TRANSCRIPT OF THE NATIONAL HEALTHY PEOPLE CONSORTIUM MEETING AND PUBLIC HEARING

WASHINGTON, D.C.

NOVEMBER 12-13, 1998

C O N T E N T S

Regional Meetings

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OPENING REMARKS BY DR. CLAUDE EARL FOX

DR. FOX: Okay, let's get started. There will be myself, Dr. Bob Windom, whom you have already met, and Dr. Linda Meyers, who is the Acting Director of ODPHP.

I want to first take just a minute and lay out the ground rules for the hearing. We want to ensure in this hearing that everybody has an opportunity to be heard. We have a lot of people registered to speak between now and five o'clock. We will not be taking a break, so any of you who need to do so, feel free. We are going to be hard pressed to get all the comments in, even with the time we have available.

Each oral statement is going to be limited to three minutes, and I am going to try to use Southern gentility, and not be too abrupt with you, but I will tell you, we are going to cut you off at three minutes. You are not going to get three and a half minutes, or four. If we give everybody an extra minute, it will be about midnight when we get out of here, so we are going to hold to the time frame.

I am going to ask that one individual per organization speak, so if you have several people in the organization, have one person say what it is you want to say, and not do it repetitively. Also, let me ask those of you, as you listen to comments, if you hear that somebody has made your comment, unless you just feel absolutely compelled to get up and say it again, we are going to ask you not to do that. Or either stand and say, I am from so-and-so, and ditto. Because again, if we could get by with less than three minutes, that would be great as well.

We are going to ask you to queue up to the microphones. We have floor microphones here, and as you come up, by the number you were given, we are going to ask you to state your name, and the state you are from, your residence. Also, if you are representing any particular organization, please identify that as well. Before you get in line, please be sure that you’ve signed in at the table at the back of the room.

I heard there is a light here that turns yellow. Is there? Where is the light? Oh, there is a beeper. Oh, well, I have been told that at a minute, it will turn yellow, and this thing goes off when the three minutes are up, with a shrilling noise. So, at that point, if you don't stop talking, Dr. Windom is going to come down with the gavel, and then your microphone will be cut off.

So again, we are going to try to be nice about it, but I hope none of you get offended if we cut you off. It is nothing personal. We just have to move on. Our staff from Social & Health Services is going to be serving as the timekeepers.

And let me also say one final thing. We are not going to provide responses, so you can sort of pose a question, make statements, whatever, but we will not make any responses from the panel. This is strictly your time to give us your comments.

So, let's begin. Lauren Leifer is first to testify, and again, we have your statements in writing, so you don't need to go back through your entire statements. We hope this is just an opportunity for you to hit the high points. Lauren? Turn the microphone on for her? Need the floor microphone on. Are these wireless? Let's try one of the others. I will tell you, Lauren-- Yes, let's try the middle one.

MS. LEIFER: Hello? Great, okay.

DR. FOX: Okay. Go.

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MS. LEIFER: Super. I am Lauren Leifer. I am from the State of Illinois. I chair the Healthy People Business Advisory Council, and as the chair it is my pleasure to speak on the Council's behalf.

The Business Advisory Council, for all of you who may not know, is an alliance of small, mid-size, and large companies, committed to promoting healthy businesses and healthy communities, and the Council is being sponsored by Partnership for Prevention with a grant from the Robert Wood Johnson Foundation.

The Council firmly believes that strong partnerships between the public and private sectors are critical to achieving our nation's health promotion and disease prevention objectives, that business leaders are integral contributors to reaching the Healthy People goals, and sound health policies and programs that support a healthy work place. And so, we of the Business Council believe that Healthy People 2010 is the road map for these policies and programs. And we have identified those objectives that relate directly to employer behavior, employee behavior, creating safe work environments, and resource allocation. We are also finalizing our comments on those draft Healthy People objectives which will, one, facilitate employees' ability to manage and prevent injuries and illness; two, help employers attract, motivate, and retain a healthy work force; three, support safe work environments; and four, help employers allocate resources toward prevention in the most effective and responsible manner. And I am here today to offer several comments on how we believe the business community can better engage in Healthy People activities.

One, Healthy People needs to be translated into a language and format that will be useful to non-health professionals and business owners. And we are suggesting a shorter companion document, oriented specifically to businesses, which would include information on how businesses can become more involved in community wellness programs, and which would be offered through user-friendly platforms such as the Internet.

Two, since businesses have a wealth of experience and resources that could help shape Healthy People activities, we of the Council believe that the public health community must make a concerted effort to reach out to businesses of all sizes, shapes, and forms. And you know, the paradigm shift is not only taking place in the public health arena, but equally in the business community, and so we want you to appreciate the potential changes in all of our corporate cultures, and in conjunction, the outreach opportunities by the public health community.

We of the Council request that the Federal Government develop Healthy People programs and incentives targeting the business community, that state and local-level agencies start your own local Healthy People business advisory councils, and work through and with local Chambers of Commerce to identify common health objectives.

We of the National Business Advisory Council see our continued role as a facilitator in the implementation of Healthy People 2010 objectives, and by working together we can and will build the foundation and infrastructure necessary to support healthy business and healthy communities.

DR. FOX: Thank you, Lauren. I didn't know you could talk so fast.

(Applause.)

DR. FOX: Number two. And what we are going to do is this, this is the odd microphone, so if you are one, three, five, seven, or whatever, here. And if you are two, four, six, eight, over there.

So, yes, sir. State your name, and the organization you represent.

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DR. EIST: I am Dr. Harold Eist, the Past President of the American Psychiatric Association. President Dr. Rodrigo Munoz sends his greetings on behalf of the American Psychiatric Association, the oldest medical specialty organization in America. We applaud the Healthy People 2010 initiative. Increasing quality and years of healthy life and eliminating health disparities have been urgent agenda items for the American Psychiatric Association, and for the American people.

Over the past five years, expenditures for medical and surgical care in America have gone up four to seven percent, while expenditures for care of those with mental illnesses have gone down by 50 percent. As the volume prepared for this Consortium indicates, over the past five years, mortality rates for the chronically ill are up, life expectancy for the first time in 30 years has gone down, and the vast majority of those suffering from mental illnesses get no treatment whatsoever, particularly children, minorities, the elderly, the poor, those suffering from disabilities, those who suffer from substance use disorders, the homeless, and prisoners suffering from mental illnesses. It is a national shame that we have the means and the resources to treat these terribly and foolishly neglected individuals, while billions are being siphoned into the profits of greedy entrepreneurs. It is a national shame that our prisons house more of our citizens with mental illnesses than our hospitals. It is a national shame that many, if not most, of those with mental illnesses could be rehabilitated for one-half the cost that it takes to keep them in prison.

We must proceed with the Healthy People objectives. We cannot ask those with mental illnesses to wait any longer. There never, ever, ever has been adequate funding for the care of the mentally ill in America, even though it is now absolutely clear that we cannot afford not to provide that care. We can begin to end millions of tragedies in the making if we open our hearts and minds today, and enjoin the Administration and Congress to ensure adequate and fair care, not just for some, but for all of our people. Thank you.

(Applause.)

DR. FOX: Thank you. Number eight. We are not skipping people. It is just that we had a gap in some of the numbers given out. Number eight.

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MS. TATE: I am Margaret Tate, and I am from Richmond, Virginia. I am representing the American Dietetic Association.

The American Dietetic Association welcomes the opportunity to comment on the Healthy People 2010 draft objectives. My comments reflect preliminary input on selected draft objectives from ADA's multidisciplinary task force composed of more than 25 nutrition professionals involved in public health research, academia, and direct care. We look forward to submitting our formal, written comments that will address the objectives more fully. We applaud HHS for recognizing the important role of nutrition in health promotion and disease prevention, as evidenced by the number and scope of the proposed nutrition and related objectives in the draft document.

We have concerns regarding the nutrition services of primary care draft objectives. As currently written, this section fails to adequately address the critical need for a comprehensive approach to nutrition services in a variety of health care settings. In addition, it also fails to recognize the important role of nutrition professionals in the provision of such services.

ADA strongly urges HHS to consider using obesity as a leading health indicator. ADA applauds HHS's leadership in the area of food security and supports an objective on this important public health concern.

ADA recognizes the important role folic acid plays in reducing the risk of neural tube defects, and understands the need for folic acid supplementation and fortification. However, we strongly urge that the wording of this objective be changed to reflect the important role of a healthy diet that includes folic-rich foods in addition to supplementation and fortification.

ADA urges HHS to include a terminology section for the nutrition focus area as included for other focus areas. We will be providing details with the suggested terminology that should be included in such a section.

And finally, ADA will be providing more detailed recommendations, and we stand ready to assist in implementing these important national objectives.

On a related note, we look forward to working with HHS and other agencies toward reauthorization of the National Nutrition Monitoring and Related Research Act in coming years.

(TOP)

DR. FOX: Thank you. We are very pleased to have an analog watch up here, since the electronic one is not working. I am going to tell a story while they are trying to reset the clock. Dr. Windom, during his tenure as Assistant Secretary, was chairing a panel of Federal officials, and each one of them was given 20 minutes to make a presentation, and the first person gave their presentation, 20 minutes, and sat down. And the second person gave their presentation and sat down. And the third person got up, and at 15 minutes they didn't give any indication of moving toward the end of their speech, so Dr. Windom slipped him a little note, and it said you have five minutes left. And they kept going, and at 20 minutes they were still talking, and Dr. Windom slipped them another note saying your time is up, and they kept going. They went on for another ten minutes, and he slipped them another note, and he said your time is up, please sit down. They went on for another ten minutes, and finally, at that point, Dr. Windom stood up and he grabbed the gavel like he has here, and he started banging the gavel on the podium. And as he did, the head of the gavel flew off, and it hit the woman in the front row in the forehead, and as she slumped over into unconsciousness, she was heard to say, "Hit me again! I can still hear him."

