operations that run in nine different languages.

We serve about 70,000 low-income people annually. I just would like to put forth to you the concept of cultural competency and linguistic accessibility. It is a critical issue for us out here in California. It is more than having a brochure available in a language with pictures. It is more looking at, also, the understanding and the cultural awareness of the people communicating.

To give you some anecdotal information which will cut across a lot of the different objectives that we have in maternal and infant health we operate a weight program, and my personal experience teaching childbirth education and, also, breast feeding to a variety of different cultures, on one hand I was looking at a breast feeding report that was put out by DHS that indicated amongst the Southeast Asian population that they had one of the lowest rates of infant breast feeding, and I was teaching a class with women from Muong and Vietnamese cultures, and I am Chinese myself, but I speak Spanish, and we were talking and encouraging them to go for postpartum care and talking about breast feeding, and it became very clear to them that in their culture for these particular individuals they had been taught by their mothers and their grandmothers that breast feeding was dangerous for their children, and so, we began to look to those issues. They are willing to talk to me about that.

Now, that is not the case for everyone from that culture. There are other things that we have found when we have been offering infant car seat classes when I used to work for Foundation Health, and we targeted the Hispanic population because when we looked at the data for the children that had died in car crashes for under the age of 4, the majority of those children were Hispanic children.

So, we launched a program that addressed those issues that tried to outreach to that population and looked at why there were some practices that they didn't have children in car seats.

The other thing that we have come across, too, because we work in so many different languages, I was out the other week teaching a class, talking about the accessibility of MediCal, how to use MediCal, Healthy Families to a Russian-speaking population, 15 Russian families, and they had never heard of Healthy Families before, and so part of the things that we are looking at is outreach into those communities, providing that cultural conduit and so, I encourage you as we write it not to say, "Cultural competency," for some people meaning one thing, and for another person it will mean a different thing, and to reach these high objectives that we want for the benefit for the children and families across the nation, we need to encourage people to go for the highest standard.

Thank you.

DR. BANKS: Thank you.

Any other comments?

You just made it.

DR. MOBED: Hello, again. My name is Dr. Ketty Mobed, working for Sacramento County DHHS, and I find myself as an advocate of prison health although I wasn't until yesterday, and the reason was because I read the draft, and I did not find any mention about our prison population, and it is important that the prison population is part of our population. Some prisoners will come out, but in California if they have a three strike, they will actually increase our prison population. They need health. They deserve health, just as we do outside of the prison.

I think it is very important that you include the prison population in the Healthy People objectives.

Thank you.

DR. BANKS: Thank you.

One last opportunity for anyone who wants to share?

I won't tempt you then. I certainly want to thank all of you for participating in this focus areas session. I think it has been very, very helpful and I, also, want you to be aware that all of your comments have been recorded, and you certainly can access these comments, the transcript of these comments by going to the Healthy People Web site, and you can look at these comments.

I think this day and one-half session dealing with Healthy People 2000 experience that we have with Healthy People 2000 and, also, what we want to do with Healthy People 2010, I think the time we spent together has been well worth while, and we certainly have benefitted from your comments, and I want to assure you that your comments will be considered as we move from the draft to the final document.

I, also, want to say that the final document will not satisfy everybody. Some think we have too many objectives. Some think we don't have enough. Some think we don't have their burning issue in here.

I was recently asked to fill in for the pharmacist and Secretary of Health, Dr. Phil Lee at UC, Berkeley School of Public Health as a seminar spokesperson, and I talked about Healthy People 2000 because that was the subject of the day, and I would say about 20 percent of the graduate students to whom I was speaking were concerned that there were too many objectives and that we were being overwhelmed by the number of objectives.

Other people thought we should include other things.

The other thing I want to assure you is that this is not a done process. It is not a process where a few individuals will make the final determination of what is in the final document. There is, indeed, a truly broad diverse section of individuals in groups from all sectors of society who will deliberate and come up with the final document. It has been a great effort on the part of the Department to try to be inclusive in this process.

Perhaps we haven't done as good a job as some would like for us to have done, but I will assure you every effort has been made, and for those individuals who did not come today I just want to let you know they can still have their input. We still have that Web site page, don't we? So, they still can have input if they have access to the Internet.

I want to implore you to continue to participate in this process and see it through, and if you do have additional comments you want to make write those or contact the individuals who are responsible for your area of interest and their names are printed in this draft document.

Thank you for coming. Thank you for participating.

This session is adjourned.

Have a safe trip wherever you are going.

(Thereupon, at 11:25 a.m., the meeting was adjourned.)

Sacramento Transcripts and Summaries