Transcript of the Healthy People 2010 Regional Meeting
Seattle, Washington
December 2-3, 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. LYONS: Good morning, again. My name is Dick Lyons. I am the Regional Health Administrator for Region X in Seattle, and Karen Matsuda on my right is our Deputy Regional Health Administrator.

All we are going to do is kind of introduce the subject, and the federal experts that are sitting up at the table to my left here as we come to their focus area.

This session is Session Number One which is the first 13 components of the yellow book that everyone is carrying around, and we are going to take the items in the order that they are written up in the book and indicated on the agenda, and we are really anxious to get everyone's opinions about the information in this book, and we know that we cannot get all that flavor here today, especially by limiting you to 3 minutes.

We are going to spend about 20 minutes on each of the chapters, and so if you have comments on Chapter 13, I really hope you will stick around because I am sure that some elements will come up there that are of interest to you because as I feel this population of attendees I think we are all very interested in public health. I really get that sensation talking to people in the halls and listening to the comments, and it is hard to focus in on one individual chapter when maybe your main interest is another one, but I encourage you to stick around and maybe you will think of something as you hear people talk that you will want to get a comment in and you can make it here if there is time, and again if there isn't time, I think we have mentioned probably ad nauseam all the other possible ways that you can get your input to us, and I don't think I will review those again. They are the Internet and written comments. You can hand them to the people with yellow badges, the Office of Disease Prevention and Health Promotion staff, and if you cannot find them, just give them to us up here.

So, we want your comments, and I want to let you know that I am getting extremely frustrated already because I would really like to talk about a number of the comments that have already been made, and I am sure that I am going to be a cabbage by the end of this session because I am eager to talk about some of these things that are really exciting, and the comments that have already been provided are very thought provoking, and I really hope that those pieces of information get amplified during these sessions.

So, I think we are about ready to begin the first one. I thought I would read a couple of things about the topic and try to find my notes which I have now misplaced. Here we go. Now, the first topic, Chapter 1 is physical activity and fitness, and I want to read the goal that is in the yellow book just to remind everybody what the overall subject area is, to improve the health, fitness and quality of life of all Americans through the adoption and maintenance of regular daily physical activity, and our federal experts today are sitting on this end of the table.

The first one is Adele Franks, and the next one is Christine Spain, and they are on the President's Council of Physical Fitness and Sports and work at CDC and Christine is a member of the Healthy People Steering Committee and Work Group Coordinator for this focus group.

So, you have got the main person here, and she is eager to hear your comments and so we are ready to get the first one, and we will identify you as eligible to speak. We will start our clock, and Karen is going to tell you how we are going to regulate the process of presentation.

MS. MATSUDA: I have my instructions here. Each oral statement will be limited to 3 minutes so that we can hear from as many people as possible.

I have a little box here, and I am going to push the button when you start talking. It will turn green. The yellow light will come on when you have 1 minute left, and then the red light will come on and flash when your time is up, and if you don't see the flashing red light I am going to hold up a time thing like this to allow as many people as possible to testify.

DR. LYONS: All right, are there any comments on physical activity and sports and fitness?

Ma'am?

I am sorry I didn't notice if Adele and Chris raised their hands so you know who you are talking to. Okay, over here.

MS. CLAYBROOKE: I am Charlotte Claybrooke. I work for the Department of Health in Washington State, and I have a number of small comments which I won't make here, but I will submit in writing, but two comments that are rather important about potential new objectives.

The first deals with increasing the proportion of people who take trips, excuse me, to increase to at least 10 percent the proportion of walking trips taken by adults for transportation, at least 15 percent and the proportion of walking trips taken by children for transportation as a percentage of all trips taken to 15 percent.

The rationale for this particular objective is that walking is a very popular form of physical activity in the United States. However, people need to be given the opportunity to walk safely in order to make the decision to go and do the walk.

According to the national personal transportation survey conducted by the United States Department of Transportation walking trips as a percentage of all trips taken has declined over the years since the surveys were first taken.

Walking dropped from 9.3 percent in 1977 to 7.2 percent of all trips in 1990, and again, it drops to just 5.4 percent of all trips for adults in 1995.

Walking declined even more sharply for children. This documented decline in walking has wide implications for the health of adults and children.

The second new objective that we would like to propose is to increase to X percent the opportunities for all people including children to walk and bicycle by promoting the development of sidewalks, trails and bike lanes in communities and the rationale is that the Washington State Department of Health considers environmental supports to be essential to promoting behavior change and recommends that factors which enable people to practice healthy behaviors be included in every chapter.

For example, in this chapter there is no mention of essential elements as sidewalks, bike and walking paths and trails or partnerships with urban planning and public works agencies which are key to creating walkable and bikable communities.

Without such environmental supports people cannot safety practice this health-promoting behavior and make it a part of their daily lives.

Thank you.

DR. LYONS: Thank you very much for your comments, and I don't know if we remembered to tell you to please sign in back at the back table so we have a record of you.

Thanks a lot.

Next comment on this chapter?

Don't be bashful.

All right, thank you very much, and we will certainly take these things into consideration and get them into the documents and worry about them.

The next topic is nutrition, and Dr. Paul Coates from NIH is the work group coordinator for this focus area. So, again, please step forward and if you have any comments about nutrition identify yourself and sign the log at the back table.

MR. SHEWMAKE: I am Roger Shewmake of the University of South Dakota School of Medicine. I am on the task force for the American Dietetic Association Toward Healthy People 2010.

One comment I would like to make is about obesity. We believe it should be a leading health indicator along with physical fitness. Obesity is the No. 1 malnutrition problem in the United States. It is escalating rapidly. It is recognized as a chronic disease in itself. It is an independent risk factor in itself.

We support text on the role of TV, computers, video games as a contributor to this problem. We, also, would emphasize an exercise deficiency as a major cocontributor. We would like to see education of parents, caregivers and children in making behavioral and life style changes related to food and activity.

We, also, believe there is a failure to address the underweight as a risk indicator. There are no supporting objectives to that especially among the elderly living alone and those that are institutionalized. It is a small but growing and important group.

We address nutrients as calcium and iron, but we do not address calorie intake per se and calories count.

Also, back to nutrition education and disease prevention early in life it is important to stress nutrition and the value of physical activity. We would like to, also, modify draft objective 18 to state, "Increase to at least 75 percent the proportion of primary health care providers who screen for nutrition-related risk as defined in the US Preventative Services Task Force recommendations."

Another modification would combine several into Objective 19 to be reread, "Increase to at least 75 percent the proportion of patients with a diagnosis of diabetes mellitus, hyperlipidemia, cardiovascular disease and obesity who receive nutrition counseling and educational services from a primary care provider or a referral for nutrition services from a nutritional professional."

Thank you.

DR. LYONS: Thank you very much. If you have a comment or a question you need to sort of get into this queue, and we will identify you, and you can make your comments.

Ma'am?

MS. DOUGHERTY: Hi, I am Joyce Dougherty with the Washington State Department of Health. I have something written, and I just want to reiterate just one part of that for today. Based on what Dr. Satcher said yesterday in terms of the importance of physical activity and nutrition in terms of healthy behaviors I want to reiterate that it would be nice to have an addition in the nutrition section that recognized the importance and role of nutrition leadership in public health by qualified dietetic professionals for achievement of the objectives and supporting this through the basic infrastructure so that all the population has access to credible and reliable nutrition information programs and services.

I, also, want to say based on ASTPHND, the Association of State and Territorial Public Health Nutrition Directors -- do I get another 3 minutes? -- that with the nutrition section in the related objectives component there were several areas that were not related to nutrition that we think should be added. For example, there was nothing in the related area on food safety or environmental health. There was nothing in there on folic acid for the broad-based population, and there was nothing in there on breast feeding although the breast-feeding section was in MCH, but those are the comments for the ASTPHND, the Association of State and Territorial Public Health Nutrition Directors.

DR. LYONS: You even have a couple of minutes left for all those groups.

Thank you.

DR. RAMAN: I am Dr. Raman. I come from Calcutta. So, I know pretty much about the state of nutrition health, not only in this country and, also, in other parts of the world.

I would like to make two comments. I think the quality of the school lunch program in this country is an embarrassment to nutritional science. So, No. 1 is we need to do something very radical in terms of making sure our kids have a right healthy start even before they come to school.

The second thing is that I strongly recommend though it has been rhetoric for the past 25 years there has to be a comprehensive nutritional education program and, also, a nutrition curricula at the medical colleges, especially for pediatricians.

Thank you.

DR. LYONS: I will probably keep reminding people to sign in the back as we go along.

