Session II: Improving Systems for Personal and Public Health

DR. WILLIS-FILLINGER: Good morning. Welcome. As you know, you heard all the instructions this morning. I am Deborah Willis-Fillinger. I am the HRSA coordinator for the Midwest states here in regions V and VII.

I want to welcome you to this session, which is the public comment session for improving systems for personal health and public health. We cover chapters 10 through 15 of the Healthy People 2010 document.

That includes the access to quality health services. As you know, there are four sections in the access to quality service chapter. That includes preventive health, primary care, emergency services and long-term care and rehabilitative services.

Then we also have included in this section family planning, which is chapter 11, maternal, infant and child health, which is chapter 12, medical product safety which is chapter 13, public health infrastructure, which is chapter 14, and health communication, which is chapter 15.

To help assure a fair opportunity for everyone to participate in today's hearing, we will be using the same procedures as in the previous session. So, we have had a chance to model that behavior and we can all follow suit.

As you know, each oral statement will be limited to three minutes. So that we can hear the greatest number of participants, each chapter is limited to 20 minutes.

So, if you do the math quickly, six people approximately per chapter would take up 18 minutes, if everyone speaks for three minutes.

So, you may want to be considerate in that way. If we want to get more comments in, please try to cut your comments to a few seconds less than three minutes, so it will give us a little bit more opportunity to get more people included.

For your information, the access to quality health services, as I said, is broken into four sections, and that still gets 20 minutes.

I do want to assure you, at the end of this session, if there is additional time left, we will be open for additional comments.

We don't want you to feel squeezed or limited by that. Feel free to make further comments at the end of the session.

Then, as you know, there is always the opportunity for additional comment in writing here today, and on the Internet, and we encourage you to do that as well.

Each individual and organization will be limited to one oral statement for each focus area.

We will allow 20 minutes, as I mentioned. I will ask each of you to introduce yourself by name and state of residence. Also, please let us know if you are coming here on behalf of an organization as opposed to an individual.

The sign-in sheet, earlier, being very good meeting participants as you all are, you came in and signed in immediately.

I want you to know that what we will be doing is, that sheet has been moved to the side because we want the sign-in sheet to be specifically for listing the public comment speakers.

We have another sheet in the back. Those of you who may have signed in already, please sign in again if you are making a public comment, immediately after your comment.

We will begin by hearing comments on the focus areas as mentioned. I want to introduce you to our panelists who, as you know, are here to listen to your comments.

We won't be making responses to those comments, however. We will simply be here gathering information and listening here today.

I will introduce them. Immediately on my left is Mary Jo Deering, and she will be listening specifically for comments in the health communications section.

We have Pomeroy Sinnock next, who will be listening to comments on public health infrastructure section.

Eileen Parish, there in the center, is here for medical product safety.

Paul Nannis is actually far to the left.

MR. NANNIS: I am actually not that far to your left. [Laughter.]

DR. WILLIS-FILLINGER: Also, Kate Rickard is another listener, and she is here in the front row. We have gotten a little bit tight here on the dais.

Then for family planning services, Evelyn Kappeler is there to my left as well.

We would like to go ahead and begin with the comments. We will begin by hearing comments on access to quality health services.

As you know the rules with the lights, the yellow light means one minute left and the red light means you are gone. Will you please step forward and state your name and your state and your organization.

DR. KIRSCH: My name is Thomas Kirsch, Chicago, Illinois. I am representing the American College of Emergency Physicians.

I made some preliminary statements in the primary session about overall access. I would like to comment more specifically about access for the emergency department section.

To reiterate, the emergency departments see 100 million patients per year. Almost 17 percent of those patients are uninsured, which is twice the rate of any uninsured population at any other clinical setting in America.

DR. WILLIS-FILLINGER: Could you limit your comments to additional comments beyond what was made this morning, because those were recorded?

DR. KIRSCH: The American College of Emergency Physicians has become increasingly involved in public health, as we have become the de facto safety net for the country.

There are major initiatives within our college on adult immunizations, injury control, violence, STD prevention, HIV transmission and other important issues for public health.

We strongly support, once again, access to universal health care, both in objective 10-A-1, as well as access to primary health care, objective 10-B-1, because we feel that will have a major impact on the care delivery in the emergency department.

ASEP has worked very carefully in the Healthy People 2010 process, framework, on issues such as injury control, disease surveillance, pre-hospital care, poison control, pediatric emergency care, thrombolytic therapy and mental health services.

Not only is there a moral obligation for physicians to treat, regardless of insurance status or social status or any other issue.

There is currently on the federal registrar, a law for emergency departments to provide care to 100 percent of the people who present to those doors.

Currently, there is no barrier to care for even the uninsured in the United States. As a result, once again, we will become the de facto safety net.

Therefore, based on the above, we find it very difficult. The last-minute changes were made to sections 10-A-1 and 10-C-2, which state specifically that there are financial barriers to care in the emergency department.

The current statement reads: the lack of insurance remains a major detriment of access to necessary health services, including preventive care, primary care and tertiary care and emergency care.

There is currently absolutely no scientific evidence to support that statement, specifically in reference to emergency care.

In fact, there is overwhelming scientific evidence, which our College has presented to this committee, to show otherwise.

Therefore, we would suggest that these last minute changes that were done without consultation with the community be changed back to their original language.

We were puzzled by these wording changes and would specifically ask that the words emergency care be removed from the first sentence in the support statement of objective 10-A-1, and that the words, by their insurance status, be removed from objective 10-C-2.

We look forward to working within the framework of the Healthy People 2010 process in the future, and we look forward to strengthening the bonds between the preventive health services in the United States and emergency departments. Thank you.

DR. WILLIS-FILLINGER: Thank you. Be sure to register your name at the back.

DR. SLOBODKIN: David Slobodkin, Chicago, Illinois, also an emergency physician, speaking as an individual.

I have been in emergency medicine practice for 10 years and, until recently, was in the emergency department at Cook County Hospital and the chairman of the hospital quality assurance committee at that hospital. I am now at the University of Illinois at Chicago School of Public Health.

Again, I am very pleased that the overview on access recognizes the role of the emergency department and the unique role of the emergency department, in that we are mandated by law to see all patients.