(Laughter.)

DR. FOX: That is not a true story, obviously. Are we ready with the clock? Okay. All right. Okay, great. Number nine. Do we have a number nine? Sis Wenger?

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MS. WENGER: My children wish we would count like this. One, two, eight, nine. I am Sis Wenger, and I am Executive Director for the National Association for Children of Alcoholics, and I am here to make a few brief comments about children of alcohol- and drug-dependent parents, and where I think they fit into this overall picture of Healthy People 2010.

There are over 28 million Americans who are children of alcoholics in this country. Nearly 11 million of them are under the age of 18. This figure is magnified by the countless number of others who are affected by parents who are impaired by other psychoactive drugs. Many of these children are exposed to chaotic family environments that lack consistency, stability, and emotional support. Many will develop alcoholism, other drug problems, and/or other serious coping problems. And most will have seen their pediatrician, their adolescent medical specialist, family practitioner, school nurse, and many others who deal with children on a regular basis, multiple times along the way.

Health care practitioners particularly can play an important role in identifying and assisting these children. Unfortunately, the specific knowledge and skills necessary to allow them to capitalize on their unique vantage point has not systematically been addressed in either the training for health professionals, or in clinical practice. As a result, our organization began to work with a number of major medical groups, and to develop core competencies for involvement of health care providers in the care of children and adolescents affected by substance abuse.

The reason we did is that these children are the ones who are most at risk for addiction later on. They are the most at risk for mental health problems. They are most likely in their adolescence to suffer from anxiety disorders or depression. They are the ones most likely to show up in our juvenile justice system. They are the ones most likely to be adolescent addicts. All of these are serious health problems that have been addressed throughout all the recommendations and discussions in this very thick document, "Healthy People 2010." And yet, specifically, we have not addressed the children of substance abusers. They are one in five children in this country under age 18. And I urge you to add the extra "and", and the extra question when you are developing the fine tuning for these objectives. Thank you.

DR. FOX: Thank you. Can I ask, as we have a speaker, the next person queue up? So, if the next person after this lady will come over here, just be ready. Yes, ma'am.

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DR. SCHOEN: I am Delores Schoen of Baltimore Maryland, representing NAON, the National Association of Orthopaedic Nurses.

We welcome your acknowledgment that arthritis is the leading cause of disability. Arthritis affects more than 40 million Americans, almost one out of every six people, making it the most prevalent disease in the U.S. In many cases, disabilities due to arthritis deprive individuals of their freedom and independence, disrupt the lives of family members and care givers, and shorten life expectancies. Disabilities from arthritis can result in enormous individual health care costs, and have an economic impact on the nation roughly equivalent to a moderate recession.

Early detection and treatment of arthritis is crucial. Health care providers must know the early warning signs and effective treatment. We urge a continued strong focus on providing patients with arthritis the means to enter and stay in the labor force if that is possible. For those unable to work, we urge that solutions be sought to allow those individuals to remain at home with adequate care, and resources for that care. We are concerned that medication and the cost of treatment for individuals with arthritis, especially those with rheumatoid arthritis, may be out of reach for many, and that access to specialty care of rheumatologists may not be available, or difficult to obtain. Funding for research on the cause, prevention, and treatment of arthritis, the many types, must continue.

As orthopedic nurses, we are encouraged by the emphasis on osteoporosis, and the fractures that occur as a result of that condition. However, we are concerned that osteoporosis is still being viewed as an older woman's disease. It is really a pediatric condition with its manifestations in geriatrics, and affects both men and women. Individuals must develop a good bone structure when they are young, in order to prevent the symptoms and the fractures that occur from the loss of bone mass as the result of normal aging.

We support the interventions to prevent the development of osteoporosis. We urge education campaigns on how to keep bone structure, the proper diet that includes the appropriate amount of calcium, minimal amounts of caffeine, avoidance of smoking, and increased physical exercise. We also encourage programs for boys and girls on how to build good bone mass from birth, and stress the importance of including nurses as well as physicians and teachers in their educational process.

Regarding injuries, we are encouraged by the focus on reducing childhood injuries, and the emphasis on child safety seats, and the use of bicycle helmets. We applaud the emphasis on abuse of children and women. As orthopedic nurses, we see more and more that victims of violence are occupying hospital beds.

However, nurses experience work place violence, mostly from patient assaults, as reported by nurses surveyed in seven states. Thirty percent reported having been victims of work place violence in the previous year. Fifty-five percent of those same nurses stressed the need for the involvement of all employees in creating a safe workplace.

DR. FOX: Time is up. Thank you. Yes, we look forward to your complete statements in the record. Number 11?

(TOP)

MS. KNOX: I am Becca Knox with the Center to Prevent Handgun Violence, in Washington, D.C., and first, I want to thank the work group coordinators for violence and injury prevention. They have done a great job, both this year and last year, with the group process.

I first off want to support the grouping of intentional injury with unintentional injury. The Center is in favor of that. However, we do have a request that suicide be linked with violence and injury as well as with mental health. And our rationale for requesting that is the lethality of firearms. If people attempt suicide with a firearm, they are going to be very successful in completing it, and so, the cry for help, which is a cry for mental health services, often goes unheard.

Secondly, over the past ten years, many advocates have called for an approach to firearm injury prevention that is similar to what we apply to reducing motor vehicle injuries. Study the problem, look at the design of the product, license the owner, and register the car or the gun.

In the hopes that Healthy People 2010 objectives can take a lead in articulating that model for our community, we hope that there can be objectives on at least surveillance and the design of guns. Objective 9.15 from the last round actually did target state-level laws to change designs of guns. And the Institute of Medicine very recently issued a report that supported the need for both non-fatality and fatality surveillance for all injuries. Thank you.

DR. FOX: Thank you. Number 12.

(TOP)

MR. BRISCOE: I am Andy Briscoe. I am Director of Public Policy at the Salt Institute in Alexandria, Virginia. The Salt Institute supports the consensus of the November 1997, Indianapolis meeting of Healthy People Consortium, which required deleting from the draft the population goals for sodium consumption. We would recommend substitute goals of improving the percentage of the population consuming other electrolytes such as potassium, magnesium, and calcium to current recommended levels; encouraging all Americans to have their blood pressure checked regularly; developing simple, inexpensive, and reliable tests for blood pressure, for salt sensitivity; and intensifying the commitment of resources to combating our natural epidemic of obesity. We also recommend the comprehensive study of health outcomes of low-sodium diets, to identify why published studies of health outcomes of sodium-restricted diets consistently find elevated risk of heart attacks among those in the quartile of low-sodium consumption.

Twenty years ago, the first Healthy People goals advocated 40 percent reduction in salt intake as a goal for the year 1990. No progress was achieved. The Healthy People 2000 goals were aimed at discouraging salt-use in cooking and use at the table. Again, no progress was achieved, and in fact, backsliding has been recorded. The draft 2010 objectives track this approach, and in fact, they returned to the more heavy-handed, ineffectual approach of the 1980s.

I don't have any clock.

DR. FOX: We are keeping time, up here.

MR. BRISCOE: Good.

We recommend the deletion, and specifically in reference to 2.10, we recommend the deletion of this objective. Sodium intake for the population is moderate today, as it has been for the past century. Evidence for the recent meta-analysis of clinical trials documents the insignificant changes in population blood pressure.

All in all, the draft objective is a great disappointment. As a participant in the Healthy People proceedings for the past decade, and particularly at the meeting in Indianapolis, where a roundtable discussion offered guidance in drafting this objective, the Salt Institute feels the author of the draft objective wasn't listening carefully, or wasn't even in the room. As mentioned earlier, in Indianapolis the consensus was that the sodium objective was unnecessary. The NIH-prepared summary conceded the direction of the group seemed to be that with a normal, healthy population, sodium consumption isn't an issue, but those with hypertension, coronary artery disease, should check with their physician.

That is all I have got. Thank you.

DR. FOX: Thank you very much. Next.

(TOP)

MS. LUCKENBILL: I am Doris Luckenbill. I am the President of the National Association of School Nurses, and we thank you for the opportunity to testify today.

The National Association of School Nurses supports the concept of coordinated, comprehensive school health programs, and we support the many objectives throughout the Healthy People 2010 document that address the various components. In the belief that schools are an appropriate place to deliver health promotion strategies to school-age youth and school staffs, we totally support objective 4 in the Educational and Community-Based Programs section, which recommends increasing the percent of schools with school nurses. We have a recommendation to replace the second paragraph (lines 19-26, in "Educational and Community-Based Programs," objective 4: School Nurses) of rationale with language that more clearly articulates the school nurse's ability to impact student and staff health issues that cross over many of the other focus areas, because we believe that school health services are necessary at all schools, not just those with model programs such as primary care services and full service schools.