Any other comments on nutrition?

All right.

MS. SHULER: Hi. I am Betty Shuler, a nutrition consultant with the Seattle King County Health Department, and I work in the child care health program, and somewhat in follow-up to the last comment and, also, additionally I would like to address Objective No. 13. Because more than half of the children in this country and even more than that here in Washington State are cared for in out-of-home care prior to school age, I would like to see No. 13, recommend that Objective No. 13 include that and be expanded to include children 1 through 19 years of age and children cared for in out-of-home care and, also, making reference to our Head Start Program, it is in the Head Start performance standards that good diet be there, but I think it needs to be included here as well as these are extremely vulnerable children, and additionally I would like to see an objective added to the nutrition section that is similar to the objective in the smoking section, No. 20 that addresses increasing the proportion of children, and I know eighth graders I think is what is referred to in the smoking objective who associate harm with poor dietary choices.

I think that it is extremely important that in this social environment that reinforces the acceptability of poor dietary choices, much as the social environment reinforces smoking that we need to have some way to address changing the social environment.

Thank you.

DR. LYONS: Thanks very much, and sign up.

We have room for I think maybe two more comments.

MS. KENT: Helene Kent, Colorado Department of Public Health and Environment, Women's Health Section. I am going to make a comment regarding food security, No. 20. This is philosophically different than the stand I will take on many of the other issues, and this is basically a philosophical statement. I would like to see the incidence and prevalence of food security among US households increased and it says, "To 94 percent of all households." I would like to see that be 100 percent given that this is the United States, and the issue of food security is such a basic and bottom line issue. Better than the best is not where I usually go in this document, but philosophically with this particular issue I don't think we should have hunger in the United States.

Thank you.

DR. LYONS: Thank you.

Any more comments on nutrition?

Thanks very much.

The next section, and I am sorry, I forgot to read the goal for the last one is tobacco use, certainly uncontroversial around here. We have David McQueen from CDC, Centers for Disease Control. Sorry about the acronyms that I use. Dave, it is good to have you here. You raised your hand? Okay.

That is the man you want to talk to. Tobacco use, I would like to read the goal. Reduce disease, disability and death related to tobacco use and exposure to secondhand smoke by No. 1, preventing initiation of tobacco use, No. 2 promoting cessation of tobacco use, No. 3, reducing exposure to secondhand smoke and No. 4, changing social norms and environments that support tobacco use.

Are there any comments on tobacco use?

That is hard to believe. Does anyone ought to say that we ought to limit tobacco use?

(Laughter.)

DR. LYONS: For some of you who don't live here, our Attorney General for the State of Washington was one of the main negotiators in the recent tobacco settlement. So, we are kind of, you know, we have been living through the information about tobacco in the State of Washington for quite a while, and I guess we have kind of gotten our thoughts out and feel like we have expressed them.

Would you like to make some comments?

MS. ARTHUR: Yes, I have a quick comment. My name is Kathleen Arthur. I am a nurse at the Portland Mentor(?) Area, and these are personal comments. I actually was going to address this in the maternal infant health, but it, also, has to do with tobacco use, and this particular subject is having to do with sudden infant death syndrome, and that is an objective measurable data piece that we can look at for helping to prevent sudden infant death syndrome. Specific to tobacco of the specific objectives there are two having to do with women who are smoking during pregnancy, objective three two and objective twelve twenty-two in the maternal infant health. I just want to point out that these two objectives actually have two specific different data points that they are looking at. One is reducing smoking to 95 percent and the other is to 2 percent, reducing to 5 percent and 2 percent. I would just call for standardization of that, to get together and make sure that we have specific objective goals with one particular number in mind.

Thank you.

DR. LYONS: Thank you.

Any other comments on the tobacco use?

Okay, the next chapter is educational and community-based programs, and Dave McQueen is the work group coordinator for this focus area, and we just introduced him from CDC, and I will read the goal.

Increase the quality, availability and effectiveness of educational and community-based programs designed to prevent disease and improve the health and quality of life of the American people, a real small one, isn't it, easy to do; any comments about this?

MS. KELLER: Hello, I am Heidi Keller with the Washington State Department of Health, and I want to endorse the importance of this chapter and, also, to say that there is a lot to like in Chapter 4. I will make four main comments and submit additional comments in writing.

We would like to propose more consistent definitions for the term "health education and health promotion" throughout this chapter and, also, in other places in the document. We will be suggesting some definitions by Creter(?) and Green, and I know those will be coming in from other organizations as well.

Objective 2 related to school health, we suggest that you specify the eight components of comprehensive school health and, also, that when we refer to health education in schools that it be combined as health and physical education in schools. They are of equal importance and it, also, supports our nation's objective of getting our youth more active.

Also, under school health there is Objective 3, undergraduate risk-taking behavior. We suggest that we include vocational technical schools. Considering the health disparities related to education, educational completion, this objective should not be limited to colleges and universities.

Under Objective 4 related to school nurses we are very concerned about the use of a strict ratio of nurse to students. It assumes that each building has students with similar needs, and we know this is not true.

We will, also, suggest new language for alternative staffing to include trained competent paraprofessionals under the supervision of nurses. This is an area of great interest in Washington State, and we are doing a lot of work on this staffing problem.

Let me see, additional comments on work site health promotion and elderly participation in health promotion opportunities will be submitted in writing.

Thank you.

DR. LYONS: Thanks very much. After we have gone through each of the chapters then we will have a general session for any comments about any of the chapters if there is time left, and I am pretty sure there will be.

People are being very concise and precise. That is great. I keep marveling that we can get to Mars and everywhere but we cannot figure out how to get our audiovisual things to work, and I am not criticizing the man that is devoting his life to it at the moment.

(Laughter.)

DR. LYONS: Do you dare make a comment with that machine there?

MS. CAIOLA: Can I do it sitting down right here?

DR. LYONS: Yes.

MS. CAIOLA: My name is Nancy Caiola, and I am with Wyoming Health Resources Network. We are a non-profit organization in Wyoming, and the Wyoming Department of Health contracts with us to promote healthy community processes and activities around the state. Like the previous commenter I like this chapter a lot. I think it is a really good chapter. My concern is that it is a chapter, and the document being so thick the way it is I think it is going to be used as a reference document. I don't think people are going to read it from cover to cover.

I think collaborative community-based action is essential to achieving all of the objectives, and I think it is going to get lost. So, I don't have any proposal, but I think somehow the comments in that chapter need to be made in such a way that everybody looking at the objectives can see it because I think it is critical to achieving all of them.

Thank you.

DR. LYONS: Thank you.

MS. PETERSON: Hi. I am Jane Peterson, from Seattle University, and at Seattle, Washington. I liked this chapter very much, too, and I just want to reiterate the comments before me. One, the words "multi-sectoral" come up here, and again, it is kind of embedded in the document in Chapter 4 someplace down the line where I think that that notion is pervasive throughout the whole document, if you read it. So, it would be nice to see that reflected other places.

The other thing that I really liked that I would encourage expanding into either other parts of the document or part of the preface has to do with the different places, the work sites, school that all of a sudden kind of capture everyone. I am in a university but when I stop and look at we have a student population and then we have a work force who always would consider themselves out of it except looking at this document are now forced to see themselves as part of the health care giving concern, and it just is no longer in the school of nursing. I think that is essential. So, I commend you on this.

Thanks.

DR. LYONS: Thank you very much.

Any other comments?

Okay, that closes this chapter. Thank you very much.

The next one is environmental health and Bill Jirles from NIH will be the person to listen to, and he is the group coordinator for this focus area. So, Bill, welcome.

I would like to read the goal which is short but very comprehensive, health for all through a healthy environment.

Comments from environmental health?

Again, please identify yourself and who you are representing.

MR. SLAGLE: Good morning. My name is Eric Slagle.

DR. LYONS: Can everyone hear okay?

(There was a chorus of no's.)

MR. SLAGLE: Good morning. My name is Eric Slagle. I am Assistant Secretary for Environmental Health Programs of the Washington State Health Department. I just wanted to make a couple of comments about the environmental health chapter.

First of all I will reiterate a couple of points I made in the general comments section earlier, those revolving around the need and value for possible funding, the need for solid, adequate infrastructure and, also, the need for partnerships. I think all three of those fundamental elements are essential keys to achieving environmental health objectives.