Although that doesn't specifically say so, that specifically means that we are not allowed to discriminate on the basis of insurance.

Again, I am also very disturbed by some of the wording in both 10-A-1 and in 10-C-2. It is known that emergency departments are the safety net for the uninsured.

I can assure you that, while we frequently have problems getting follow-up care for our patients, while we certainly have problems keeping the level of services where we want them in the face of a large amount of uncompensated care that we give, I have never ever, ever, in 10 years, had to turn away a patient because they didn't have insurance. Any emergency physician who did so would face the very real contempt and condemnation of their colleagues.

Specifically, in line 22, 10-A-1, lack of insurance is a major deterrent to access to emergency care, is not correct, and the phrase emergency care should be deleted.

Again, in C-2, I would like to urge that, first off, the blank be filled in by 100 percent. I think that no patient should be denied service because of his or her insurance status or by his or her health plan's coverage.

This phrasing actually obscures an important point, which is that it is the insured patient, not the uninsured patient, who faces barriers to emergency care.

I very frequently watch patients call over and over to their gate keeper, while they wait in the emergency room, pacing up and down in pain, and then when I call, the physician is all of a suddenly miraculously available to Dr. Slobodkin. I think that is very unacceptable and is something that needs to be stopped.

I think it needs to be specifically focused on in a clear manner in C-2, by removing the erroneous statement, that insurance status per se is a barrier to care. Thank you very much.

DR. WILLIS-FILLLINGER: Thank you.

MS. STONIS: My name is Nancy Stonis. I am from Park Ridge, Illinois. I am here today representing the Emergency Nurses Association. I am also employed there.

I am going to cut to the chase, because I am also going to reiterate what these two gentlemen have said.

Objectives 10-A-1 and 10-C-2, as written, obscure problems of the managed care population and denies the long role of emergency departments in providing access to the uninsured.

ENA supports the American College of Emergency Physicians' efforts to change the current written language to the original language.

In turn, ENA requests that the word, emergency care, be deleted from the first sentence of the support statement in objective 10-A-1 as well as the words, by their insurance status -- from objective 10-C-2.

Furthermore, we urge removal of the unsubstantiated and offensive assertion that the uninsured face barriers in the emergency department, which currently appears in the 10-C-2 support statement.

In keeping with the stated criteria requiring scientific evidence to support objective 10-1-A, it should focus on the well-documented lack of access to preventive, primary and tertiary care amongst the uninsured and under-insured.

10-C-2 should focus on the well-described and increasing threats to access to emergency care amongst the insured. Thank you.

DR. WILLIS-FILLINGER: Thank you. If we could try not to repeat the same comments, because we do have a limited amount of time, and in an effort to try to get as many comments in as possible, we would like to eliminate duplication, please. Thank you.

DR. IRVINE: I would like to thank the panel for this opportunity to address the Healthy People 2010 objectives.

I am Charlene Irvine, assistant professor in the department of emergency medicine, Wayne State University School of Medicine, Detroit, Michigan, and I would like to make some comments on behalf of the Society for Academic Emergency Medicine.

The recognition that emergency departments provide prompt, first contact care for millions of Americans, regardless of their socioeconomic status, age, or special need, as written in the overview for chapter 10, is applauded.

The next paragraph correctly acknowledges emergency department physicians as the only health care providers mandated by law to evaluate everyone, regardless of their insurance status.

This information is accurate. It does, however, conflict with information submitted to support objective A-1 and C-2.

The suggestion that lack of insurance is the major factor limiting access to emergency care is contrary to the statements made in the overview section.

Both A-1 and C-2 discuss barriers to emergency care. There are two issues involved with this objective, and there may be confusion when they are combined.

Concern over barriers to emergency care due to lack of insurance is a completely different issue than barriers to emergency care caused by the insurers themselves.

Since it is a violation of federal law to withhold emergency care treatment due to insurance status, concern over lack of insurance as a true barrier to emergency care is not founded.

As described in the overview section, the emergency department evaluates anyone. Data to support the care of the uninsured is found in the National Ambulatory Medical Care Survey where, in 1996, almost 17 percent of the ET visits had self pay as the expected source of payments. These patients were evaluated and treated, regardless of their insurance status.

The other barrier to emergency services, namely the insurance companies themselves, is a different issue.

Frequently, denial of access to emergency services made as a result of a phone call to the insurance company is prior to an evaluation by the emergency physician.

Frequently the patient is informed that the emergency department is ready and willing to evaluate the patient, but that the insurance company will not authorize the visit. The patient may decide to leave.

This barrier is real and it is dangerous. The emergency department is available and ready to evaluate these patients, who will then choose not to be evaluated for fear of non-payment by the insurance companies.

We urge that objective A-1 and C-2 be revised to more truly differentiate the barriers to preventive care, primary care and tertiary care due to uninsurance, from the barriers to emergency medical care due to managed care gate keeping.

We also urge that the goal of unimpeded access to emergency medical care in objective C-2 be set at 100 percent of Americans.

We urge that the data be collected through the National Health Interview Survey and other instruments to monitor access to emergency care. Thank you.

DR. WILLIS-FILLINGER: Thank you.

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

Last year, I took one bite of a salad in a restaurant and I started to have an anaphylactic reaction. My throat started to close and I could not breathe well.

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

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

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

All medical providers should only use low-allergen, powder-free latex gloves, or powder-free non-latex gloves throughout their facilities. Food service and housekeeping should never use latex gloves.

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

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

[Applause.]

MS. CLARK: Good morning. My name is Ann Clark. I am from Illinois. I am also addressing latex allergy.

The only place we found in the draft which referred to latex allergy was occupational health, but as it is as a big issue in emergency medicine that we are speaking to you today.

We do not have access to safe medical care. The American College of Allergy and Immunology has declared latex allergy to be at epidemic proportions.

Researchers estimate 2.8 to 18 million Americans suffer from latex allergy.

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

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

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

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

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

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

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

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

The precedent that this consent agreement set was that life-threatening IGE-related allergies are a disability.

Legal challenges from consumers will establish that under the ADA the only option that medical facilities have is to safely accommodate persons with latex allergies.