School nurses assess the students' health and development, help families determine when medical services are needed, and serve as a professional link with physicians and community resources. Federal Laws entitle students with disability to attend public schools in their neighborhoods. For children with disabilities, the nurse is an essential resource. The National Health Interview Survey on Child Health (1988) estimated that 31% of children under the age of 18 years have one or more chronic health conditions, not including mental health conditions. These are children who are dependent on daily medication, nursing procedures, or special diets for normal functioning. The school must be prepared to address these needs as well as their health-related emergency needs. Students with chronic conditions warrant a full-time registered professional school nurse on each campus. This nurse will spend her or his time managing care and providing services to support and sustain students' school attendance and academic achievement. School attendance is mandatory; thus the schools can be considered the workplace of students. Industry supports their workers with professional occupational nurses. Students deserve comparable care from professionally prepared registered school nurses. The registered professional school nurse is the keystone of a healthy school (Hatfield, 1998). Thank you.

[For written comments from this participant please click here.]

DR. FOX: Thank you very much. Yes, sir.

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MR. HAMM: My name is Michael Hamm. I am Executive Director of the National Association for Public Health Statistics and Information Systems. We are an organization representing state offices of vital records and public health statistics. These are the branches of state government that have direct responsibility to collect, analyze, and distribute much of the data that will be used to measure compliance with Healthy People 2010 objectives.

We were somewhat concerned in that lengthy volume, due to the importance of the work that our members do, that there was almost no mention of these offices and data centers. Accordingly, we are recommending that an additional goal be added to increase the capabilities of state and local data centers to provide comprehensive information services to support the essential public health services.

Another area of concern we wanted to point out is the use of the term "national vital statistics" in the terminology part of this section and in the Data Issues Introduction section. The system described by this term should be called the "Vital Statistics Cooperative Program." This is a combination, state-Federal effort to produce important data that will also be used for many of the objectives. This program has funding problems and we think it is very important for the benefit of all the other goals, that somehow or other the 2010 objectives address this finance issue.

And last but not least, I just wanted to point out that our members are caught in the awkward position of trying to do more, but with a continuing decrease in resources. The Healthy People 2010 objectives consistently ask for more data, more detailed collection of data, better timeliness, and enhanced services, such as geocoding. The common issue in all of these is that it can be done if more resources are available. That is the bottom line. Thank you.

[For written comments from this participant, please click here.]

DR. FOX: Thank you. Next.

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DR. MARGE: I am Michael Marge, President of the American Association on Health and Disability, an organization dedicated to the prevention of primary disabilities, and the prevention of secondary conditions, or additional health complications in people with disabilities.

We commend the Secretary, the Surgeon General, and the members of the Healthy People 2010 Steering Committee for recognizing the important health problems of people with disabilities by including Chapter 19, called "Disability and Secondary Conditions." But I regret to say that the draft document falls short of our expectations to include, at least, people with disabilities as a select population in the goal statement and in every chapter throughout the document. I think it is time for that to happen.

There are many reasons for our recommendation, but let me just present three in the interest of time.

First, people with disabilities represent a significantly large population. According to current estimates, there are 51 million children and adults with chronic, disabling conditions.

Second, people with disabilities experience major health disparities that need to be recognized, studied, and tracked.

And third, since the enactment of the Americans with Disabilities Act in 1990, it has become very clear to us that full accessibility, guaranteed by the Act, will never be realized unless people with disabilities enjoy good health, free of secondary conditions, throughout their life span. Health, good health, is essential, especially in the areas of employment and independence.

Given these, and many other reasons, we strongly recommend that people with disabilities be included as a select population in the goal statement and in each chapter throughout Healthy People 2010. This recommendation and the other suggestions that we have concerning Chapter 19 will be included in our written testimony that I will submit today.

[For written comments from this participant, please click here.]

Thank you very much.

DR. FOX: Great. Thank you. Yes, ma'am.

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DR. DRUGAY: My name is Dr. Marge Drugay, and I represent the American Nurses Association. I am the chair of the Council on Community-Based Primary and Long-Term Care.

The American Nurses Association is the only full service professional organization representing the nation's 2.6 million registered nurses through its 53 constituent associations. ANA supports the role of the registered nurse as an essential provider of health care in all practice settings, and with a variety of patient populations. ANA applauds the work of the Department of Health and Human Services in identifying and disseminating key objectives to improve the health status and welfare of the nation, through health promotion and disease prevention.

Today's environment demands that the nursing profession assert its powerful voice in the time-honored role as patient advocate by supporting public policies that protect consumers, enhance accountability for quality, and promote access to a full range of health care services, including health promotion and disease prevention strategies. A diverse range of disciplines and coalitions are involved in the prevention of disease and health promotion, and prevention has long been a part of nursing's scope of practice.

Nurses delivering care to clients across the life span in a variety of practice areas can support individuals and coalitions structured to promote health and prevent disease. Nurses have involved themselves in activities that move individuals, families, groups, and communities toward higher levels of health and wellness. In all direct and indirect practice arenas, nurses must continue a strong orientation for prevention.

The ANA Council on Community-Based Primary and Long-Term Care Nursing Practice represents the interest of nurses in diverse settings, but all are invested in the goal of promoting healthy and safe communities. We believe that the section "Education and Community-Based Programs," number four, does not demonstrate strong and clear linkages, either to mental health issues such as depression and stress management, or to violence prevention. This section deals with the health education in schools, work site, and community settings, places where we believe education in these issues must begin, and continue throughout the life span. We encourage the committees to review the need for stronger health education programs across settings that address preventive aspects of mental health education and screening, as well as interventions to prevent violence.

Thank you for this opportunity.

DR. FOX: Thank you. Next.

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MR. DOWNEY: Good afternoon. My name is Morgan Downey. I am from Washington, D.C. I am the Executive Director of the American Obesity Association, and I am a person dealing with obesity.

In contrast to the Surgeon General's comments at lunch, obesity is the health epidemic that the Healthy People 2010 process has forgotten. The facts about obesity are straightforward. Incidence is skyrocketing in the United States as well as globally. Increases are being seen among children and adolescents at an alarming rate. Racial, ethnic, and socioeconomic disparities are glaring.

Obesity is an independent risk factor or an aggravating condition for 30 other serious and major health conditions, most of which are rising hand in hand with the rising incidence of obesity. Poor diet and inactivity has been recognized as probably equal to smoking in the number of preventable deaths in the United States. It is a major cause of functional limitation, disability, and lost years of quality of life. Persons with obesity are the last group in America for which outright ridicule and stigmatization is socially acceptable.

At this time, the United States is divided into three communities. One is obese, is sick, dying, and disabled. One is in denial, which may include the public health community. And one is phobic about obesity. Our children, our adolescents, and many individuals are engaged in dangerous and threatening dieting activities and eating disorder behaviors. And many are using smoking as a tool for weight management.

And yet, one has to search through hundreds of pages in Healthy People 2010 to find even a reference to obesity. It continues the failed strategy of Healthy People 2000, and a new strategy and new direction are needed. We are moving farther and farther away from the targets set out in Healthy People 2000. It is time for the public health community to stop being in denial about obesity.

Our statement, which is available in the back, proposes that obesity be considered a leading health indicator, and a new chapter added in the section on preventing and reducing diseases and conditions, reflecting obesity and related eating disorders and other conditions. The criteria for leading health indicators and focus areas are amply, if not overwhelmingly, met by obesity. We propose a broad campaign of education about obesity and healthy weight management involving corporate wellness, managed care, schools, and other social and academic institutions.

Obesity is soon to become the normative condition in America. We are losing three to 500,000 people in premature deaths a year. We cannot wait another ten years for the systems needed to address obesity to come online. It has to be done now, and the time is here. Thank you.

DR. FOX: Thank you very much. Next.

(TOP)

DR. HIRSHON: Good afternoon. I am Dr. Jon Mark Hirshon, Assistant Professor in the Department of Emergency Medicine at Johns Hopkins School of Medicine, and with a joint appointment at the Department of International Health of the School of Public Health. And today I am here as a representative of the American College of Emergency Physicians, a national professional member organization of emergency physicians.

The American College of Emergency Physicians has taken an active role over the past two years in developing objectives in Healthy People 2010. There are important objectives in a number of areas that are likely to impact how we serve the needs of our patients, including objectives related to injury control, disease surveillance, prehospital emergency services, management of poisonings, pediatric emergency care, thrombolytic therapy, and mental health services.

Members of the American College of Emergency Physicians have worked hard to help develop national health objectives for the next decade. Nowhere have we been more active than in the area of access to appropriate health services. As a practicing emergency physician, I am afforded a unique and sometimes disturbing view of the successes and failures of public health in the United States, and of the American health care delivery system.

By Federal law, any individual who presents to an emergency department is to be seen and evaluated. Emergency departments are often viewed as the provider of last resort, the "safety" net when all other avenues of health care are unavailable. If you are three days old, or 103 years old, a victim of stabbing, gunshot, suffering from AIDS, undergoing a heart attack, it doesn't matter. Insured, uninsured, we see you. That is my job.

But the operative words here are, if you come to the emergency department. Over the past several years, we have seen attempts to impede the ability of individuals to come to the emergency department in their time of need. Those who are being denied access to emergency care, sometimes with disastrous results, are not the uninsured, but the unsuspecting clients of health insurers. These individuals are facing increasing delays or denials of emergency services as the penny-pinching gatekeepers of managed care and other health insurance companies erect financial and administrative barriers to receiving timely and needed emergency services.

The American College of Emergency Physicians worked hard in the development of objective 10-C.2, which mandates access to emergency care. Unfortunately, last-minute wording changes to objectives 10-A.1 and 10-C.2 obscure the problems of the insured population, and deny the critical role that emergency departments play in the delivery of health care to the greater than 40 million uninsured citizens of the United States.