In the Department of Health we have identified a number of strategic initiatives that we are working on over the next 3 to 5 years. Two of those relate to environmental health. One is food safety which is a separate chapter. The other is drinking water. Just as a point of information, the drinking water area is becoming increasingly a major challenge for us particularly in Washington State as we deal with the listings under the Endangered Species Act and the pressure and focus that that puts on drinking water, both in terms of water quality and water quantity as balancing that out against the need for water quality and water quantity for fish. It just is an interesting area as a point of reference, I think, to see where the kinds of public health issues are really fundamental in other times in society and not always in the issues that we are dealing with here.

Generally we think there would be some value in listing the overall number of objectives especially where there may be redundancy and, also, to focus on those objectives that are most directly related to health outcomes where that is possible.

The Washington State Department of Health in conjunction with local environmental health directors did develop a document on environmental health indicators and it may be of significance for your consideration in review. There might be something that would be useful as you continue to look at these objectives.

The last area I would comment on has to do with the surveillance system, and there was reference to that earlier. Surveillance systems are absolutely essential. It is going to require a major effort on the part of the state and local and Federal Government to accomplish those, and there is going to have to be the development of adequate standards and of course, the funding to achieve that.

I appreciate the opportunity to comment and will provide written comments as well.

Thank you.

DR. LYONS: Thank you.

MR. OSAKI: Good morning. My name is Carl Osaki. I am the Chief of Environmental Health with the Seattle King County Department of Public Health and I am, also, a member of the Washington State Board of Health.

My comment relates to Objective No. 27, monitoring diseases caused by environmental hazards. This, I think is a laudable objective. Just one disease that is in that list of environmental hazards that has to do with asthma, we are not sure that asthma is directly attributable to only environmental causes because I think there are issues of access and other issues that might be contributing to that particular rate as well, but that is not necessarily my comment.

My comment has to do with the fact of a developmental standard. Right now in the State of Washington we are in the process of updating our reportable diseases list. A concern that I have raised in this process has been the reporting of the illnesses to public health officials by medical care practitioners, and I think there needs to be something either as an indicator or as an objective that relates and deals with some incentive or some way of increasing physicians, medical care clinics, medical laboratories, hospital clinics, diseases so that we can get good data on what is happening within the community.

Thank you.

DR. LYONS: Thank you very much and sign in the back, please?

Any more comments on environmental health?

MS. SULLIVAN: Good morning. My name is Marianne Sullivan, and I am with Seattle King County Department of Public Health, and I am speaking for myself.

I would like to see in the introductory section a comment that notes the disproportionate exposure of people of color and low-income people to environmental hazards. This is a well-established finding. I would like to see it further noted that environmental justice is an important framework for understanding this.

I think that it would be important to integrate some explicit environmental justice objectives, also, in the document, and I will be making some suggestions in writing as to what those could be.

DR. LYONS: Thank you.

We still have a little more time.

MS. WOODWARD: Jennifer Woodward with the Oregon Health Division, and I am speaking on behalf of the Oregon Health Division. We have one additional comment on Page 5-29 which is under related objectives for other focus areas, and I have just added this one into Chapter 5, but all of the chapters have related focus areas, and there is one specifically related to communication in that public and consumer participation is essential to frame the content message and media delivery strategy to improve clarity and effectiveness of environmental health-related messages.

There has been a concern that including public and consumer participation has been overlooked in a variety of chapters throughout the Healthy People 2010, particularly in the health communications chapter but I was specifically concerned about this chapter as well.

Thank you.

DR. LYONS: Thank you.

Any other comments?

Okay, let us close this one and go to focus area No. 6 which is food safety, and Don Voeller with the FDA is our point person for this one, and I will read the brief goal. The brevity is not to indicate that this is real easy, reduce the number of food-borne illnesses and comments on food safety?

This won't be your last chance, but this is a good chance.

I am going to wait just a minute just in case someone is hesitating but going to show up.

Okay, sorry, Don, that we didn't get any complaints about this one. I guess that means it is pretty ready to go. So, that is a challenge to you. It is pretty ready to go. It is going to be just like this. It is never going to be changed again.

(Laughter.)

DR. LYONS: Okay, focus area No. 7, injury and violence prevention, and we are ready to hear comments on this. One comment I should make about this one, Martha Highsmith from CDC is the work group coordinator for this focus area, and she is the one you want to talk to, and this subject in the book and on our agenda is separated into unintentional injuries, violence and abuse and cross-cutting measures, and we are not going to take it in that order. So, any subject relating to violence and abuse and injury is open.

MR. FINGER: My name is Reg Finger, from Colorado representing myself. I think the two objectives related to suicide should be moved from Chapter 23 into the injury prevention chapter. I think that the classification of injury and in the introduction it makes the point that many of the sequelae are the same regardless of intent, and if you have indeed injuries that cut across intent I would say that the injuries that are self-inflicted should be folded into that whole concept and all injuries, violence related, self-inflicted and unintentional as well as those of undetermined intent all be folded together into the chapter.

Thanks.

DR. LYONS: Thank you.

MS. KELLER: I am Heidi Keller representing the Washington State Department of Health, and we agree with the previous comment. We are concerned that suicide has several causes, one of which may be mental health conditions, but certainly firearms storage and other safety issues are contributing factors.

We suggest that it can appear in both chapters but should not be removed from this chapter. Also, the mental health approach we regard to be intervention and treatment rather than prevention, and that is what injury prevention is about.

DR. LYONS: Thank you.

DR. THORBURN: My name is Kim Thorburn, Spokane Regional Health District here in Washington, but I am speaking for myself. I am a former prison physician, and I want to use this chapter to comment on the absence of the recognition of incarcerated populations in the document.

The reason that I will use this chapter is that injury is highly prevalent in incarcerated populations, and I would recommend that we take a look at some of the areas since we are talking about eliminating disparities.

Certainly the access to public health programs for incarcerated populations is a disparity, and this is a rather significant population in our communities. I think that injuries is one area that it should be recognized, in addition HIV. I do note that there is one reference to offenders and substance abuse treatment access but that is the only place that I found it in the document, and I think there are a number of places where incarcerated populations could be recognized, and I will send further comments in writing.

DR. LYONS: Thank you.

DR. SMYSER: My name is Michael Smyser. I am an epidemiologist with the Seattle King County Department of Public Health. I am speaking on behalf of myself. I just wanted to see some sort of objective having to do with reporting of hate crimes and, also, survey information on hate crimes, harassment and discrimination.

Thank you.

DR. LYONS: Thank you. Be sure to sign in, everyone who makes a comment.

MR. GOMEZ: Good morning. My name is Tony Gomez, and I manage Violence and Injury Prevention Programs for Seattle King County Health Department and I, also, chair our Drowning Prevention Coalition here in the region, and I think most of the section looks pretty good, especially the areas of motor vehicle injury and firearms

One of the comments I have is that related to drownings I think we need to add an objective to increase to 50 the number of states with life jacket laws for children. I think we are at about 26 or 28, and actually better yet we are probably better off to go to a federal law that is consistent so that as folks boat along various borders they would have some consistency there, and then in relation to suicide prevention I think we need to see some federal funding to help develop support for local health departments.

I think I can count on one hand the number of local health departments involved in suicide prevention through gatekeeper training and other sorts of activities that we can do at the local level to prevent these injuries and so I would strongly encourage that we look at the development of doing that work especially here. I know many communities are like ours where suicide is the leading cause of death in terms of violence and injury and yet we, as probably most health departments across the country have zero FTEs and dollars dedicated to this.

Thank you.

DR. LYONS: Thank you.

Any more comments?

Thanks very much, we will close this session and go on to the next one which is occupational safety and health, and we have Chuck Gollmar with us who is a member of the Healthy People Steering Committee and is the one we are talking to. Thanks, Chuck, for being here.

Any comments on this area? The goal is to promote worker health and safety through prevention.

MS. WOODWARD: Jennifer Woodward from the Oregon Health Division. I am speaking on behalf of the Oregon Health Division with regard to Objective 12, latex allergy. The Oregon Health Division applauds the inclusion of a developmental objective on reducing latex allergy among health care workers.

Thank you.

DR. LYONS: Thank you.

Any other comments?

Okay, thanks very much. We will go on to the next area which is oral health, and it is back to Dr. Coates, again, from NIH, and I will read the goal.

Improve the health and quality of life for individuals and communities by preventing and controlling oral, dental and craniofacial diseases, conditions and injuries and improving access to oral health care for all Americans.

Any comments on this chapter? I saw my dentist in here a few minutes ago. Where is he? I really did. That is no joke. He is hiding. Come on up here and tell us something.

You have already told me what I need to know.