Patients and workers have the civil right to reasonable accommodations in all public facilities, including hospitals, dental and doctor offices, schools and restaurants, under the ADA.

In the document, I submit to you today are recommendations calling for the use of low allergen powder-free latex gloves and powder-free non-latex gloves, from various esteemed organizations, such as NIOSH.

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

DR. WILLIS-FILLINGER: We have approximately two speakers left for the access to quality services section.

MR. MARTIN: My name is Bob Martin. I am the director of a center for health care information. I am a health advocate as well as spurred on by putting patients first.

Under that framework, I would like to move forward a national interprofessional health care council that would bring various professional groups together, so they can talk on a common ground issue basis.

Now, I do recognize that it is much easier to bring down the Berlin Wall than it is to break down some of these professional barriers.

I think we ought to make a first start in that area, because chiropractic care and osteopathic care is here to stay. We need to put patients first, not last. The bottom line is patient health, and that is the system.

Tied into that is an educational program for allopathic physicians to understand what other medical traditions, and other medical care traditions -- and we have 52 of them globally.

We are moving into a global economy. So, I would like to see those two issues move forward under accessibility of care.

DR. WILLIS-FILLINGER: Thank you. Please register your name.

MS. LEMLEY: Good morning. My name is Katie Lemley. I am a family nurse practitioner and I am a doctoral candidate at the College of Nursing at the University of Illinois at Chicago.

I would like to thank you for the opportunity to comment on this very important document today.

There are three issues that I would like to bring up in this section. One is, I would like to see some language referring to primary care research.

We have been talking a great deal about data, the importance of it, in our policy making process. I think primary care research has been sort of the stepchild of research for a while.

One way would be to include and encourage the formation of primary care research networks. This would be consistent with the Institute of Medicine report on primary care.

My second suggestion, in the section where you state, increasing proportion of physicians, et cetera, I would like to see the advanced practice nurses be included there, such as nurse practitioners, clinical nurse specialists, and certified nurse midwives, as they are taking on more and more important roles in quality primary care services.

This also would be consistent with the Pew Report on Health Care Professionals.

Lastly, when appropriate, I would like to see the term physician replaced with health care providers. As our health care systems are becoming more complex, quality health care is demanding collaborative efforts of many, many professionals as well as consumers.

We know that primary health care, for example, involves whole communities. Primary care involves various health care providers and consumers, and community-oriented primary care involves everyone. Thank you very much.

[Applause.]

DR. WILLIS-FILLINGER: Thank you. Okay, that was the section on access to quality services. Our next section will be family planning. As I mentioned earlier, Evelyn Kappeler is here receiving those comments. Would those of you interested in commenting on family planning please queue up.

MS. DAVIS: I am Margaret Davis, the State of Illinois, Southside Health Consortium, Healthy Start Southeast, and the Chicago Chapter of the National Black Nurses Association.

I think that as we look at the Healthy People 2010 objectives for family planning, I think that in order to reduce the barriers in terms of eliminating disparity, we must begin to elevate family planning separate from abortion.

I think that because of the abortion question, family planning continues to lose its Title X funding stream.

What we are seeing is not enough dollars to bridge the services, especially as we are beginning to develop demonstration projects, such as Healthy Start.

Under welfare to work initiatives, and the new TANIF populations, there was an opportunity to embellish family planning in those dollars.

Many states have chosen not to do that because of the issue of abortion. I think that all of us can agree that spacing families is important for good birth outcomes, as well as employment opportunities for women.

Lastly, family planning is a major source of treatment for sexually transmitted diseases. Yet, most family programs under Title X are not allowed to provide services for the male counterpart.

I think that this is a disservice, because the woman always comes back with a ping pong infection. I think that could be eliminated if monies could be allocated for sexually transmitted treatment for males.

MS. BAYOU: Good morning. Thank you for the opportunity to speak to you today. My name is Billee Bayou. I am from Wisconsin. I am representing the Wisconsin Family Planning and Reproductive Health Association, which is a membership of all the family planning providers in Wisconsin, Title X and MCH block grant dollars.

I had a brief opportunity to look at the document, and the sections on family planning, the sections on STDs and maternal health.

One of the things that I think is important to recognize is that family planning cuts across a lot of chapters in that regard.

I think that is something that we as providers deal with on a daily basis, trying to provide a number of services.

You probably know all this. We are doing teen services, women in childbearing years, and now women in mid-life services, as well as men, as often as we can.

I think the previous speaker had a good point about our limitations in serving men.

Some of the important things that I think have come up in the past year that need to be addressed and supported are access to contraception through equity in prescription coverage by insurance companies. So, we would support that.

Also, access for teens, not limiting their access by parental consent. We certainly want to continue to encourage parental involvement and help teens with that process, if they feel like they need it, but not to mandate parental consent or notification.

There are too many -- we know of too many situations where that is not beneficial to the teen, and the outcome that we are looking for, which is to prevent unintended teen pregnancy.

The other thing that I heard this morning that I think is really important is the confidentiality of family planning services, particularly in data collection.

We need to be really tuned into that, in terms of large data collection systems that turn a number of people's lives into numbers, and watch for that danger of their privacy being taken away because of data collection. Thank you.

DR. WILLIS-FILLINGER: Are there any other comments for the family planning section? I will give a few seconds here for that, for a response. If not, we will have more time at the end and we will move to maternal and infant health.

DR. KOHRMAN: Good morning. Thanks for the opportunity to discuss the development of the 2010 objectives.

I am Dr. Arthur Kohrman. My present position is as the associate chairman for child advocacy at Children's Memorial Hospital in the department of pediatrics at Northwestern University.

My previous position was as president and CEO of La Rabida Children's Hospital and Research Center, a hospital dedicated to the care of the chronically ill and disabled children.

I am particularly interested in this discussion and the inclusion of children with disabilities and chronic illness in a full manner in the Healthy People 2010 objectives, to assure that each of our children has the opportunity to reach his or her maximum potential to become contributing members of our society.

At least 10 percent of children under the age of 18 in the United States have significant disabilities or chronic illnesses, requiring multiple medical, educational, developmental or social services.

Looked at in the aggregate, this is a very large population. In fact, any other condition affecting 10 percent of our children would be considered an epidemic.