We are puzzled and disappointed by the word changes and dismayed by the unresponsiveness of the access work group coordinators to our deep concerns over these changes. We ask that the words "emergency care" be removed from the first sentence of the support statement for objective 10-A.1, as well as the words "by insurance status" from objective 10-C.2.

[For written comments from this participant, please click here.]

DR. FOX: Thank you.

(TOP)

MR. GRIZELL: I am Jim Grizell. I want to thank HRSA and you for help with our companion document.

The American College Health Association strongly urges that college students be included in as many measurable objectives as possible. Fourteen million college students should be included as a "select population." The National College Health Risk Behavior Survey provides data for measurable objectives. The American College Health Association will provide suggestions for Healthy People 2010.

The reasons for including college students as a population distinct from the 18- to 24-year-old adolescents and young adults include the fact that the average age of college students is close to nearly 24 years old. The draft and NCHRBS state that 43 percent and 36 percent, respectively, of college students are over 24 years old. The character of college students form a community of young adults and adults who have their own social norms; behavior; governance; shared world view, outlook, expectations; and health communication needs.

As far as growth goes, college students are in a distinct transition stage toward independence that allows for mentoring and guidance by faculty and staff. The college students also form the nuclei for leadership in the future. College students are the ones who are going to care for us in our future.

Some specific comments and objectives: the terminology. Use "students attending postsecondary institutions" or "college students." Draft objective 4.3 uses the term "students attending postsecondary institutions." Objective 26-7.B, on binge drinking, uses the term "college students." Maintain consistency with the title of the data source, the National College Health Risk Behaviors Survey. Have sub-select populations for students attending postsecondary institutions, possibly 18 through 23, 24 through 29 and 30 and over. And also, sub-select populations for ethnicity and race.

Objective 4.3 includes a rationale for having the objective. It should state that many programs are not comprehensive in design, or of sufficient duration, and therefore, are potentially limited in their impact on college student health and well being.

Include objective 9.19 of Healthy People 2000 to increase athletic protective gear. Also include objective 20.11 of Healthy People 2000, to increase immunizations through postsecondary institutions. And include college students under eating disorders in chapter 23, Mental Health and Mental Disorders. There are two questions (77 and 78) in the College Health Risk Behavior Survey that addresses those.

The American College Health Association will submit additional objectives to you. These will be based on measurable objectives from data in the NCHRBS. Thank you.

DR. FOX: Thank you very much. Number 20.

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MS. FONSEKA: Good afternoon. I am Jamila Fonseka, from the Arthritis Foundation, and I am here to strongly support and affirm the inclusion of arthritis objectives, and the arthritis chapter in Healthy People 2010.

This new chapter is a crucial addition to Healthy People 2010, given the high prevalence and high burden of this set of conditions on this nation. I would like to add that, in the past, arthritis has not been included in Healthy People framework. Arthritis is associated with a number of myths, for instance, that it is just a minor condition, minor aches and pains; it is a disease of aging; and nothing can be done about arthritis.

But in fact, arthritis is the nation's leading cause of disability and the second leading cause of work disability, so it is not "just minor" for those who are affected. It affects nearly 43 million Americans. All ages and all races and ethnic groups are affected. While 50 percent of the elderly population is affected by arthritis, the majority of people with arthritis are less than 65 years old; thousands of children and teens are affected, juvenile arthritis is one of the most common chronic childhood illnesses.

In 2020, some 20 percent of the population, or nearly 60 million people, will be affected by arthritis. This set of conditions has an immense economic and social impact on this nation. It costs the nation nearly 65 billion dollars annually, equivalent to a moderate recession.

Also, it is perceived that nothing can be done about arthritis, but in fact, there are effective interventions that are currently underutilized. In fact, some arthritis interventions reach less than one percent of the population. In the light of the high prevalence and staggering social and economic impact of this set of diseases, and the fact that there are effective interventions which are underutilized, it is crucial that Healthy People 2010 include arthritis and arthritis objectives in the upcoming document.

Let me ask you this. How can this nation hope to achieve the Healthy People 2010 goal of increasing years of healthy life, not just increasing life expectancy, but years of healthy life, if this nation's leading cause of disability and that of 43 million people with arthritis is not addressed? So, therefore, it is paramount that arthritis and arthritis objectives are included in Healthy People 2010. Thank you.

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DR. FOX: Thank you. Let me again tell you, we now have 104 people who want to speak, and any of you who don't want to use your full three minutes, it certainly will be appreciated. Number 21. Twenty-one, Albert Donnay? Twenty-two, Jane Dion. Jane Dion. If people aren't here, they will lose their chance, because we are going to keep moving through this. Linda Harmon, number 23. Is Linda Harmon here?

MS. HARMON: Yes.

DR. FOX: Okay.

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MS. HARMON: I am Linda Harmon, Executive Director of Lamaze International here in Washington, D.C. I would like to take this opportunity to testify on behalf of childbearing women and their families regarding inclusion of the proposed new developmental objective concerning preparation for childbirth in the Maternal and Infant Health Focus Area of Healthy People 2010. The proposed new developmental objective reads as follows: "Increase to 90 percent the proportion of pregnant women and their partners who attend a formal series of prepared childbirth classes."

In addition to reducing cesarean rates in labor, and increasing the proportion of mothers who breastfeed their babies, two of the objectives already included in Healthy People 2000, prepared childbirth classes are recognized as an important component in the content of prenatal care. Childbirth education classes enhance a woman's confidence in her innate ability to give birth; can be a critical component of a coordinated prenatal care package; offer an opportunity for social support during pregnancy; increase appropriate use of hospitals, clinics, and health care facilities; facilitate positive birth outcomes including reduction of cesarean birth; foster positive feelings toward the birth, the caregivers, and the infant; set the stage for successful initiation of breastfeeding and adjustment to new parenthood; and are an integral part associated with reaching other Healthy People 2010 objectives.

While solid baseline data is currently unavailable on the numbers of people who do take childbirth preparation classes, we estimate currently that 50 percent are attending such class attendance. Additionally, 47 percent of pregnant women are WIC recipients, and most in need of childbirth preparation classes.

In the context of providing optimum care to the people of the United States, and on behalf of mothers, babies, and families everywhere, I urge you to include the proposed developmental objective on prepared childbirth classes in the goals for 2010. Thank you.

DR. FOX: Thank you. Number 24, Jim Tozzi.

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MR. TOZZI: Thank you. Distinguished members of the panel, I am Jim Tozzi. I am with an international regulatory consulting firm. We specialize in trade issues and regulatory issues. We have been asked to look at this proceeding by the Miller Brewing Company.

First of all, we compliment the committee for addressing alcohol in the report. We think it is an extremely important addition to the report, and continuation of what you did in the past. We also think you addressed an extremely important societal issue, one of binge drinking, and you put a quantitative statement in there that five drinks constitutes binge drinking. We think that kind of guidance to the nation's children is very important. There is a void in your report, though, and one we think you have the opportunity to correct, and that is, what constitutes a drink. If any of you looked at what children drink now, if you look at kamikazes, zombies, sex on the beach, whatever that is, not literally, and a number of other things, the idea of one drink is not defined. And what we think you can do is correct the error in the nutrition guidelines. The wrong way is one and a half ounces of whiskey is equal to one beer is equal to five ounces of wine.

The problem is, distilled spirits are not served, generally, in one and a half ounces. And what we suggest to you, the committee, is that you would state that when you look at binge drinking, you have to look at serving size, whatever that is, and that serving size be the guidance to the nation's youth, and that to get the appropriate serving size for both distilled spirits and wine, because beer generally is 12 ounces, that you ask SAMSHA to maybe do a statistical survey.

We would recommend, therefore, that in your report you make an advance forward by, one, stating that binge drinking is, as you said, five drinks, that the serving size is appropriate, and that the committee is going to look at the appropriate serving size, maybe with the help of SAMSHA. We think if you do that, it will be a great step forward, and we compliment you for addressing this issue.

I also compliment you. I wish the House of Representatives would put three-minute limitations on testimony also. Thank you very much.

(Laughter.)

[For written comments from this participant, please click here.]

DR. FOX: Thank you. And I appreciate everybody respecting that. Twenty-five, Lynn Bradley.

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MR. BECKER: Actually, I am Scott Becker. I am representing the Association of Public Health Laboratories, and Lynn has given me her time.

We appreciate the opportunity to testify today, and are supportive of this public participation process. It is very commendable to the agencies to do this.

APHL represents public health laboratories at the state and local level, as well as individuals with an interest in laboratory issues of public health importance. We are particularly pleased with the public health infrastructure objectives contained in the plan in general, and the laboratory services objective in particular, but note that access to quality laboratory services is key to the success of many of the other objectives contained within the plan. In particular, environmental health, food safety, maternal and child health issues, HIV/AIDS, immunization and infectious diseases, STDs, and many, many others. Public Health Service laboratory services are a crosscutting core of public health infrastructure needs for the entire country.

We also note that environmental health uses approximately half of the nation's public health expenditures, and encompasses many issues, yet it is allotted only one goal in the draft plan. We encourage the public health infrastructure goal to be moved to Chapter 1, not Chapter 14 as it now is, since we feel that we must improve the nation's public health infrastructure so that we may be able to positively impact all health outcomes.

Thank you for the opportunity to testify.