DR. DELGADILLO: I am Paul Delgadillo. I am a dentist with the Coast Guard here in Seattle. The only comment I have was on the last one, No. 21, and about oral pharyngeal cancer examination. I am not sure if patients are aware that their dentist does this. So, maybe there was an underreporting on these numbers here. That is just a thought, and my training included training in this procedure. So, I am not sure if the other dental schools do this or not. So, I figured you would include that.

Thank you.

DR. LYONS: Sorry to embarrass you. I just cannot resist an opportunity to make a comment about this issue because the first complete dental or oral health cancer exam that I can remember having was one I got from the fellow who just spoke, and I do think this is a very important issue that some dentists don't do that procedure, and I think we need to emphasize that. I am sorry to make a comment about that.

MR. GRUBB: I think your comment was very timely. Terry Grubb. I am the Chairman for the Council on Access, Prevention and Interprofessional Relations for the American Dental Association. I just take this opportunity to give a short report on where the association is with regard to developing its comments.

The officers and members of the Board of Trustees will be meeting beginning this weekend and into next week to review the objectives of the oral health chapter and the relevant objectives of other chapters.

Input from five association councils representing science, public health, insurance, practice and governmental affairs has been received by the board. In addition to that we have had the opportunity for our 143,000 members to contribute by way of notices placed in ADA publications and the ADA on line Web site for their participation.

Obviously the association will review in relationship to guiding its comments as it relates to ADA policy. That is the comments will be consistent with our standing policies. It has been noted, I believe, that in 1991, our House of Delegates adopted a policy that endorsed the oral health objectives and encouraged its state and local societies to work with their respective health departments towards achieving the Healthy People 2000 goals.

We are hoping that we can achieve that same end for Healthy People 2010. Given that 80 percent of the ADA membership are general dentists we are looking at the objectives from the perspective on how feasible they will be for the private practitioner as they serve the general population.

The more practical the objectives are, the more the association can do to target its resources such as technical assistance, lobbying efforts and mobilizing its members to carry out their fulfillment.

The association's formal written comments will be submitted before December 15. Thank you very much.

DR. LYONS: Thank you very much.

Any other comments on oral health?

Okay, let us close that session and go on to focus area No. 10, access to quality health services, and I apologize for this one particularly because of my misunderstanding of the things that are written for me here and who is the main guru, but I guess I will introduce them in the order I have got them on a sheet and hope that I got one or two of them right. David Atkins from the Agency for Healthcare Research and Quality (AHRQ) is the work group coordinator. Did I get that right, Dave? Okay, and Carol Roddy, are you going to be listening to this one, too?

MS. RODDY: Sure.

DR. LYONS: Good. Carol Roddy is from Health Resources and Services Administration. So, those two people are hearing you about this focus area, and I will read the goal. Improve access to comprehensive, high-quality health care across a continuum of care, and does anyone have comments on this area?

MR. MURRAY: My name is Jimm Murray with the Wyoming Department of Health representing the Division of Public Health. Also, on the first two items, a member of the National Heart Attack Alert Program within NHLBI.

On Page 10-24, Objective C.4A I would like to offer an addition and a change. My suggested wording would be, "Increase to at least 25 percent the proportion of eligible patients with acute myocardial infarction who receive," and then a change would be definitive reperfusion therapy, in parentheses, mechanical or pharmacological within 1 hour of symptom onset.

On the same page, next item would be C.4B. Again, I have two additions and one change to the current draft, increase to 50 percent the proportion of persons with witnessed out-of-hospital cardiac arrest who are eligible and receive their first therapeutic electrical shock within 5 minutes of collapse recognition.

My final comment is down on the same page, C.5A. I would like the addition, consideration of the addition of the words "first responder" to preface emergency medical technicians and paramedics. First responder is the third nationally recognized level and we believe it should be included along with the other two.

Thank you.

DR. LYONS: Thank you.

DR. JUI: Good morning. My name is John Jui. I am a practicing emergency physician at Oregon Health Sciences University. I am speaking for myself, as well as the American College of Emergency Physicians and in particular David Atkins.

The first comment I would like to add is two suggestions under goals to assure appropriate high-quality emergency care. Nowhere in that section is acute stroke care mentioned, and I would suggest that the writing group look at acute stroke care and in particular the timing of acute reperfusion intervention less than 3 hours. It is the standard in our community, and I think it fits pretty well.

No. 2, under increasing access to appropriate systems, I would add perhaps a second goal, increasing access to appropriate trauma systems.

As you know in the United States trauma systems are being implemented as we speak. Currently about six or seven states have full trauma systems. About 20 to 25 states have partial trauma systems and a small number of states have no trauma systems. I think a goal would be to implement all 50 states to have trauma systems. There is a substantial body of literature that would suggest that this improves both life, enhances better quality of life and prevents mortality.

Speaking for the American College of Emergency Physicians we do have a problem with the first sentence as stated as well as the barrier to the needed use of emergency services by individuals with no or inadequate health insurance coverage. While not denying that this may be a factor, we feel that there is inadequate literature that would support this statement or we would support the further investigation of knowing exactly how much financial barrier there is to access to care.

The American College of Emergency Physicians supports universal access. In fact, it is the only health services mandated by law to guarantee access of care as this panel all knows with the Entala(?) law. So, we would support further research in this area, and finally, one of our concerns in the State of Oregon is that our rural hospitals are being threatened right now. We are actually looking at two to three of our hospitals being closed and those emergency departments will cease to exist and basically leave a whole county or a significant portion of our population as exists. So, we have significant concerns about our infrastructure.

Thank you very much.

DR. LYONS: Thank you.

DR. EISENBERG: Hello, my name is Mickey Eisenberg. I am a professor of medicine at the University of Washington, and I am speaking on behalf of the Academic Society of Emergency Medicine. I would like to comment on two objectives in Chapter 10, No. C, Emergency Services.

First one, Objective C.1 says that 90 percent of the population in urban areas will have an EMS response time of 9 minutes between initiation of call and arrival at the scene 90 percent of the time, and while I applaud the panel for stating a concrete time such as 9 minutes, I think to accept this would actually be a regressive step.

First of all, most EMS fire department based systems in the United States have response times of 4 to 5 minutes. So, obviously 9 minutes would be a regressive step.

Secondly, a 9-minute response time would save few of any patients who are in cardiac arrest. It is just simply too long to be of any benefit. Therefore, I would like to suggest that this objective be set to 5 minutes which is an attainable goal, and it is the standard that many fire departments already have in the country.

I would like to comment on a second objective, namely, C.4B which states that it attempts to increase the proportion of persons with witnessed out-of-hospital cardiac arrest who receive their first therapeutic electric shock within 10 minutes of collapse. Again, I would like to state that this is simply too long to give any benefit.

Work conducted in the past decade here at the University of Washington and at many sites throughout the country has shown that few, if any patients in cardiac arrest will be saved with a response time of 10 minutes. I think 6 minutes is an attainable goal. I just mentioned 5 minutes for that first response and another minute to set up the defibrillator and apply the defibrillatory shock is an attainable goal in many cities in the country and recommend that the objective be changed to 6 minutes 90 percent of the time for that first defibrillatory shock.

Thanks very much.

DR. LYONS: Thank you.

Everyone sign in, remember now.

MS. PAISLEY: Good morning. My name is Rose Paisley, and I am a student of naturopathic medicine here in Seattle at Pasteur University, and first of all I would like to comment to the entire board that all of the chapters are well focused in this.

One thing that I am concerned about is the lack of mention towards complementary and alternative practices being referred to as a means of attaining these goals and in that they are one and the same, I would like to see a push towards getting these medicines into the forefront.

More specifically towards improving access to comprehensive and quality health care across a continuum of care, I see that in Section 10-7 there is a definition of primary care, and integration is one of the words. I think that that is all well and good, but I think that it could use a little more direction towards mentioning other kinds of medicines that are out there, other kinds of treatments and other kinds of care and a way of attaining or actually a way of putting attention towards improving access and outreach would be for one if there are increased residency opportunities for graduate health are professionals as well as increased loan repayment programs we can incorporate these health care practitioners into the community services which will not only, one, improve the quality of health care professionals that we are putting out into the field, but it will, also, increase the number of qualified health care professionals that are available for these people utilizing these community facilities, and I, also, realize that there is an element of uncertainty in this incorporation and to reduce this I think one step would be towards putting further attention to performance measurements which I am confident will not only emphasize the high standards of this field as well as the quality but it will, also, educate the population of the importance that the practitioners of natural medicine are in fact graduates of accredited institutions and are therefore qualified.

Thank you very much for the opportunity to speak.

DR. LYONS: Thank you.