Because the children in this population represent many different diagnostic entities, however, and because their disabilities are often not easily detected, we tend to look at them as a set of small populations.

Yet, the vast majority of many common needs are for both diagnostic and interventional services, for support for their families and for research into the best ways to deliver the needed services.

We know from many studies that our intervention reduces both the physical and economic tolls of developmental and physical disability and chronic illness.

However, developmental disabilities are not always immediately apparent. Thus, children need to have periodic assessment by competent professionals, adequate primary and specialty care when disabilities are detected or chronic illnesses occur in previously well children, and extensive care management and support system for the children and their families.

We know that all too often children with far advanced disabilities come to our attention in medical, social service, and educational systems, well beyond the time at which early intervention might have prevented important secondary disability, and sometimes even beyond the period of being able to rescue the child.

In the last decade, significant efforts have been made in raising public and professional awareness of the needs of children with disabilities.

However, in this light, I would like to mention the specific recommendations of several groups that I am representing, including the Children's Hospitals of Chicago, several of which you heard in Mrs. Daley's presentation this morning, and I shan't repeat them.

I do want to emphasize that every infant and child detected with a disability, or suspected of having one, must be referred and, most importantly, receive appropriate consultation, care and treatment.

All families should have available home visitation services for mothers before and after delivery, and for the infants, as appropriate, in the first year of the child's life.

All pregnant women should be educated, tested and counseled about HIV when appropriate, as part of routine prenatal care, in order to reduce the risk of transmission of the virus to newborns, and that all newborns whose mother's HIV status is unknown, are tested for HIV at birth.

Finally, we request that an objective be included that requires education for parents about the importance of early detection and intervention, as well as information about monitoring your children's physical, social, emotional and cognitive development.

The appropriate dissemination of such information must be seen as a joint obligation of the medical, human services and educational systems in our country. Thank you very much.

DR. WILLIS-FILLINGER: Thank you very much.

MS. BARGER: Hi. I am Jan Barger. I am a registered nurse and a board certified lactation consultant from Wheaton, Illinois. I am representing the International Lactation Consultant Association. We are specialists in breast-feeding with close to 4,000 members in the United States.

I am addressing objectives 12-29 and 12-30 in the maternal, infant and child health, pages 12-28 and 12-29.

Objective 29 is quite familiar to us, sort of an old friend, as a similar objective was put forth for the health promotion and disease prevention objective for the nation for 1990.

On the one hand, while we have not yet attained the goals for 1990, let alone Healthy People 2000, the goals for 1997 -- I am going to update you just a tad on that, because you have got 1996 as the last bit in the draft.

1997 did see a modest increase both in breast feeding initiation and duration, with a 62.4 percent initiation rate, 26 percent breast feeding for six months, and 14.5 percent continuing for 12 months.

It is exciting to even see small increments in the percentage of babies ever breast-fed. The difference between 60 percent in 1996 and 62 percent in 1997 means that approximately 80,000 more babies received at least some breast milk.

We are certainly pleased to see the additional target of increasing the percentage of women breast feeding to the first year.

The definition of breast feeding, objective 29, is not clear as to whether -- on line 11 -- the use of human milk with a supplemental bottle of formula -- means one supplemental bottle per day maximum, or if it means any breast feeding with formula supplementation.

In the immortal words of President Clinton, I guess it depends on your definition of A. [Laughter.]

ILCA suggests a revised definition of breast-feeding for objective 29, which will make this distinction clear.

For objective 29, breast-feeding is defined as either exclusive breast or breast milk feeding, or partial breast-feeding supplemented with other foods or drinks.

For objective 30, which is to increase the proportion of women whose children are breast fed exclusively, one of the ways of meeting this developmental objective is to increase the numbers in support of human milk banks, which can provide human milk to infants whose mothers may, for whatever reason, be unable to provide an adequate amount of breast milk for their infants.

Education of consumers and health care providers on the importance of exclusive breast milk feedings are of paramount importance.

We also recommend moving the three paragraphs that discuss the importance of breast-feeding, but do not talk about exclusive breast feeding, to objective 29, and are submitting three paragraphs that talk about that.

We recommend that exclusive breast-feeding be defined as breast or breast milk feeding without water, juice, formula or solid foods added.

Finally, ILCA would recommend that data collection on breast-feeding be done by other than a formula company. Thank you.

DR. WILLIS-FILLINGER: Thank you. Would the gentleman who spoke earlier also sign? Would you make sure that you register your comment? Thank you.

MR. MYERS: Good morning. I am Bill Myers, health commissioner for the City of Columbus, Ohio. My remarks are reflecting those of the Columbus Health Department this morning.

First of all, let me begin my remarks by thanking our federal partners for organizing these regional forums.

We believe that in the infant and child health objectives, we need greater recognition in the narrative section, that if we are going to get close to the infant mortality objective, then emphasis needs to be placed on America's urban centers.

The disparities in rates between majority and minority populations are increasing in many urban centers, and communities of color primary reside in our cities.

I would also like to reinforce -- I had some comments on universal home visitation by public health nurses, or others, for all newborns, and I will just reinforce what has already been said on that.

A specific comment on objective 35. Under objective 35, there are currently two bullet points that respond to the words in order to.

I would suggest a third bullet point to read, in order to enhance individual decision making and provide information so that individuals will be making more fully informed choices about obtaining genetic testing.

Also, I would recommend the addition of the following two objectives to the listing at the end of related objectives from other focus areas.

From the injury/violence focus area, I would add objective 35, which deals with reduction of physical abuse between intimate partners, and objective 37, which deals with reducing the percentage of the proportion of battered women and children turned away from emergency housing due to lack of space.

There is research to suggest that pregnancy may trigger the beginning of physical abuse against women. Clearly, physical abuse during pregnancy offers significant risk, both for the fetus and the mother.

Additionally, if women and children are unable to find safe housing from an abusive situation, this increases risks on many levels.

The physical, mental and spiritual health of women and their children and the outcomes of pregnancy are all adversely affected by physical abuse. These connections need to be acknowledged in our 2010 objectives. Thank you.

MS. OVERHOLT: Good morning. My name is Tish Overholt. I live in Illinois and I am a concerned parent.