DR. FOX: Thank you. Number 26, Sally Lusk. Is she here? Sally Lusk? I am going to only call you twice. Number 27, Susan Wooley?

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DR. WOOLEY: Yes, I am Executive Director of the American School Health Association that represents people working for the health of children and youth through school health programs.

We want to bring to your attention that there are very few references to children, other than to infants or adolescents in the whole document of 2010. They are an important part of the population, and addressing health promotion at that level can address a lot of the issues later on.

And then, we also urge recognizing schools as important sites for delivering interventions that address health promotion and disease prevention and management for young people, throughout the whole document. Places to mention schools as important sites for delivery include Chapter 4, where it is, Chapters 10 and 14, "Health Communication to Underserved Populations," and 15, the environmental chapter.

Also, schools are important for ensuring high rates of immunization, but we would suggest expanding it beyond kindergarten and first grade, especially if we are to eliminate immunization disparities among the immigrant children, who may not be there by first grade.

The chapters on emergency care, mental health, substance abuse, and asthma, should include school as sites important for identifying students with needs, as well as for providing access to services, and referrals to services. Possible objectives could be that school staff recognizes students exhibiting signs of asthma, mental health problems, substance abuse, and know how to make appropriate referrals. Other objectives should specify that schools provide or have referral procedures with community providers to ensure that students have access to the services they need in order to function as part of the regular educational program.

The objective that calls for increasing the proportion of children with disabilities included in regular education programs requires services that include school nurses, occupational, physical, speech and hearing therapists, counselors, social workers, and psychologists.

Another omission from the overall draft is the coordination of services and education with each other and with environmental factors, both in the school as well as in homes and communities. The document needs to explain, for instance, what a comprehensive coordinated school health program is, and wherever it makes reference to specific components, that it says "as part of a comprehensive or coordinated school health program."

The current draft includes several elements of a school health program which we support, including objectives related to quality physical education, general health education, education about specific risk behaviors, the school nurses, and the environment, and rural health.

DR. FOX: Thank you. Thank you very much. Number 28, Lori Moore.

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MS. MOORE: Yes. Good afternoon. My name is Lori Moore. I am the Emergency Medical Services Director for the International Association of Fire Fighters, an AFL-CIO affiliated union representing more than 225,000 professional fire fighters and paramedics throughout the United States. I am very pleased to be here to represent the views of the IAFF and its General President, Alfred K. Whitehead, who unfortunately is unable to be here in person.

In nearly every community throughout the United States, fire fighters and paramedics play a vital role in the delivery of prehospital emergency medical services (EMS). This role may include the provision of time-critical intervention performed by fire fighter first responders, or the provision of advanced life support and transport services delivered by rapidly responding paramedics.

Fire fighters and paramedics must respond to a variety of situations, including trauma from motor vehicle crashes or acts of violence, burns, poisonings, and cardiac arrest. Many of these medical emergencies occurring outside the walls of a medical facility are considered major, unresolved public health problems. For example, the American Heart Association notes that each year sudden cardiac arrest strikes more than 300,000 Americans. That is more than a thousand per day. In fact, 90 percent of cardiac arrest patients die because cardiac defibrillators, which could be supplied by prehospital personnel, arrive too late, or not at all.

Common to all prehospital emergency situations is the critical need for rapid response. These incidences are unscheduled and urgent. Emergency medical personnel are called to react quickly in an environment with a zero margin for error.

Fire fighters and medics play a major role in the chain of survival for people throughout the United States, daily. Therefore, the IAFF urges the Department of Health and Human Services, and the Surgeon General, to revise Section 10, "Access to Quality Health Service and Emergency Services," particularly objectives C-1 and C-4.b in the final version of the Healthy People 2010 objectives to read as follows. We would like you to change objective C-1 to read, "This portion of the objective defines urban areas as response times of less than five minutes between the initiation of an emergency call and arrival of EMS providers on the scene for 90 percent of such calls."

We feel strongly that nine minutes is far too liberal. In objective C-4.b, "Increase to 90 percent the proportion of persons with witnessed, out-of-hospital cardiac arrest, who received their first therapeutic electrical shock within six minutes of collapse recognition."

Support for these changes comes from the American Heart Association, which recommends a basic life support response, including defibrillation, within four minutes, and the National Institutes of Health, Heart, Lung and Blood Institute, which suggests that it would be medically optimal if every community in the United States were covered by first responders arriving on the scene in less than five minutes from the time of dispatch on 90 percent of all calls.

Because time is a critical factor in the delivery of prehospital emergency medicine, we urge the Surgeon General to pursue data exposing the efforts of health care insurers and managed care providers forcing members to bypass the telephone emergency reporting number, 911, in the event of an emergency. We recommend that this practice be prohibited, allowing a prudent layperson to place an emergency call for assistance if they believe it is warranted. Therefore, we support developmental objective C.2 found in section 10.

DR. FOX: Thank you very much. And again, let me tell all of you, your comments in writing will receive just as much weight as verbal. We obviously want to hear your verbal comments, but again, we will be looking at both.

Number 29? Again, if you will, go ahead, and if number 30 will make their way up to the microphone so we won't have any dead time between presenters. Yes, sir.

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MR. MACDONALD: I am number 30. I am Steve Macdonald from the Washington State Department of Health, and I am representing the Council on State and Territorial Epidemiologists, CSTE.

We are generally pleased with the Healthy People 2010 development. CSTE's two primary issues are data comparability and epidemiology capacity in state health agencies and local health jurisdictions. For the latter, we are quite pleased that Healthy People 2010 recognizes epidemiology services as essential in objective 14.13, absolutely necessary for fully five of the ten essential public health services, and therefore, the Healthy People 2010 September draft is a substantial improvement over Healthy People 2000.

For the issue of comparability, the September draft is more mixed. In the comparability area of clear documentation of code sets, the September draft falls short, as did Healthy People 2000. ICD9CM codes for morbidity objectives were not included in Healthy People 2000, or in the midcourse review in 1995, or in any of the NCHS annual Healthy People 2000 Review reports. The September draft continues that unfortunate tradition of inadequate documentation further, by failing to include ICD10 codes for the mortality objectives. The September draft extends this tradition of inadequate documentation. CSTE believes that these shortcomings can and should be corrected, and the plan for Volume 3 can fill this gap.

The final point I want to make about data comparability lies in the area of selection of data systems for measuring progress toward a target such that states can use existing state-level data systems. I will use one example. A number of focus area work groups have struggled with the issue of whether to base some specific objective on the National Health Interview Survey, NHIS, or the Behavioral Risk Factor Surveillance System, BRFSS, Berfus. I used the search function on the Healthy People 2010 Web site to find objectives that use either NHIS or BRFSS as a source of data, and found 72 objectives. Of the 45 of those which are not developmental, in other words the 45 legacy objectives carried forward from Healthy People 2000, there are 39, or 87 percent, which rely on NHIS only; three of these 45 which may use either NHIS or BRFSS; and three which use BRFSS only. That means that only 13 percent of these objectives are specifically designed to produce state-level estimates. This is an unacceptably low proportion for those of us faced with trying to apply the national health objectives at a state or local level.

We in CSTE would recommend that for each of these 39 problem objectives, either the objective should be revised to make it compatible with BRFSS, or CDC should force comparability between NHIS and BRFSS, or the objective should be dropped.

On the other hand, the breakdown for the 27 developmental objectives is quite a bit more encouraging. Only eight, or 30 percent, rely on NHIS only. Twelve consider either NHIS or BRFSS to be possible data sources, and seven intend to use BRFSS only.

DR. FOX: Thank you.

MR. MACDONALD: Thank you.

DR. FOX: Thank you very much. Are you number 29?

DR. CRALL: I am the substitute for number 31.

DR. FOX: All right. Well, state your name, please.

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DR. CRALL: Thank you, yes. Jim Crall, representing the American Academy of Pediatric Dentistry. I would like to speak specifically to the oral health objectives, first the overview, and then, some of the specific objectives.

The overview states that access to primary preventive dental care for most Americans has been improving, as has their oral health status. Problems of the poor elderly are singled out in the overview. However, data from NHANES III and the 1996 DHHS Office of the Inspector General report on access to dental services for children covered by Medicaid clearly indicate that significant problems also exist for this sizable segment of the population. Failure to highlight this disparity could leave policymakers and public officials with the mistaken impression that attention and resources do not need to be targeted to improving the access to primary preventive dental care for low-income children.

Also, the last two paragraphs in the introductory section of the overview address the issue of the relationship between coverage and access, and unfortunately in our opinion, the language leaves the impression that providing coverage is sufficient to assure access. As noted by the OIG report and the HCFA/HRSA sponsored conference in June this year that does not necessarily equate. We think that the points made through the OIG report and the HCFA/HRSA conference summary need to be stressed under this overview section.

I will move now to specific comments regarding objectives. Objective number one sets targets for levels of childhood caries. We believe these targets should be set at lower levels. Data from the NHANES III show that 18 percent of two- to four-year-olds and 61 percent of 15-year-olds have had one or more cavities. The respective 2010 targets are only set at 15 percent and 55 percent, based on our criterion of better than the best. However, the data actually supplied in the draft report indicate that the best in each category is not defined by race or ethnicity, but rather by income level. Specifically, respective bests for two- to four-year-olds of 10 percent, and for 15-year-olds, 51 percent, are actually cited in the draft, and we think those should be used to establish the targets.