MR. SIMPSON: Good morning. My name is Evan Simpson. I am here representing Harbor View Medical Center and the American Trauma Care Advisory Council. I am basically reiterating the comment made by the emergency room physician from Oregon Health Sciences that basically we would encourage strongly an objective that would extend trauma systems to all 50 states.

I wanted to point out that this was an objective in the Healthy People 2000 document. It stated, "Extend to the 50 states emergency medical services and trauma systems linking prehospital, hospital and rehabilitation services in order to prevent trauma, deaths and long-term disability."

We would just like to again point out the need for that objective and extending health trauma systems to all 50 states.

Thank you.

DR. LYONS: Thanks, much.

MR. LUX: My name is Gene Lux, and I am here by virtue of the fact that I am on the Senior Caucus at Group Health, and if I may I just had a pre-op class and the first thing that is required when you have a total knee replacement is to get a clean bill of health from your dentist to make sure that your oral health is in good shape. I didn't realize that. So, apparently they found that that is very, very important.

The thing I want to talk about is the fact that I am a fire commissioner. I heard several comments about paramedics and cardiac arrest and so on. I think that folks have to understand that the system is being totally abused and it is unfortunate that over 75 almost 80 percent of our calls are medically related, and fire suppression is a minor part of the business now, and I think by the year 2010 if things continue we are in the extension of the emergency room service and we make home calls, and we have a great number of folks in our district that I don't think have medical provider or have access to a primary care provider.

This function is financed by property tax. We are going to have to make some changes, some drastic changes. The response from the public is not as good as it should be, but we do have acceptance, over 90 percent acceptance from the public, and I think the fire, paramedics and the EMTs that we have could be a service in education. We educate in the schools now not only fire suppression but health care and CPR, and I think if there was some type of publication put out by you folks that have the expertise and the knowledge to put facts in the frame of reference that people could understand we could be a service because we are in the neighborhoods. We are there every day, and we go into these homes, and some of these folks needs some education in how not only to raise kids but just to take care of themselves.

We need some help, and I think that the Public Health Service could be a great assist in making sure that people use the service in the way it was intended and not for cut fingers, spousal abuse, headaches, belly aches, all kinds of aches and pains and that is not what the service was intended for.

Thank you very much.

DR. LYONS: Thank you. Glad you are providing it anyway.

Any other comments on access?

MR. SMYSER: Michael Smyser, Seattle King County Department of Public Health speaking on behalf of myself. I am noting objective A1, the old 21.4 reduce to zero percent proportion of children and adults under 65 without health care coverage. I would like to see this changed to make health care a right of all Americans by 2010. I am sad to see that we are now entering the 21st century and still have over 40 million Americans without insurance.

I have a couple of other points to make. I would like to see some objectives concerning patient satisfaction with care in regard to cultural sensitivity, language and interpreter needs, perceived discrimination when receiving health services and accessibility of services, and I would, also, like people to look into maybe some ways of monitoring health services, the appropriateness of them received by persons of different racial, ethnic and other minority groups.

Thank you.

DR. LYONS: Thank you.

MS. BEFUS: I am Nancy Befus. I am actually here representing people with disabilities, and I am employed by ARC(?) of Denver, but when I saw on the list the long-term care and rehabilitative services separate from the disability and I felt it was important to sort of skip rooms, I wanted to mention two things, one under long-term care. As a private citizen I have been in the last 2 years faced with some of the difficulties involved with aging parents. My mother has had the need because of a stroke that has only affected her memory, she has had need for someone to help her get up in the morning and to remind her to take medication, and she needs help at night going to bed and taking medication at night, but we could not find a home health care service that would agree to provide service in the morning for 1 hour and in the evening for 1 hour. We had to have 4 hours of service all at one time.

So, as a result the family has taken on most of this. I know that many people end up in nursing homes and under Medicaid assistance because all they needed was 2 or 3 hours of service but there wasn't anything available for that small amount of time. They have to pay and the government has to pay for a lot more time in order to provide that service. That is one thing I wanted to say, also, that the quality of direct care services for both people who are elderly and people who have disabilities is not monitored. Very often it is very poor and even dangerous for people.

I see many people with disabilities who are taken advantage of by individuals who have not passed stringent employment tests when they go into a person's home to take care of their personal needs.

I think that is important to look at. The other thing that I wanted to mention under rehabilitative services I am directly involved with several people who are in rehabilitation centers as a result of strokes and these people are really being warehoused in many situations. They are just there. They sit there all day. They are fed. They are not being helped to learn new skills. They are not really being helped to move back out on their own into the community, and that is a great concern to me, and I thought it was important to mention that.

Thank you.

DR. LYONS: Thank you.

I think we have time for about one more.

MS. CAIOLA: Hi, I am Nancy Caiola with Wyoming Health Resources Network. In the Rural and Frontier Group yesterday we talked a little bit about objective B4, about reducing by 50 percent the number of individuals lacking access to primary care provider. While we didn't take issue with the objective we thought that the data source being a HIPSA(?) designation was probably not the correct source, that whether or not you are HIPSA is more a reflection of having a good person crunching the data and keeping on top of the designation than it was necessarily a true reflection of shortages. Also, a lot of people in rural and frontier areas receive primary care from midlevels, and I am not sure that that is reflected in that and, also, with the HIPSA designation being under scrutiny it may be changing. If that were to change, then this whole objective could become irrelevant. That was the data source we were concerned about.

Thank you.

DR. LYONS: Thank you.

MS. VINCENT: I have a comment to make. I think that it is very, very important that you people listen to what we have to say. Thank you.

DR. LYONS: Thank you very much. I have to apologize. I didn't understand every word you said, and I want to make sure that we get it into the record, and maybe some of the people with you -- thank you though for making the effort you did.

MS. BEFUS: What Kathy was saying was people need to listen so they understand and not jump to conclusions of what the problem is. Right?

MS. VINCENT: Yes. We don't always have three and four word sentences. We are dying.

MS. BEFUS: What Kathy said was if we don't take time to listen we could die in that time because oftentimes she is alone. She lives independently. Kathy has a support person who comes in to help her get up in the morning and help her go to bed at night, but the rest of the time she functions independently. There are times when there may be an emergency, and people in emergency services are very often impatient with the fact that it takes time to understand and maybe repeating is necessary, and what we found out in traveling in making arrangements to come to this conference was that it was difficult for people to take the time and cope with understanding Kathy's speech. Sometimes I, even though we spend a lot of time together on trips, I have to say, "Tell me that again," and I feel badly that I take longer to understand, but Kathy is patient with me in helping me understand, and that is what she is asking other people to do is be patient and take the time to understand.

MS. VINCENT: I think that you deal with other people. We need, we are telling you that the system is so bad. Okay, thank you.

DR. LYONS: Thank you for making the effort to get here. We really appreciate hearing from you, and you have well documented a need.

Can we be sure to get your sign in just like everybody else?

MS. VINCENT: Yes.

DR. LYONS: We lost the person before Kathy. All right, thank you very much. Any other comments about access?

All right, we will close that. Oh, okay, we have time for one more.

MS. TOM-ORME: This will be short. I am Lillian Tom-Orme from Utah, but my native home is the New Mexico area. I am glad to see that in this particular section we are thinking about increasing the number of health professions to 1 percent. At least we will be a blip, I think in the charts that where we are normally either not included or just ignored outright. I am concerned about a couple of objectives dealing with long-term care needs. I would suggest that there be consultation with American Indian, Alaskan Native organizations, tribes, Indian Health Service and so forth to look at some of those issues because people who need long-term care services from this particular population often are in rural areas. They have to go off the reservations, go into another state to seek long-term care services and whereas other people live right there in the same city, town and can see their family, in some of our situations we send people away to die because we just cannot see them that often due to distance and all kinds of other needs.

So, I really would like to encourage that and, also, long-term care services for our population would require culturally competent care and so I would like to again stress the need for consultation.

Thank you.

DR. LYONS: Thank you.

All right, the next focus area is No. 11, family planning and Evelyn Kappeler of OPHS, that is Office of Public Health and Science, by the way, is the Healthy People Steering Committee person for this and, also, the work group coordinator.

In family planning the goal here is every pregnancy in the United States should be intended, and we are open to comments on this one.

MS. NYBO: Good morning. I am Suzanne Nybo. I am the head of the Women's Health Section at the Montana Department of Pubic Health and Human Services, and I am here today representing the Region VIII, Title X family planning directors, and as most of you know, we are from the states of Montana, North and South Dakota, Utah, Wyoming and Colorado.