Thank you for your attention today, and I am delighted to comment on Healthy People 2010.

I am the mother of two children. I have an eight-year-son named Maxwell. He was diagnosed with autism at age three. I also have a seven-year-old daughter named Maggie who was born with multiple birth defects, that have resulted in her being technology dependent for breathing and eating.

I hope sharing my experiences as a parent will demonstrate the critical importance of parent education, early detection and early intervention.

Because of Maggie's numerous congenital defects, she has a host of medical challenges, not unlike thousands of other children.

It has been proven, and I have experienced it first hand, that children benefit from early detection and early intervention.

For example, Maggie can walk, run, swing, climb on the monkey bars and raise a general ruckus, but when she turned one, she was not walking.

Due to her extended in-patient stays during her first year of life, she was not reaching the milestones that most children reach by the age of 10 to 12 months. In fact, she could barely hold a sitting position.

My husband and I took Maggie to see a physical therapist. Thanks to a course of intensive physical therapy, Maggie finally learned to walk, but without early detection and early intervention, she could never have reached her childhood markers that have allowed her to develop as a normal, although medically fragile, little girl.

Last year, Maggie was also diagnosed as learning disabled. Again, due to early detection and intervention, Maggie's non-verbal learning disability was addressed.

She now has access to special educational services for her learning disability. Maggie is showing remarkable improvement and achievement in her neighborhood school setting.

My husband and I have also experienced the same benefits with our oldest child, Maxwell. At age three, Maxwell was diagnosed with autism.

We were aware of the developmental milestones that children should achieve and the importance of early detection. We knew to initiate an evaluation for Max.

As a result of early aggressive intervention, Maxwell has been mainstreamed in school, and has even progressed far enough for his specific diagnosis to be upgraded to Asberger's disorder, which has a more promising prognosis.

He continues to receive therapy that allows him to function as a normal child.

I strongly believe that all parents need to be educated about the importance of early detection and early intervention for the child at the earliest opportunities.

Parents need to be taught how to monitor the physical, social, emotional and cognitive development of their children, and under what circumstances they need to seek medical assessment and treatment.

I am thankful and grateful that my husband and I were educated about child rearing and when to raise suspicion levels when children are not developing normally.

Both of my children were diagnosed, referred for treatment, and received appropriate intervention before age 5.

I believe that early detection and early intervention have had a profound impact on the health and well-being of our children. I strongly urge policy makers to include standards for the year 2010.

The Healthy People 2010 section on maternal, infant and child health speaks to the importance of early detection, but its objectives do not include specific goals about early intervention for children with developmental delay, hearing and speech and language disabilities.

DR. WILLIS-FILLINGER: Thank you very much. Make sure that you sign in, and you can register your documents there as well.

MS. DAVIS: Margaret Davis, the Southside Health Consortium, Healthy Start Southeast. I am going to address five areas that I think are lacking in the Healthy People 2010 for maternal, infant and child programming.

One of the areas in which we could do a bit of better programming in the area of disparities is in the area of fetal and infant mortality review.

We need to look at perinatal networks to find out the causes of death and target our intervention to eradicate those particular targets.

As the previous speaker talked about case management, the state of Illinois has instituted a 10-visit case management intensive outreach to all prenatal patients in the state of Illinois.

This has resulted in very favorable outcomes for prenatal patients. This could be replicated in many of the states as a way to reduce poor outcomes for pregnant women.

We just completed over 30 focus groups on why don't women get into care early, with our public aid department in the state of Illinois.

One of the frequent findings was that many women were saying, if my man doesn't want the baby, why should I?

That would call for increased funding for male involvement in maternal/infant health and child issues.

I recently had a patient to lose her baby as a result of spina bifida that resulted in termination. The question, given the media blitz on folic acid, her question was why wasn't I told about folic acid before I lost my baby?

That needs to be mainstreamed into all of our maternal/infant/child care. Preconceptional training is another issue.

You know, you have to prepare to have a healthy baby, and that is not a mandated teaching in our schools from kindergarten to 12^th grade.

Life education and life skills should be taught, as well as parenting.

Lastly, I am a little concerned about what is included in our perinatal systems. Each state, each jurisdiction has various aspects, but very few have the total service delivery that encompasses a comprehensive perinatal system.

DR. WILLIS-FILLINGER: Thank you very much. That looks like the timing is perfect. You are really learning.

The next section, then, I will ask you to direct your comments to Eileen Parish, on medical products safety.

As I am waiting for you to consider medical product safety -- and this is not related in any way -- I want to remind you also that flu shots are available outside on your way out, for those of you who have not received them.

Hearing no comments on medical product safety, we will go to public health infrastructure, and that is Pomeroy Sinnock. Public health infrastructure?

MR. MYERS: Good morning, again. I am Bill Myers, health commissioner for the City of Columbus, and my remarks reflect those of the Columbus Health Department.

Arguably, infrastructure could be viewed as the most important chapter of 2010, because this is the one chapter that defines what should be present in every community, to effectively work on the remainder of the 2010 objectives.

This chapter gives our profession the opportunity to explain to people not working in public health, just what our profession is all about.

I have been impressed in Columbus, how other agencies and systems have repeatedly referenced Healthy People 2000 objectives in their own planning processes, and have used the data out of Healthy People 2000. So, the current document is being read and used.

This is our opportunity, then, to present our profession to physicians, to elected physicians, to managed care organizations, to business leaders, to our community service partners, and to the general public, and others obviously.

This is our opportunity to talk about public health, not only in its broad community context, but also about the glue, the governmental entity, that holds it all together.

Yesterday morning, in my remarks, I suggested that we dump the term infrastructure. I am going to suggest it again, that we dump the term infrastructure.

I would suggest calling this chapter something like, improving the health of our communities.

I think we need to talk about the 10 essential services in the beginning narrative. The only reference I could find to them is in the definitions section.

I think the narrative section gives us the opportunity to talk about these as the basics that the public should expect from its local public health structure.

I think we could also give examples from each level of government regarding each of the 10 essential services.

I think we could also reference how many of our community service providers also use all or some of these 10 essential services in the work that they do in our communities.