Objective number nine deals with sealants. The targets set here are actually quite aggressive, relative to all the other targets, and although sealants are an important component of any contemporary caries prevention program, the goal as written can be achieved without significantly extending sealant coverage to the segment of the pediatric population most in need of preventive services. And so, we think, that needs to be refined.

The final comments have to do with where there are blanks in the report in terms of levels that could be suggested for screening. We think these ought to be high targets, 70 percent or better of two- to four-year-olds, and 70 percent of children entering school should have been screened, and had their needs addressed, and so, we would offer those as suggestions, and we will file those as part of written comments.

DR. FOX: Great. Thank you very much. Number 32.

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DR. WICKEN: I am Allen Wicken. I am a physical therapist, Associate Director of Practice and Research Division of the American Physical Therapy Association.

The American Physical Therapy Association wishes, first of all, to thank the Consortium for the opportunity to offer comment today. We will also be providing a more detailed written comment in early December, just as we did last year for the developing objectives document. Today's comments, in fact, relate to many of our thoughts and suggestions as offered in 1997.

As far as the overall framework and goals are concerned, in looking at them we suggest that quality be incorporated into the first of the two main goals. Your goal to increase quality and years of healthy life is now more descriptive, especially with the discussion on health-related quality of life, which now includes an emphasis on functional status as a key focal point.

With respect to goal number two, eliminate health disparities, we urge an operational definition of health disparities. While that has not been done specifically, the thorough discussion of the elements of that goal make considerable movement toward thorough clarification.

In our comment on the 1997 document, we saw a lack of focus on musculoskeletal disease and impairment. The inclusion of arthritis, osteoporosis, and chronic back conditions as one of the 26 objective areas is a welcome move in this direction. While not all-inclusive in the area of musculoskeletal disease and impairment, these three conditions do represent a significant share of disabling conditions affecting our active and aging society.

And in the area of physical activity as it was proposed last year, we commend the dual emphasis on "Physical Activity and Fitness" in the new title and discussion in objective one.

And finally, under the "Health Services" focus area in last year's document, we urged an added emphasis on "Rehabilitative Services" for maintaining or improving physical mobility and functional abilities. This added emphasis is readily apparent in the current draft.

As far as comments related to the specific 26 draft objective areas, under physical activity and fitness once again--earlier we mentioned the importance of including the concept of fitness in this objective. We also urged that the chosen language make clear that there are three very important components of fitness--cardiovascular, muscular performance, including strength and endurance, and flexibility. This appears to be adequately addressed in the current discussion.

One of our concerns relates to the relative lack of attention placed in this objective to special populations. Accessibility and other barriers to physical activity faced by particular population groups are mentioned, but none of the specific, measurable goals addresses these populations directly. It is noteworthy, however, that within objective 19, Disability and Secondary Conditions, that a core set of items to identify people with disabilities in all data sets used for Healthy People 2010 is included as a developmental subobjective. We urge added emphasis in this important area.

[For written comments from this participant, please click here.]

DR. FOX: Thank you very much.

MR. WICKEN: Thank you.

DR. FOX: Thank you. Thirty-three.

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DR. GRUBB: Thank you. Terry Grubb, Washington. State of Washington. Chair, Council on Access, Prevention, and Interprofessional Relations, American Dental Association. As a Consortium member, the ADA recognizes that this is an enormous undertaking for the Department of Health and Human Services, Office of Disease Prevention and Health Promotion. In particular, we thank the CDC and the National Institute of Dental and Cranial Facial Research for their time and efforts on the oral health chapter.

The ADA officers and the members of the Board of Trustees are carefully reviewing the objectives of the oral health chapter and relevant objectives in other chapters. Input from the five association councils representing science, public health, insurance, practice, and governmental affairs, have been received by the Board. In addition, the Association has provided an opportunity for all of its 143,000 members to contribute; notices have been placed in the ADA publications and on the ADA Web site urging the membership to submit comments. Obviously, the Association reviews will be guided by its policies; that is, our comments will be consistent with our standing policies. It should be noted that, as Dr. Satcher said today, in 1991, our House of Delegates adopted the policies that endorsed the oral health objectives and encouraged its state and local societies to work with their respective health departments toward achieving the Healthy People 2000 objectives. Given that 80 percent of the ADA's members are general dentists, we are looking at objectives from a perspective of how feasible they will be in relationship to private practitioners as they serve the public. 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 them out to fulfillment.

The Association's written comments will be submitted prior to the December 15th deadline. Thank you for this opportunity.

DR. FOX: Thank you very much. Number 34?

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DR. WEISBUCH: Thank you. I am Dr. Weisbuch, the chief health officer in Maricopa County and the Director of the Department of Public Health in that area. I serve this year as the chair of the National Commission for Correctional Health Care, which accredits 450 prisons, jails, juvenile facilities, which meet the NCCHC standards. I am here today to request that the Healthy People 2010 guidelines emphasize the health services provided to those who are incarcerated. In the 2010 draft document, I found only one reference to correctional health care, and that was for hepatitis B vaccination of inmates. Yet the guidelines focus on several issues which are easily addressed in prisons--substance abuse, hepatitis A and C, problems of teenagers and unwanted pregnancy, injury and violence prevention, oral health, HIV, STDs, mental health and suicide, and increasing immunization.

Prisoner health care deserves introduction into the 2010 guidelines for the following reasons. One, prisoners are among the highest risk groups of disease, disability, and death in the United States. Two, the 1.7 million Americans now behind bars are truly a captured population whose health needs can be served appropriately and effectively if resources and good direction are available. Three, over 11 million Americans, nearly four percent of the U.S. population, are incarcerated annually. Many have their first visit to a provider since childhood as they enter the jail. Four, virtually all 11 million people who are processed by the correctional system return to society, many with the same illnesses that they had when they came in, or with others that they have acquired in the institution. Five, the health problems identified and treated in prison can be followed on the outside only if the correctional providers forge linkages between correctional health, public health, and clinical services. Six, inadequately identified problems, which are incompletely treated in prison may produce serious problems in the institutions, and in the community when the individual is released. Tuberculosis, hepatitis, STDs, et cetera, are examples.

So then, the opportunity to provide care in prisons, for example, immunizations, health education, initial drug treatment for dependency, is greater than in any other comparable setting. So, I would recommend the following.

One, that a section is added on correctional health care to the 2010 guidelines. The second, encourage improvement of the health services in prisons and jails, focusing on expanding immunizations in prisons, dental care for prisoners, health education and prevention, initial drug treatment, mental health services, especially suicide prevention. Three, that the linkages with public health and clinical programs to assure continuity of care for those incarcerated when they are released, are encouraged by the guidelines. Four, that adequate funding, probably through Medicaid, is provided.

DR. FOX: Time is up. Thank you so much.

DR. WEISBUCH: You are welcome.

DR. FOX: Number 35, Andrew Nettles? Is he here? Andrew Nettles? Thirty-six, Steve Ritzel?

MR. RITZEL: Steve Ritzel.

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MR. RITZEL: I am with the State University of New York in Brooklyn, New York, and I am on a personal level representing as the City Chapter Coordinator for the Lesbian-Gay Immigration Rights Task Force in New York City.

I have general comments on the overall draft. I feel that there has been omission of any reference to migrants, refugees, immigrants, or people who are entering this country, whether it be undocumented or documented, throughout the entire document regarding any of the objectives we need to set forward. And I think that the problem is that right now in this country we, politically, do not want to even touch the subject. Two, I think there are competing priorities, if we are going to look at trying to reduce racial and ethnic disparities in health, we really need to focus on these issues from the infectious disease route to the mental health.

And the other area I would just want to discuss, there is no mention regarding female genital mutilation in the draft objectives. The omission of that, and that is a guideline set up by the U.S. government, I don't see where we are going to be if we don’t track that.

And then, three, as my last statement, is that there should be an inclusion and development of some sort of surveillance activities against hate crimes. I think that would be a major public health problem in this country. Thank you very much.

DR. FOX: Thank you. Thirty-seven.

DR. WINDOM: I think that is the American College Health Association. They have already testified. Thank you.

DR. FOX: Thirty-eight.

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DR. TAUBMAN: Good afternoon. My name is Dr. Ross Taubman. I am a trustee of the American Podiatric Medical Association. On behalf of the more than 10,000 members of the APMA, I am honored to represent our nation's foot and ankle specialists to the Healthy People Consortium.

I would like to illustrate some general concerns that we have about the integration of goals within a given chapter. To illustrate this, I will use examples from the diabetes chapter that relate to foot care. Although, I am sure we could use these in other chapters as well. Specifically, objective nine states, "to reduce the frequency of foot ulcers in persons with diabetes," and objective ten says, "to reduce the frequency of lower extremity amputations in persons with diabetes to five per thousand." As part of the action plan are the following treatment goals which say "to increase the proportion of persons with diabetes to have an annual foot examination," and "to increase to 52 percent proportion of persons with diabetes who have received formal diabetes education".

While each of these goals is critical to decreasing the morbidity of foot problems in persons with diabetes, these goals do not go far enough with their recommendations that can actually achieve these goals. Specifically, if we are truly committed to reducing the morbidity associated with diabetic foot complications, an action plan must be in place that clearly identifies diabetic patients who are at greatest risk for foot pathology. Diabetic patients have poor circulation, loss of protective sensation, structural abnormalities, skin problems, and are at significantly greater risk for foot ulceration and amputation. These at-risk patients must be identified through intensified foot screening by primary care providers. The APMA has submitted in our detailed comments a protocol for the components of a comprehensive foot examination to assist the primary care provider in determining which patients, patients with diabetes, are at risk.