We have two general comments on the family planning objectives. The first is that we would like to recommend that there be consistency with stating objectives in a positive language, for example, in Objective No. 1, from the language reduce to no more than 30 percent to increase to at least 80 percent, and also, to change the supporting information and demographic breakdowns, etc., to reflect that same positive language, and the second comment of general nature is that we recognize the value and importance of eliminating disparities, and we applaud the reasoning behind the better than the best target setting method. However, the objectives need to be attainable, and we recommend changing better than the best, the target setting method.

Our specific comments on the objectives regarding Objective 1, 7, 8 and 9 that relate to a comment I just gave on better than the best, that the targets set be more realistic. In addition, we have a comment on Objective 10 and the objective we feel is cumbersome and unclear, and the objective should focus on encouraging adolescents to use the most effective contraception, for example, OCPs, Depo-Provera and Norplant(?) and barrier protection. A specific comment is on Objective 13. The objective as stated, impaired fecundity should not be in this section. Rather we feel that an objective dealing with infertility due to STDs should be in the STD chapter.

We thank you for the opportunity of being here and being able to comment, and additionally we will be submitting written comments with maybe more specific target on what we have just talked about.

Thank you.

DR. LYONS: Thank you.

MS. LAHDENPERA: Thank you for the opportunity of being here today. I am Kay Lahdenpera, from the Municipality of Anchorage, Department of Health and Human Services, Family Planning. I have three areas on the format that I want to speak about. One is a couple of comments on the overview. Two are the specific objectives and three are focus areas, and I will send written, if I can do this in 3 minutes, but I wanted to thank the members in preparing this about giving the references for back-up statements that are commonly myths about the area, and I am sure this format is throughout the whole 2010 objectives and that is specifically on Page 11-6, Lines 6, 13 and 18. These are going to be very helpful politically, and it is helpful for our new partners and for people that are maybe not quite as familiar with the subject of family planning.

No. 2, under overview is, I am glad you put some emphasis on hard-to-reach populations, the time and expense. This is an area that is concerning for those of us who are looking at federal funding, and No. 3, and I will be specific on that, that is on Page 11-8, Line 15-18 where it is talking about the main sources of information and education in the nation are with the media. The media is terribly important, but even more important is getting a generalized sex education, healthy life skills program throughout the country in our school system and, also, including our faith communities in this area. Until we do that we probably will not meet Objective 12.

So, then I would like to go on to the specific objective and as Suzanne already mentioned putting the format in a positive framework I think would be easier and helpful for not only the health are providers but, also, the general public to look at this, and it might give more incentive that we are helping to make the objective, and that was true in Objective 1.

There might have been a little confusion here in Objective 1 where it talks about plan, 70 percent plan or intended and then the selected populations information. I am not sure if that was planned or unplanned. That is not real clear there, and then I wanted to especially thank you for the new objective. I think that is really helpful, the new objectives, No. 2, because these are areas that we really look at in family planning and haven't addressed particularly and that is the repeated unintended pregnancy. We really need to look at that, and we need to study it and see why this is occurring and why we haven't prevented that, and then the other objective here, Objective 5 is new and that is the postcoital hormonal contraception and I think this is really important that the public understand this and get more information on this and that we do spread this throughout not just the health care professionals who need more information on this as well but, also, through the general public and our political system. So, I think that is good for visibility and acceptance by the public.

No. 6, male involvement, I have a little story. I don't know if I have time to tell it, but I will write it and send it in of the effectiveness and how this in our area has really increased goal 2 that you have, and I think that is exciting. We need to spend more on male involvement.

MS. MATSUDA: Are you just about through, Kay?

MS. LAHDENPERA: No, what I want to talk about next then would be I do appreciate that you involved other focus areas, but I think you are really shy in the family planning component because reproductive health for men and women could be considered a core. Out of that comes prevention, comes conceptual health and many other things. So, if I could just list numbers I won't go into -- but No. 1 under your promote healthy behaviors, I think all three should be included under family planning. Under No. 2, promote healthy and safe communities, I think four, five, six and seven need to be added. Under 3, improve systems for personal and public health I think you need to add 14 and 15 and prevent and reduce disease and disorders I think you need to add 18, 19, 23 and 26. I think these all really relate, whether it be domestic violence, diabetes, mental health or whatever. It really does relate to family planning.

MS. MATSUDA: You are out of time.

MS. LAHDENPERA: Thank you.

MS. MATSUDA: Thank you, Kay. Be sure to sign in, too, at the back. Are there other comments on area No. 11, family planning?

If not, we will be accepting testimony for maternal and infant health, and I would like to introduce Carol Roddy who is from HRSA. Carol, do you want to raise your hand? She will be pleased to accept testimony from all of you related to this chapter. The goal is to improve maternal health and pregnancy outcomes and reduce rates of disability in infants thereby improving the health and well-being of women, infants, children and families in the United States. The health of a population is reflected in its most vulnerable members. A major focus of many public health efforts, therefore, is improving the health of pregnant women and infants including reductions in rates of birth defects, risk factors for infant deaths and deaths of infants and their mothers.

We now welcome your comments.

MS. DOYLE: Good morning. I am Deb Lochner Doyle, and I am the President of the National Society of Genetic Counselors. We have genetic counselor members in every state in the country, and I would, also, point out that genetic counselors make up the majority of genetics health professionals who are educating other health and social service providers in this field.

I have several comments, but I am going to limit my comments to some of the global overarching issues and submit specific objective information in writing.

First let me state that the NSGC is delighted to see a conscientious effort to incorporate public health genetics into the Healthy People 2010 document.

While organizationally genetics issues may reside in the Maternal Child Health Bureau of the Department of Health and Human Services we would suggest that such a limitation should not be even inadvertently prescribed nationally as a suggested as is suggested by placing the majority of genetics issues and objectives within Chapter 12.

As you well know genetic disorders and genetics issues are not limited to this subpopulation. Even the proposed definition for genetic disorders under the terminology in Chapter 12 is limiting, and it is inaccurate. Consider cancer. While not all cancers are heritable, they are all the result of an alteration in DNA. Thus, we would suggest that the definition for genetic disorders be corrected. A possible definition for genetic disorders may be a group of health conditions that result from alterations to genes or gene products.

It is clear from the intent of the objectives that there are many concerned about the need for increased education about genetics and genetic issues to health care providers and consumers.

A similar sentiment is acknowledged in Chapter 17 on cancer where Objective 14 states to increase to at least 40 percent the proportion of physicians who appropriately counsel or refer their genetically high-risk patients. With this strong emphasis on genetics education noted, the complete lack of a topic area of genetics being mentioned in Chapter 4 in educational and community-based programs, Chapter 5 on work site health promotion seems an obvious oversight.

Finally to ensure that all of the readers of Healthy People 2010 can easily be directed towards complementary objectives we would propose that the complementary objectives be cross referenced within the text or that the related objectives from other focus areas in each chapter be expanded to include more descriptive information about the related objectives.

Just to summarize the National Society of Genetic Counselors would like to see the following changes: The genetics objectives currently placed within Chapter 12 should be separated out into a distinct chapter. The definition of genetic disorders should be corrected. All public education and health promotion sections should include genetics, and finally, the cross referencing of complementary objectives should be improved.

Thanks.

MS. MATSUDA: Thank you.

Be sure and sign in.

MS. FEYH: Hello, I am Barbara Feyh, and I am the Director of Community and Family Services at Spokane Regional Health District in Spokane, here in Washington State. First of all, I am pleased to see that Objective 33 that we now have an objective to increase by 100 percent of newborns who will be receiving hearing screening by 1 month. That is certainly something that we have been working on, and we appreciate that kind of support.

When I looked at some of the things that our field staff deal with in visiting mothers and children in homes, the area of child mental treatment is one of the prime ones and I see that cross referenced from the injury and violence prevention piece. What I don't see cross referenced is another very big situation that children witness and impact at a shocking level and that has to do with domestic violence, and I would like to suggest that that be cross referenced there, too.

When I look at some of the objectives it has an 18-month cutoff, and it feels like that is too soon to cut it off for where children aid staff are focusing on and I would like to see that expanded up to perhaps age 6. I am just pulling that out of the hat, but we definitely see children much older than 18 months of age.

Then the last comment would be, and I didn't see it elsewhere in the document, some emphasis or some objective that deals with a safe and healthy child care environment. Since so many of our parents work, the whole welfare movement is pushing towards parents working, and I think that it is still a big need, and it feels very fragmented at least in our community, and I would like to see this as an emphasis.

Thank you.

MS. MATSUDA: Thank you.