In summary, then, this chapter provides us with the opportunity to establish our profession as essential to the very fabric of our communities, and I think we ought to take advantage of that opportunity. Thank you.

DR. WILLIS-FILLINGER: Thank you. Could you register your name again with that comment?

MR. TINBERG: My name is Martin Tinberg, Rock Island County health department administrator, Rock Island County, Illinois. I speak for the Public Health Administrators Group of the Illinois Association of Public Health Administrators, plus my own comments.

I want to speak specifically to the chapter, the overview chapter, on the public health infrastructure, specifically to the statement about, in Healthy People 2000 objective, 8.14, addressed the public health infrastructure by saying, increase to at least 90 percent the proportion of people who are served by a local health department that is effectively carrying out the core functions of public health.

Then the writers go on to say that they didn't carry that objective forward to the year 2010. I think that is a critical objective.

I think that is a critical objective, if we are going to have any improvements in health status of our populations.

I firmly believe, and I think a lot of people do agree, that public health is also a local endeavor, local communities, and it changes health status sometimes a person at a time, sometimes a block at a time, sometimes a neighborhood at a time, but sometimes at a people at a time.

I think the writers need to carry forward the draft comments, but include the original objective from the year 2000.

Look at the data, how many people are served by local health departments currently. That data does exist. Put that into then re-examining the phrase 90 percent.

I know in Illinois, about 90 percent of all Illinois residents are currently served by local health departments. It is that 10 percent breast-feeding, the intelligence points that I didn't get from my mother.

I also think that in Illinois we have had good success in changing and improving health status. I think everyone in the country should have that same accessibility.

MS. BAYOU: Billee Bayou from Wisconsin Family Planning again. I guess a reminder, our association is representative to another statewide organization in Wisconsin, the Maternal and Child Health Coalition.

I guess what I want to do with these comments is to remind everyone that public health is a partnership of local public health agencies and community-based organizations.

I think we have a proud history of that in Wisconsin, and I hope that we will be able to continue that. Just a reminder of that. Thank you.

DR. WILLIS-FILLINGER: Thank you. Now I am sure that everyone has read the whole document, especially these chapters that we are here to talk about today.

So, think a little bit more. Take a look at the documents, actually, because it looks like we may have a little time and you have them with you, so that you can make comments at the end of this on sections that you may not have thought to comment on before.

Hearing no other comments on public health infrastructure, we will go to health communication with Mary Jo Deering. Health communication?

MR. STASICA: My name is Ed Stasica. I am a health economist who works on an independent basis with both the public and private sector.

I just wanted to suggest some thoughts regarding better quality health care information.

The statistics are that, conservatively, 100,000 people in this country each year die from mishaps in the health care system, misdiagnosis, prescription interactions, hospital acquired infections, et cetera.

I think people need to realize that that 100,000 figure, which it is probably largely avoidable, is equivalent to the number of people who die from AIDS, auto accidents and homicides, all put together. It is like a jumbo jet going down each day.

My thoughts on this are, one, I hope that we can somehow build into our high school curriculum, either a semester or a segment of a semester, education about health consumerism, self care, preventive health.

Secondly, there are some pretty inexpensive self-help consumerism materials out in the marketplace. Some of them cost about $2.00.

Considering that we spent about one seventh of our economy on health care each year -- about a trillion dollars or so -- for a very modest investment I think we could really upgrade the level of consumer understanding in this country, which some experts peg at about a sixth grade level of understanding.

That is not only speaking to underserved or middle class, but even relatively well educated people just don't understand health economics, quality of care issues, et cetera.

That might be a reasonable possibility. I think also we should have a national system of reporting hospital outcome information, maybe for the top 20 or so procedures.

I think the state of Pennsylvania, I know, has done this for some years, things like coronary bypass surgery, et cetera, et cetera, maybe pick those 15 or 20 top procedures and require hospitals nationally -- maybe tie it to the Medicare funding -- to be the carrot or the stick regarding that approach.

Lastly, I think maybe medical consent forms could be revised for, at least for a defined set of procedures, some kind of relatively quantitative statement of the range of outcome possibilities, so people really kind of know that there is such and such a chance of doing well or not doing well, and some description of the outcome of those cases, so that people could make more effective decisions in their own self interest. Those are my thoughts, and thank you very much.

DR. WILLIS-FILLINGER: Thank you. Everybody should be reading their chapters very quickly now. We are going to have time to talk about other things.

MR. MARTIN: Bob Martin, director of the Center for Health Care Information. To add on to the previous speaker, I would like to see if a medical report card could be advanced, so that physicians and the health care professions would have more built-in accountability and responsibility.

To me, this is sorely lacking right now. There is no accountability, which is a tragic circumstance.

The other aspect, regarding partnerships with your health care professional, we have been able to identify four or five different categories of patients.

One is the passive patient who accepts anything that is given to them. That relates to the I don't care what happens to me.

You have got the rebellious, who will smoke in their oxygen tent, and we all know people like that.

Then we have the great majority who are very obedient.

The growing emphasis in the 21^st century is a participative patient relationship with your health care professional.

As I understand it, the literal translation of doctor is teacher. A doctor is a resource. You have a physician in yourself as well. Nobody knows us as well as ourselves.

This has to be communicated with your health care professional, because they only can do as well as the accurate information that you give them.

I am a firm believer in open communications with your health care professional and the advancement of a participative patient relationship should be very much a part of health communications in the 21^st century.

DR. WILLIS-FILLINGER: Thank you. It looks like we are going to have a little time, and I want to challenge the audience here, because I think we have got some great thinkers, to take a few minutes, look at some chapters, but think of your comments in terms of recommendations.

What are you recommending? Are you recommending changes? Are you recommending specific figures be included? Are you recommending specific words? Give us your recommendations on what we have done, so that we can do a better job. We will just take a few minutes, don't feel pressured, you are not going anywhere.

When you start to think of things, just come forth. At this point, we are open for comments from any of the sections, on access to quality health care, family planning -- okay, the lines have started. This is good. Maternal and infant health, medical product safety, public health infrastructure, health communication.

They are big documents. They are easy to follow. At the bottom of the page is chapter numbers. Feel free.