Additionally, diabetic patients in certain socioeconomic and ethnic populations are also at increased risk for developing diabetic foot complications. Once these at-risk persons are identified, it is crucial these patients be adequately educated about how to recognize and prevent foot-related complications. This can only be achieved by a comprehensive education plan of patients, payers, health care providers, employers, and community groups. Also, the APMA strongly recommends that guidelines be adopted that direct at-risk persons with diabetes to podiatrists for preventive foot care services. Adoption of this protocol is the single greatest means by which we can achieve the reduction in ulcerations and lower extremity amputations. Thank you.

DR. FOX: Thank you. Number 39.

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DR. PAUL-BROWN: Good afternoon. I am Diane Paul-Brown, the Speech-Language Pathology representative for the American Speech-Language-Hearing Association. ASHA is the national scientific, professional, and credentialing organization for more than 96,000 audiologists, speech-language pathologists, and speech, language, and hearing scientists. Firmly grounded in our profession's scopes of practice are prevention, early identification, and treatment of hearing, communication, swallowing, and related disorders for children and adults.

ASHA strongly supports the new chapter devoted to disability and secondary conditions. The draft target objectives will be important in providing needed data on access to health care systems and providers by persons with disabilities. We recommend additional objectives focused more on children with disabilities. Also, we urge additional consideration of disability status as a special population targeted in all chapters throughout the document.

ASHA also urges the Healthy People 2010 lead agencies to continue to stress morbidity reduction objectives as critical goals of the Healthy People’s project scope. We commend the drafters for their efforts to incorporate eliminating health disparities for select populations, including persons with disabilities. We strongly support the continued expansion of this project beyond a focus on mortality objectives to enhance quality of life through reduction of morbidity.

In the area of oral health, Chapter 9, ASHA suggests including speech and language components to the oral hearing screening objective number 13. Also, ASHA supports the inclusion of objective 18, ensuring a viable system for recording and referring infants and children with cleft lip, palates, and other cranial-facial anomalies. Because the Asian and American Indian populations have the highest incidence of cleft lip, with or without cleft palate, they should be added as a select population.

ASHA urges the inclusion of laryngeal cancer to the cancers of the oral cavity and pharynx, as the risk factors are closely related, and this is in Chapter 17, with cancer.

In Chapter 19, disability and secondary conditions, ASHA supports the definition of people with disabilities as inclusive of communication activities, and suggests the addition of hearing as another example of a potential limitation. Hearing loss and deafness affect 98 million Americans, with an increasing prevalence due to recreational and occupational noise exposure, ototoxic medications and chemicals, and life-saving successes at birth. Approximately 46 million people, one in six in the U.S., are affected by hearing loss or communication disorder.

DR. FOX: Thank you.

DR. PAUL-BROWN: Thank you.

DR. FOX: Number 40, Steve White. Number 40. Number 42. Number 42. If I call your name, and you have already testified, we would be glad for you to pass. Or if your association has already testified. Forty-two. Number 43, Charlene Irvin.

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DR. IRVIN: I am Charlene Irvin, Assistant Professor, Department of Emergency Medicine, Wayne State University School of Medicine, from Detroit, Michigan.

I would like to commend the panel on the effort put forth in preparing the current draft of Healthy People 2010. The emergency medicine community sincerely appreciates all the energy and research that were expended in preparing this document, and we are both pleased and honored to be a part of this process.

I would like to propose death from injuries, both intentional and unintentional, as a leading health indicator. Injuries have replaced infectious diseases as a leading threat to premature mortality and potential years of life lost. For the population age one to 44, injuries are the leading cause of death, exceeding deaths from cancer and cardiovascular disease.

Injury mortality meets the criterion for health indicator on multiple levels. Injury deaths cut across age, gender, or socioeconomic groups, affecting a diverse population with a balance among targets. Because injuries affect the majority of the population directly or indirectly, they readily engage the public's attention. Much of America's population would likely be able to identify motor vehicle accidents or firearm homicides as prominent public health issues.

Many of the objectives related to injury, such as firearm control, and seat belt and helmet use, already exist in the policy realm. The creation of injury mortality as a leading health indicator will further aid policymakers in assessing and utilizing this information. This indicator would be tracked as a compilation of the existing injury mortality objectives, most notably, the reduction of unintentional injury and homicide mortality rates. The major data source would be the National Vital Statistics System.

Finally, with regard to the framework of the Healthy People 2010 process, it occurs to me that there is no system in place to evaluate what strategies worked best in achieving objectives in Healthy People 2000. Significant strides have been made in achieving these goals, and identifying geographic regions or hot spots where the greatest improvement has been made is crucial. Simple interventions that may have had significant impact on achieving these goals should be advertised. One possible means to address this would be to identify these geographical hot spots, go back to these locations and survey the specific people, and ask them, "What happened in your community? What programs, either public or private, were initiated that helped you achieve this goal so well?" Then inform other communities via the Internet.

Without a means to close the loop, without the ability to go back and say what worked well before, many communities will continue to reinvent the wheel, and some may continue to make the same mistakes that other communities have made in the past, instead of tapping into successful strategies that have worked for others. Thank you.

DR. FOX: Thank you very much. Number 44.

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DR. MORAZAN: Yes, hi. My name is Cris Morazan. I am with the Hispanic Dental Association of New York University, and I am also speaking on behalf of the American Association of Dental Schools.

We believe that there are many issues affecting oral health. Still, we believe that one of the single most critical and important issues that should be addressed as one of the primary goals of Healthy People 2010, and currently isn't, is the one that we need an immediate increase in the amount of minority (when I say minority, I mean African American and Hispanic) dental students and medical students in this country. Just to quote you a specific example, at New York University College of Dentistry right now, the largest dental school in the country--250 plus people in that class--there are two Hispanics, there is one black. Now, are these the hoards of minority providers that are going to go out there and reduce the health disparities of the minority communities? I don't see it happening.

This issue is of the utmost importance for every single aspect of Healthy People 2010. The elimination of disparities in health can only be done by providing care to the people, and it is the providers of this care who must ultimately do it. If there are minute numbers of Hispanic and African American dentists and doctors, who is going to eliminate the disparities? Who is going to reach out to these population groups and improve their health?

Minority enrollment in dental and medical schools is plummeting. We need to act to end the medical and dental schools' elitist mentalities. The time to do something about this is now.

I was once told that we should refer our problem to the Department of Education. I say we shouldn't do that. I think we should address that issue here. It should be an overriding priority to provide incentives to these schools in order to increase the number of minority enrollees. In the end, it is the individual medical and dental schools who have to choose their enrollees. It is at that level that the Department of Health and Human Services should act. Don't let us come back in 2010 and say we fell short of our objectives because we didn't have enough minority health care providers.

The need is dire, and the reality is grim. With a dwindling number of Hispanic and black health care providers, all of the objectives of Healthy People 2010 are at stake. Let's not fall short of our promise. Let's act now. It is not too late. Thank you.

(Applause.)

DR. FOX: Thank you. Obviously touched a nerve. Number 45.

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MR. CHIANCHIANO: I am Dolph Chianchiano, Director of Public Policy of the National Kidney Foundation, America's largest voluntary health organization devoted to the care of patients with kidney disease, as well as to the prevention and cure of diseases of the kidney and urinary tract. NKF represents more than 30,000 professional, consumer, and lay volunteers from every walk of life and every part of the country. NKF is pleased to participate in the continuing effort to develop national health targets pursuant to the Healthy People program.

We are, nevertheless, dismayed that the draft objectives for Healthy People 2010 fail to recognize the impact of kidney disease as a public health problem in the United States, not only for the nation as a whole, but also for certain minority populations, which are disproportionately affected by kidney disease. Moreover, the impact of kidney disease is accelerating while new intervention strategies offer the promise of slowing this epidemic.

According to the latest statistics, more than 335,000 Americans depend upon dialysis or renal transplant to keep alive after their kidneys have failed. Moreover, the number of Americans with end-stage renal disease continues to increase by at least seven percent a year. Nevertheless, the ESRD population is only the tip of the iceberg. Elevated serum creatinine in asymptomatic patients is a marker for chronic renal insufficiency with its potential impact on health and well being. Extrapolating from the creatinine data collected by NHANES III, as many as three million Americans could have chronic renal insufficiency.

Similarly, over the last decade there has been a staggering growth in the incidence of end-stage renal disease. The most recent data reported from the United States Renal Data System show the incidence rate of ESRD has increased from 142 per million in 1987 to 276 per million in 1996. The growth has been steady and is not confined to a single age group, but has occurred in a period when death rates from other diseases, especially cardiovascular disease, have declined.

Kidney disease impacts disproportionately on minority populations, especially African Americans and Native Americans. In 1996, prevalence rates adjusted for age and sex were 4.5 and 3.7 fold, respectively, higher in those populations.

Recent advances in care of patients with kidney disease show that progression of disease can be slowed by controlled blood pressure and by glycemic control. And interventions to slow the progression of kidney disease are likely to have the greatest impact if applied early in the course of the disease. Therefore, the early identification of patients at risk for kidney disease should be a high-priority public health goal.

NKF's recommendations will be provided in writing in time for the December 15th deadline. Thank you.

DR. FOX: Right. Thank you very much.