MS. KENT: Helene Kent, Colorado Department of Public Health and Environment, Women's Health Section. I would like to show the appreciation for the inclusion of new objectives, specifically Objective 19 which deals with weight gain during pregnancy and in addition I am very pleased to see the preconceptual counseling objective, very important.

I would encourage the Committee to look a little closer at some of the text regarding the preconceptual counseling and to include such areas as the role of quality and quantity of diet, prepregnancy weight as part of the text.

Thank you.

MS. ARTHUR: Hi. My name is Kathleen Arthur, and I am a nurse working on a project in hospitalized postpartum patient population to promote nursing interventions and patient teaching associated with reducing the incidence of SIDS. This is a personal comment.

Sudden infant death syndrome or SIDS is addressed in Objective 12-3. This is a significant issue as SIDS is the third leading cause of infant mortality and the leading cause of infant death for infants between the ages of 1 month and 1 year.

Although research has not been able to identify the cause of SIDS, it has identified specific objective measurable interventions that can dramatically reduce the incidence of SIDS. The specific interventions include supine infant sleep position, active and passive smoke exposure avoidance, breast feeding, infant sleep environment, firm mattress and no extra articles in crib and infant overheating and overwrapping.

Of these specific objective caregiver issues only two are currently addressed in the Healthy People 2010 draft, smoking and breast feeding. I have already addressed the smoking issue, but there is one other smoking issue that I would like to include. There is no specific objective for infant passive smoke exposure. SIDS and infant smoke exposure are dose related. The higher the smoke exposure the higher the risk of SIDS. Therefore, I suggest that this be added as a specific goal.

Supine infant sleep position has been identified as the single most important infant caregiver practice associated with reducing the incidence of SIDS.

In 1992, the American Association of Pediatrics recommended that healthy term infants be placed on their back or side to sleep. In 1996, these guidelines were modified based on current research to recommend that supine position be the best position to reduce the incidence of SIDS with the side lying as a secondary alternative position.

I would like to recommend that we include the supine or back-lying position as a specific objective measure of caregiver practice. The Back to Sleep Coalition has recommended the reduction of prone sleeping to 10 percent in the United States.

I feel that this is the most important issue in reducing SIDS and so therefore should be added as an objective and as a side note most of the current literature specifically looks at prone sleeping position but with the new AA recommended guidelines I believe that we should revise the terminology and include supine or on their back sleeping position so that we can differentiate that between back sleeping position or side lying.

Countries that have been successful in reducing the prone or face-down infant sleep position have successfully reduced the SIDS rate by greater than half. Again, as SIDS is the leading cause of infant mortality between the ages of 1 month and 1 year the goals to change caregiver practice are critical.

Teaching caregivers these interventions is currently the only known intervention to reduce risk of SIDS.

Thank you.

DR. KONE: Hello. My name is Ahoua Kone. I am an epidemiologist with the Seattle King County Department of Public Health and, also, with the cross-cultural health care program in Seattle. My comment today is personal.

It is regarding Objective 9 dealing with preconception and prenatal and postpartum care. The objective states an increase in the proportion of providers of primary care to women. I would like to recommend that you also, include providers and services of midwifery. Midwifery is a growing, is a fast-growing segment of the health care system for women and children in Washington State and in several other states. So, I feel it should not be ignored.

Since the yellow light is not on, I will break the rule and step back to the previous objective, that is family planning. My friend, Marianne and I thought that there should be a specific listing of abortion services, that that should be included in the listing under family planning.

Thank you.

MS. MATSUDA: Be sure and sign in.

Thank you.

MS. WOODWARD: Jennifer Woodward from the Oregon Health Division, and I am speaking on behalf of the Oregon Health Division specifically related to Objective 20 which is to increase to 90 percent of the percentage of infants who are put to sleep on their backs. The parenthetical exclusion in this objective is incorrect. Healthy preterm infants should be put to sleep on their backs, and there is a citation for that parenthetical exclusion by Martin et al on the invulnerability of respiratory control for healthy preterm infants by supine and that article actually only looks at 19 infants, and they just focused on the breathing of those infants and there is no discussion about SIDS in that article. So, we recommend a change in that exclusion or removal of that exclusion, and this comment was submitted through the Oregon Health Division by Dr. Ken Rosenberg the NCH epidemiologist in the Health Division and Dr. Joe Gilhooley(?) the Director of Neonatology at Oregon Health Sciences University.

Thank you.

DR. LYONS: Any other comments on this focus area?

Thank you, and we have one more and then we will have a general session and any people with additional comments can step forward, and we will still limit those comments to 3 minutes each, but you can, maybe some of you obviously can represent yourselves and some can represent the organizations that you are representing.

So, the last focus area is, let me see? Excuse me, I have got to get all my notes together. Sorry, this book is too big, a point that has been made several times. Okay, sorry about that, medical product safety and Eileen Parish, FDA, Food and Drug Administration is the group coordinator for this focus area, and is the one you need to talk to, and here is your chance.

Product safety, the goal is to ensure the safest and most effective possible use of medical products.

MS. ARTHUR: My name is Kathleen Arthur, and I am a nurse and I have a latex allergy. So, this is a particular subject of interest to me, and what I am going to discuss is interoperative latex exposure in children. Objective 8-12 addresses occupational exposure in adults but children's latex allergies are not addressed. It has been well documented in the research literature that children with multiple surgeries are at high risk for developing a latex allergy.

Children who have conditions that require frequent surgery, such as spina bifida have a 38 to 60 percent chance of developing a latex allergy. Unlike adults in the occupational therapy and health category children develop latex allergies quickly with surgical contact. Kramer cites in Pediatric Allergy and Immunology, "From our data it may be concluded that surgery without strict latex prophylaxis is the main cause of new sensitization and worsening of pre-existing latex antibody levels."

Latex allergy prevention by primary latex prophylaxis during surgery was, also, investigated by Kramer in allergy. Prior to establishing an intraoperative prophylaxis in surgery 38 percent of children with spina bifida developed latex allergy with a mean age of 1.2 years and 3.3 surgeries.

After the establishment of a latex-free operating theater no children were sensitized to latex with a mean of 1.3 years and 3.6 surgeries.

As health care professionals we must ask ourselves the question at what point do we protect our children from latex exposure during surgery, at the first surgery, at the second surgery? Can we predict which child will have an accident or develop a condition that requires multiple surgeries?

Two studies looked at developing screening policies for children, Tetleman(?) and Templebaum. In both of these studies they had children who intraoperatively developed latex anaphylaxis that had no identified risk factors.

I challenge all health care professionals to investigate this issue themselves, spend 1 hour in front of your computer to do an advanced Medline search into the words "latex allergy in children."

Over 300 abstracts will appear with the same overriding themes. Children exposed to latex intraoperatively have a high likelihood of having a latex allergy. I would suggest a goal of reducing intraoperative latex exposure to 100 percent for all children by the year 2010.

Thank you.

DR. LYONS: Thank you, much.

Any more product safety, medical product safety?

Okay, now, then our attention by chapter is terminated or concluded, not terminated, concluded, and we will accept comments from anyone about any of these chapters.

I think we are kind of limited to these chapters or subjects closely related to them.

Yes, sir?

Would you please not only identify yourself but identify the focus area that you would like to speak about?

MR. MACDONALD: I am Steve Macdonald at Washington State Department of Health but I am speaking at the moment for the American Public Health Association Injury Control and Emergency Health Services Section.

In our section we have a broad area of interest in emergency health services which includes disasters and I am speaking although disasters are multidisciplinary and cross-cut many of the chapters in Healthy People 2010, specifically to the environmental health chapter because at the Healthy People Consortium meetings a couple of weeks ago, a month ago now, I guess in Washington, DC, there was discussion of that focus area work group of the desirability of including specific objectives related to disaster preparedness, disaster response and disaster recovery in the chapter on environmental health.

We very much applaud the interest in the environmental health chapter in seeing those objectives being added, recognizing that the chapter and the book as a whole already has many objectives, but since disaster is so important as a public health problem we very much appreciate the opportunity to see those objectives be added.

Thank you.

DR. LYONS: Thank you.

I was just corrected. We can receive comments on any of the chapters, and the good, even better news, I guess is that we can receive comments on anything, whether there is a chapter or not. Sorry.

MR. MURRAY: Jimm Murray from Wyoming Department of Health speaking for myself. I noticed references throughout the document pertaining to state and local. What I find wanting is references to the Federal Government, and I would suggest that there are in fact areas in here where references most appropriately should be to the Federal Government in addition to state and local government and entities partaking in Healthy People 2010.

Thank you.