MS. WATERS: My name is Trinka Waters from Elgin, Illinois. I am not here representing any specific group, but I am a part of a network of free clinics in Illinois. There are 24 free clinics in Illinois.

I think a piece of data that maybe is necessary for everything is to look at what the free clinics are able to provide.

There is a national organization for those, and I think that is somehow missing in some of the public health information.

DR. WILLIS-FILLINGER: Is that in the public health infrastructure section?

MS. WATERS: I am not sure what that would go with, if it is access, probably infrastructure.

DR. WILLIS-FILLINGER: Thank you. You don't have to know which section it goes in. We can figure that out.

DR. FRIZZELL: I can never pass up a free mike. I am Dr. Linda Frizzell. I am the Leach Lake Reservation clinic director, and health planner.

In rural America, we all wear many hats. I have not had the privilege, as the result of wearing those many hats, to read this document in detail, but I promise you I will.

My comments relate to statistics that relate specifically to rural Americans. I would like to see some of that data carved out and correlated, to see some of the impact we see daily in our clinics, as to impact on health status. I am not aware of any of that that is being done right now, or a real good way to do it.

I can say that in our system we have a very advanced method for collecting data and we use it extensive. It is rather the envy of the public sector.

To share that with others nationally may not be as pertinent. I know the Indian Health Service has an archaic system that they currently use, the kind that is going to crash in the year 2000 anyway.

It is a good model, so that would be one mechanism to review data and compare, because most Indian Health Services are in rural parts of the country, to see what the specific impacts are. Thank you.

DR. WILLIS-FILLINGER: I see Mr. Sinnock writing that comment down. Thank you. This is open mike, almost. It will still be timed, but open.

MR. STASICA: Ed Stasica, independent health economist. I want to address the clinical preventive care and the primary care sections.

Really, having worked with the so-called 330 community health centers throughout the country, they serve about eight million of the uninsured. There are about 40 million uninsured, roughly, in the country, or highly under-insured.

It really seems that, based on the cost benefit information, emergency room visits, secondary, tertiary level care, we probably have the need for at least three times as many community health centers, migrant health centers, homeless centers, that whole umbrella of programs.

We spend less than one tenth of one percent of our national health care budget. It seems to me an investment that should be made.

Maybe the funding also should include, in terms of the preventive aspect clinically, that each patient at these centers, that the funding would be sufficient that they could each be given a regimen of preventive health screenings and services, something along the lines of the U.S. Preventive Task Force Guidelines, something of that nature.

Perhaps even give each patient a health risk appraisal, such as the CDC or some variant of that, which could be used to actually track people's progress, and maybe actually even measure the quality of health status improvement over time.

If you can compute a health age, you could compute relative progress in health status.

Also, for those that are at great variance of health age versus biological age -- unfavorable variance -- to segment those folk at high risk individuals who maybe get special programming.

So, hopefully the funding of community health centers could include that. So, I thank you very much.

DR. WILLIS-FILLINGER: Thank you.

MS. HORAK: Good morning. My name is Abby Horak. I work for the Kansas Department of Health and Environment.

I would like to respond to the clarion call to eliminate the word infrastructure from the Healthy People 2010 objectives.

I think the word infrastructure serves a very, very real purpose, especially for local health departments.

Unfortunately, we have many local health departments within the United States that are rather unsophisticated in their understanding of public health.

Interestingly, the beginning work that has been done with the term infrastructure, and the components of infrastructure have been like light bulbs going on in people's minds when they have been presented with this.

The term alone tells them that they are going to begin to talk about what capacities they should have, rather than what services they should offer.

That makes a very great difference, as those same people become educated and begin to, in turn, educate the policy makers who write the checks that support the development of those competencies at the local level.

The term is clear. It is clearly understood, and the people who are going to benefit most significantly, I believe, from these particular objectives, are the people who work in the public health system itself, perhaps more so than the general public.

DR. WILLIS-FILLINGER: Thank you. Make sure you register your comment.

DR. IRVINE: I am Charlene Irvine, assistant professor, department of emergency medicine, Wayne State School of Medicine, Detroit, Michigan. I would like to make some comments on behalf of myself.

As an emergency medicine physician, we see patients every day who come to the emergency department, many that have not been screened two weeks ago or three weeks ago when they were there with similar problems, that may have prevented that visit that came today.

I would suggest that objective 10-A-3-A be changed to include immunizations and domestic violence.

The way it reads right now is, increase to 80 percent the proportion of patients who are routinely screened about major life style risk factors. This includes diet, tobacco use, alcohol and drug use, exercise, sexual practice and contraception.

It would be easy to include immunization and domestic violence there as issues that could also be screened in a health setting, where the screening may identify patients that are high risk that need to be treated or referred to an appropriate center. Thank you.

DR. WILLIS-FILLINGER: Thank you.

MR. MARTIN: Bob Martin, the Center for Health Care Information. I will add onto the medical product safety category, since nobody has spoken up on that subject.

I would like to see FDA extend their services and operations to include medical procedures, surgical procedures, as well as medical product safety, as well as intervention procedures, or initiate an organization that will have the oversight capabilities of doing this.

As we all know, in a variety of these horrible diseases that we have, many fraudulent procedures come to the forefront, equipment, and holding out false hope for cancer patients, cardiovascular patients.

This needs to be substantially regulated, and to have oversight.

I am also concerned with the significant regional variations in treatment interventions. I see no rationale why a substantial amount of females in the northeast corridor of our country are subject to significant procedures, 70, 75 percent hysterectomies, C sections, and so forth.

If you go to Dallas-Forth Worth, for the same procedure it is about 10 or 12 or 15 percent. You will have to give me plus or minus five percent, because I am no better than any political forecaster or weather forecaster.

There are significant variations. The only rationale that I can come up with is styles of practices.

I know within Maine itself you have got significant variations for the same treatment. So, I would like to see some type of standardization or rationale that would be built into the system, perhaps a national panel that would oversee these different procedures.

To me, put more of these medical opinions into the factual area, so that people can exercise the quality of care.

DR. WILLIS-FILLINGER: Thank you. Make sure you register your comment.

MS. SHANNON: I am Iris Shannon. I am not really representing the Chicago Board of Health, but I am a member.