Let me reiterate also, that even though we are asking associations not to speak more than once, you obviously can submit, and we would welcome, more than one set of statements, two, three, four, whatever, any degree of comment you want to make would be very welcome.

Number 46.

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MS. HIPKINS: I am Sharon Hipkins, a nurse with asthma, and a parent of two daughters with asthma, and I represent the Asthma and Allergy Foundation of America, a not-for-profit voluntary health agency serving patients with asthma and allergies for over 45 years. AAFA applauds the recognition of asthma as a growing health problem as evidenced by the increased number of specific objectives in this draft.

Asthma is diagnosed in approximately 15 million Americans, with potentially additional millions undiagnosed. Asthma affects about the same number of people as coronary heart disease, which receives much greater attention and resources. Currently, even with risk reduction strategies, heart attacks still happen. But, almost all asthma attacks can be prevented with good management by the patient and the physician following the established national guidelines. The most compelling reason to increase our attention to asthma is that it disproportionately affects the most vulnerable populations, minorities and the poor. Such disparities must be reduced!

AAFA is also encouraged by the attention the draft focuses on morbidity and the quality of life. Chronic illnesses such as asthma have significant impact on a patient's quality of life, their ability to work, to attend school, to carry out their normal activities. Central to daily life is just being able to breathe.

Morbidity and decreased quality of life of all diseases, including asthma, have significant economic and social costs to our society. This has been documented in numerous studies and is verbalized repeatedly to us by our patients. AAFA supported the research of Kevin Weiss in 1991, assessing the social and economic costs of asthma, and is supporting an update of that research due out early next year.

It is appropriate for these draft objectives to address such issues of quality of life and not rely solely on mortality and years of life lost as measures of health.

We will submit written comments, but I will highlight a few concerns. Our biggest concern is adequate funding and development of the data systems to measure the developmental objectives. These developmental objectives are essential quality process measures that will enable the attainment of overall mortality and morbidity reduction goals. An asthma surveillance system is long overdue and is crucial to successfully addressing the disease. To reduce the impact of asthma on minorities and the poor, we must also address access to care, financial support for medications, environmental control, education, and culturally competent patient education.

While some of these issues are addressed, others are not in the draft. The draft addresses important issues, but some fine-tuning still remains to be accomplished, which we pledge our continued collaboration to do.

[For written comments from this participant, please click here.]

DR. FOX: Thank you very much. I appreciate all the comments. I wish we could give each one of you 20 minutes. Number 47.

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DR. BRADSHAW: Good afternoon. I am Dr. Mary Ellen Bradshaw, a pediatrician and public health physician. I was the former Chief of the Bureau of School Health Services with the D.C. Department of Health and chair of the Adolescent and Young Adult Section of Healthy People 2000. I am currently a private consultant in public health administration, child, adolescent, and school health in Phoenix, Arizona, and Vice President of the American Association of Public Health Physicians. It is the only national organization representing all physicians in public health.

In the relatively brief time allotted, I will limit my remarks to four general concept areas that I believe have not been given adequate attention in the very comprehensive and thoughtful Healthy 2010 draft document.

The first area. In my view, the active pursuit and advent of universal health care, affordable and accessible to all, eliminating the specter of the underinsured and the uninsured, and based on established guidelines for infants and children, such as Bright Futures, the American Academy of Pediatrics (AAP) guidelines, GAPS for adolescents, and the Guidelines for Clinical Preventive Services for adults, and including mental health services, not as a supplement, but as a basic component, would eliminate the need for a significant percentage of the detailed goals and objectives, especially in Chapter 10, "Access to Quality Health Care." The focus could then be on the resources required for the implementation of the core functions of public health in the evaluation and monitoring of content, quality, and outcomes of the care being provided. That is, the determinants of the health status of the community.

The second area. Based on our current and expanding knowledge of early brain development, and the exceptional window of opportunity for good or ill during the first three years of life, and the increasing awareness of the long-term effects of child abuse and exposure of children to domestic violence, I believe there should be emphasis on approximately six areas relating to maternal and child health.

Number one is adequate prenatal and postpartum care, with assessment not only of maternal substance abuse, but particularly, mental health, and experience of abuse, physical, sexual, or emotional in the past and currently (as we know the incidence of abuse increases during pregnancy) with appropriate treatment and intervention.

Secondly, the teaching of parenting skills through courses for future parents in junior high school or perhaps even younger, but certainly during pregnancy, and during the early life of the child, including guidance on appropriate discipline, and age-appropriate media exposure. Three, appropriate, skilled, early childcare.

Four, early identification of sensory and learning disabilities by primary care providers with appropriate remediation by properly trained staff, including educational professionals and the provision of adequate educational facilities.

[For written comments from this participant, please click here.]

DR. FOX: Thank you very much. Thank you. Number 48.

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MS. SEALANDER: I am Karen Sealander, from Washington, D.C. I am counsel to the American Dental Hygienists Association, and I speak on ADHA's behalf.

The nation's 100,000 dental hygienists are licensed in each of the 50 states to provide oral health services. Our focus is on prevention and wellness. This focus is well placed, because prevention is highly effective in combating oral maladies. In contrast to most medical conditions, the three most common oral diseases, dental caries, gingivitis, and periodontitis, are proven to be preventable with the provision of regular oral health care. As one of the few health care professionals dedicated solely to prevention-oriented services, dental hygienists in particular regard the Healthy People series as a vital tool in improving the nation's public health.

I would like to highlight three principal points. One, oral health is an integral part of good overall health, and as former Surgeon General C. Everett Koop said, "If you don't have oral health, you are not healthy." Two, dental caries, known as tooth decay, is an infectious, transmissible disease. Research shows that the presence of bacteria known as streptococcus mutans leads to dental caries in children. These decay-causing bacteria are typically transferred from primary caregivers to young children between 22 and 26 months of age. And three, the impact of oral disease extends well beyond the oral cavity. Research shows that the presence of periodontal or gum disease is linked to such life-threatening conditions as cardiovascular disease, stroke, and preterm delivery. People suffering from gum disease are two or three times as likely to suffer from coronary artery disease as those without periodontal problems. Pregnant women with periodontal disease are seven times more likely to deliver preterm, low-birthweight infants, and this is because periodontitis is a bacterial infection, and a bacterial infection accelerates the production of labor-inducing fluids leading to the premature onset of labor.

In closing, ADHA urges that the Healthy People 2010 document better reflect the importance of oral health to total health, and our specific suggestions are in our written statement. Thank you so much for the opportunity to participate in this important process, and we look forward to working together to shape a Healthy People agenda which will result in better oral health for the nation, because without good oral health, you are not healthy. Thank you.

DR. FOX: Thank you. Number 49.

MS. JANE MOORE: I believe Ms. Snow has been detained, and would it be possible for her to present after all others have finished?

DR. FOX: If we have time. Right now, we are scheduled at the current rate to finish at 5:50, and we are going actually to have to end at 5:30, so it depends on how many people we don't have testify, or how many stay under three minutes. Number 50, Karen Gordon. Number 50, Karen Gordon. Number 51, Toni Mitchell.

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DR. MITCHELL: I am Toni Mitchell. I am a practicing emergency physician for the past 15 years in Florida.

I have always worked at a public hospital because I think that represents the key interface between medical care and public health. Emergency physicians provide care to all who seek it, and as a result, we strongly support objective 10-A.1, which is to reduce to zero percent the proportion of children and adults under 65 without health care coverage. We believe, as emergency physicians, that this will contribute more than any other single objective to the success of Healthy People 2010, because every person in this country deserves to have some basic level of health care.

As an emergency physician, I serve in that role at this present time, because we don't have universal coverage at this point. But the other point I want to make is that universal coverage does not equal universal access, and at the present time, you are much more likely to be denied access to emergency services if you are covered by a health plan than if you are uninsured, either through gatekeepers denial of services through the prudent layperson standard, or disruption of the 911 system.

In keeping with the stated criteria requiring sound scientific evidence to support objectives, 10-A.1 should focus on the well-documented lack of access to preventive primary and tertiary care among the uninsured and underinsured. The supporting citations given do not apply to emergency services, however. 10-C.2 should focus on the well-described and increasing threats to access to emergency care among the insured, not on the alleged barriers to access for the uninsured, which is against Federal law.

Coverage must continue to translate into access, and as Dr. Satcher said earlier today, this is a health system problem. If we achieve 100 percent coverage, then we need to be careful that we don't replace an old problem with a new problem. Disruption in access to emergency services may have a disproportionate impact on those in managed Medicaid, Medicare, as well as employee-based plans.

Thank you for the opportunity to participate in this important process. We appreciate the fact that emergency services have been recognized and look forward to continuing to work with you in this process. Thank you.

DR. FOX: Great. Thank you. Number 52, Cyndi Reeser. Fifty-two. Number 53. Fifty-three. Number 53.

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MS. SEMONIN-HOLLERAN: Hello. My name is Renee Semonin-Holleran, and I am an emergency nurse, and I am here on behalf of the Emergency Nurses Association, a professional organization representing over 24,000 emergency nurses nationwide in the specialty of emergency nursing.

I just have a few comments to make. First, as with the other people, we would like to thank you for this opportunity to participate in this process, as well as to be allowed to give comments. In addition, we support our emergency medical colleagues' comments related to the objectives 10-A.1 and 10-C.2, as well as looking at injury as an indicator, as a health care indicator.

Also, as an emergency provider, we see the most critical manifestations of disease and injury. We have a tremendous appreciation for the importance of preventat