DR. LYONS: Thank you.

MS. LAHDENPERA: This is Kay Lahdenpera, again, Municipality of Anchorage, Department of Health and Human Service, and thank you for this extra minute or 2.

I would like to go back to a specific objective and just to give you an idea, I mean it was already mentioned; Suzanne and I both mentioned it before, but doing a positive approach because I think that these objectives to be meaningful to be enacted upon by the public and the health care providers need to understand them a little better and they need to be easier to feel you are successful in achieving them, and maybe like in No. 9 you might say, and this isn't actually real positive, but you can word it the way you want, but propose 75 percent of the individuals age 15 to 17 do not engage in sexual intercourse during that age period, something of that nature. It makes it a little bit easier to understand and may be better to accept.

The point I really want to concentrate on is Objective 12 in family planning. That was your new one, and I cannot believe that wasn't in 2000, but I guess it wasn't because it wasn't listed, but I really agree with having sexuality, healthy life skills. I would add more to the course requirement, and I will send that to you because I don't have my list with me but we have spent lots of time with Peter Scales and many other notable people in developing a curriculum for our Anchorage School District and I think, and this year from the school nurses we have been asked to speak a lot to elementary level. So, I think here you have only broken out two levels, your middle junior high and senior high. I think you really need to break out an elementary level. The needs are different. The approach is different and that needs to be taken into account, and I am so tickled that this in here because the public needs to appreciate that the partners and the other people that are involved now with the 2010 are really in favor of this and hopefully that everyone will be so that we can go on with it, and we can reduce teen pregnancy, and the only way we will do that is to have it universal so that we will have a qualified universal program so that if a student transfers from one state to another state or moves to another school he will get the same opportunity to learn the information. So, I really appreciate it is in here.

Thanks, again.

DR. LYONS: Thank you.

MS. MANNEL: Hello, my name is Patricia Mannel. I am a nutrition consultant with the Seattle King County Department of Public Health, and I appreciate that we can address areas for which there is no chapter. I believe the vulnerability of homelessness in general appears to be under addressed in this book, and I did see a note in the mental health section that mental health, homelessness was a risk factor for mental health, but beyond that it really should be associated with food insecurity, malnutrition, TB, injury prevention, a wide array of issues. I would like to see an objective that addressed reducing homelessness among children and families.

DR. LYONS: Thank you, good one.

MS. DOYLE: Good morning, Linda Doyle, Multnomah County Health Department in Portland, Oregon as well as Oregon Teen Pregnancy Task Force.

I would like to take us back to the injury violence prevention, particularly the intimate violence and sexual assault. It is not clear to me where childhood sexual abuse resides in here. There is the objective that refers to 12 and older, but we know that many of these young girls and boys were abused as early as 8 and 9 and even younger. So, I would like the Committee to review the objective and make sure that we accurately reflect initiation of childhood sexual abuse.

Thank you.

DR. LYONS: Thank you.

MS. PETERSON: Jane Peterson, Seattle University, Seattle, Washington. I would just like to make a comment about education and specifically trying to focus on minority groups, ethnic minority groups who have not been terribly represented in health care professions or in other areas that would help our health, advance or health. So, whether it be transportation or something else that doesn't, is not particularly health but in this multisectoral kind of view of health ask for that, some emphasis on educating those people in those areas.

The other thing brought up in another session had to do with culturally competent care as part of a, and this was a medical curriculum, they wanting it that some emphasis be given to the necessity of including that kind of core competencies in educating health care professionals.

Thank you.

DR. LYONS: Thank you.

MS. BLACK: Good morning. I am Sharon Black, a public health consultant from Portland, Oregon, and I am speaking for myself. I had the pleasure of sitting in on the racial disparity section yesterday, and I would like to encourage that when you are noting that data is not available by race that we edit that to say, "Data is needed," or "Data is required," and not leave it that it is not available. I think it is far too important for us to have that information.

Thank you.

DR. LYONS: Thank you.

MR. LUX: Gene Lux. I am, also, on the board of the Washington State Senior Citizen Lobby. Our main concern is long-term care, of course and community based. We are very interested in community-based long-term care, and I just wanted to bring to your attention, I am, also, on the board of the senior center, the importance of senior centers in the long-term care continuum. We have nutrition programs. We have, of course, these are financed by fed and state money, county money, and we have access buses that bring folks to the center for exercise, nutrition programs and many other services which keep people in their homes much longer than they would be if those services weren't available, and I just want to let you know that in South Seattle we are in the process of buying an 124-unit apartment that is contiguous to a senior center so we can make this an even more senior campus where we can offer services of assisted living and that type of care and maybe a full-service unit and I think that that in the future is going to be very, very important on how we take care of the aged, and they are coming on line so fast we are going to have to make some arrangements for that.

Thank you.

DR. LYONS: Thank you.

Any other comments?

I see one coming.

MS. SHERTLEFF: I am Cynthia Shertleff, and I am speaking for myself as a health education consultant. I would like to emphasize the importance of starting health education in elementary school and I think that we could use the firemen and the senior citizens and so forth. I think it is extremely important to get young children to realize that they are responsible for their own health care.

I, also, would like to speak to the objective on the poison centers in the injury prevention section. I don't know about the other states in these regions, but I do know that Washington State is in jeopardy of losing the state funding for the poison control 1-800 number.

I wanted you all to be aware of that and I, also, want to make two other quick announcement, if I may and that is that Governor Locke(?) came out yesterday in full support of primary emphasis on state child health insurance programs. He plans to use the tobacco monies as the state pool in order to help us access the federal dollars, and the other announcement I want to make as a board member of the Healthy Mothers, Healthy Babies Coalition of Washington State is that the national meeting will be held in Seattle next summer starting the end of July.

Thank you.

DR. LYONS: Thank you.

Other comments? We will have announcements in a minute, too, but any other comments?

MR. LEPISTO: I would like to make a comment before I get too nervous to get myself up here. My name is Chris Lepisto. I am a student of naturopathic medicine, and Pasteur University which is here in Seattle, and what I wanted to comment on was the, as I was browsing through the section of the book, this was my first contact was with it today, this is in particular regard to the access to quality health services, but there is very little if any reference to the existing practitioners of complementary and alternative medicine, as well as the future practitioners like myself.

So, what I want to get at today is one term that I did see in the book which was integrated health care and integrated to me is a broad sense of let us take the practitioners that we have and all the other systems built around health care and integrate them together in a direction for public health, and so, one of my comments is that the number of people visiting alternative practitioners exceeded the number visiting contemporary practitioners last year, and that number is on the rise, and so if for no other reason than to address the public interest that needs to be considered, and so, I would like to see some reference to including complementary and alternative practitioners towards public health.

Thanks.

DR. LYONS: Thank you.

Any more comments?

I am told we are supposed to formally adjourn and then make comments. So, we are formally adjourned, and now, I would like to make some comments.

(Laughter.)

DR. LYONS: I would really like to thank the audience for sitting here and taking all this in, and I hope that you have gotten some new ideas, and you can continue to submit your thoughts and your concerns via Internet or sending in written information. It is better to have it in electronic form especially if it is long because it will be more quickly entered into the record if it is electronic or if you put it in yourself on the Internet site.

So, I thank you for participating. I think it was very interesting, very useful to me, I am sure very interesting to our panel members whom I would, also, like to especially thank for taking the time to come, some of them way out here on the other side of the country and did not have an opportunity to share their own particular enthusiasms and knowledge about these subject areas. I am sure it must be very frustrating to sit there and not be able to respond either affirming or conflicting statements.

So, I really appreciate your taking the time to be with us, and I would, also, like to especially again thank the Office of Disease Prevention and Health Promotion for their putting on an excellent meeting, and I thought it was especially well organized and managed, and do you have any announcements back there, the people with the yellow labels?

Apparently none.

LINDA BAILEY: We should have the transcript up on the Web in 3 weeks, if you want to go to our Web site.

DR. LYONS: And will those be identified by name and location, too, Linda?

LINDA BAILEY: Yes, the name and the location.

DR. LYONS: Okay. I am sorry that she isn't here to hear it, but I really appreciate the special effort that people with special needs had to deal with to get here, and I would like to suggest to all of us on recommendation of Kathy to be particularly patient and anxious to communicate with people that have a harder time communicating with us, and I appreciate all of your time, and if you would like to enter some additional comments or get in on some more of this kind of session, the other Session Two is still going on, and you are invited to go down there, if you like, and thank you all very much.

(Thereupon, at 11:18 a.m., Session One was adjourned.)

Seattle Transcripts and Summaries