The issue that bothers me a little bit is around health communication. We are bombarded daily, almost hourly, with results, findings from research, suggesting one treatment or another treatment.

I am very pleased to see that there is a component of effective health communication in Healthy People 2010.

I would suggest to you that those individuals who are being bombarded by this information are not necessarily going to be able to use this very sophisticated tool.

Somehow or other, I think that we need to develop a way that the everyday citizen, who does not necessarily have internet or computer skills or a computer in their homes, can also understand what the limits are of what they are being told or being exposed to, on television or on radio.

I don't know who their expert will be, because we know that 41 to 43 million people don't have access to a provider or to services.

I suspect that this is a significant problem.
I must say also that there are persons who are on the Internet who are giving distorted information or incorrect information.

I know we are in a free society, and I don't know what to do about that, but it is a problem. Again, I don't have any specific recommendations, except to say that I don't think these approaches will reach the less sophisticated populations, who are at highest risk for poor health outcomes.

DR. WILLIS-FILLINGER: Thank you.

MR. RUZICKA: My name is Mark Ruzicka. I am going to speak as a citizen and not use my organization right now.

I just have a question. Section 10, goal B-1, its goal is to assure access to primary care services. Then, along the data set, it has the different populations and it has whites, not available, and then for the one underneath it, it says unavailable as well.

I know that I am not versed in the data collection of all these different acronyms, but at the same time I am puzzled by the fact that we don't have data on something that seems very important for access to health care and primary care services.

I just recommend that we look into that problem more and try to get information about that.

DR. WILLIS-FILLINGER: Thank you. I will just make the comment that, these objectives, when there is no data available, the idea is that by 2010 we would be able to measure these things. That in itself is a goal.

Could you make sure that you register your comments at the end of each one? Thank you.

MS. BAYOU: Billee Bayou from Wisconsin Family Planning. You are asking for some specific recommendations. This recommendation would build upon the other speaker in regard to family planning. I believe it would be in the chapters on family planning and health communication.

I think it has sort of been a stumbling block for us to provide reproductive health care to women and men for a long time.

I hope you all can just solve this, our society's discomfort with sexuality. That, in essence, is prohibiting us from effectively, to the maximum, providing health care to people in general, particularly women's health and their partners in general. So, go to it.

DR. WILLIS-FILLINGER: Thank you. Make sure you register your comment.

DR. MEYER: Good morning. I am Diane Meyer representing the American Speech-Language Hearing Association, or ASHA, in my comments today.

ASHA is the scientific and credentialing organization for over 93,000 audiologists, speech-language pathologists, and speech and hearing scientists.

I have several points which I wanted to comment on. First, ASHA supports the objective 12-12, reduce the prevalence of serious developmental disabilities arising from events in the prenatal and infant periods.

Second, ASHA requests modifications of the targets for hearing loss as follows: moderate to profound hearing loss bilaterally should be modified to include mild hearing losses.

Hearing loss, moderate, unilateral, should be modified to include moderate to profound.

Add then the 11.3 percent rate, and the target, 10.8 percent.

Recent past studies indicate that children whose hearing losses are identified and receive intervention by six months of age, demonstrate significant language development on par with hearing peers across degree of hearing loss and socioeconomic strata, and independent of gender, minority status, and the presence or absence of additional disabilities.

The prevalence of hearing loss in school aged populations almost doubles when children with minimal sensory neural hearing loss are included.

These children experience more difficulty than normally hearing children on a series of educational and functional test measures.

Thirty-seven percent failed at least one grade. The inability to hear during the early years of language development, and academic learning, has significant effect on employment opportunities and social emotional growth.

A third point, ASHA strongly supports the inclusion of developmental objective 12-33, increase to 100 percent the proportion of newborns who are screened for hearing loss by one month of age, have diagnostic follow up by three months of age, and are enrolled in appropriate intervention services by six months.

Research indicates that children with hearing loss or deafness in the United States are, on the average, identified between 24 and 30 months of age, missing the critical years for language learning and intervention.

Data collected for many years indicated that most of these children have educational outcomes of fourth grade reading levels. The implications for job training and employment are well documented.

New data supports clinical impressions that early identification and intervention in the first six months of life yields language and cognitive development commensurate with normally hearing peers.

With the implementation of universal newborn hearing screening programs and educational mandates for intervention, the academic and social emotional outcomes can dramatically improve.

Fourth, ASHA strongly supports objective 12-38, and requests a modification. Increase the proportion of primary care providers who routinely refer or screen infants and children for impairments of vision, hearing, speech and language and other developmental milestones as part of well-child care.

Add, and refer for diagnostic and treatment services, as well as assistive technology. Thank you.

DR. WILLIS-FILLINGER: Thank you. Make sure you register that and leave your written documents as well.

MS. RAUSCHENBERGER: My name is Meg Rauschenberger. I am with the Illinois Department of Human Services family planning program.

My recommendation would be an appeal to the experts to take some of the excellent language on quality family planning services and cross reference it perhaps under related objectives channel used in many of these objectives, to issues such as the small section on family violence, partly in comment to the known data on pregnancy as being a precipitating factor in episodes of violence against women, perhaps in the area of substance abuse -- I haven't had a chance to link that.

I do see that, in relation to family violence, there is a related objective listed as access to emergency medical services. I would appeal that that be broadened to primary care and family planning services specifically, knowing the linkage of pregnancy as an issue related to family violence, and perhaps to substance abuse, if that is not included. Thanks.

DR. WILLIS-FILLINGER: Make sure you register that.

MS. HELM-THONELL: Good morning. My name is Bettina Helm-Thonell and I am an assistant administrator at Cook County Hospital. One of the hats that I wear is the family planning director.

I am here to speak as a family planning director, but also as a member of -- as a black female in one of the targeted areas here in Chicago.

I glanced through the goal in some of the documentation on family planning. What is clear that is kind of missing in that is the aspect of family.

We are planning for pregnancy and non-pregnancy, but the whole aspect of having a family is not really clearly identified within the literature.

It takes two. When you come to our waiting room, it is predominantly female. We have very few services that we can get paid for, for our male counterparts within our family unit.

We do provide services for men within our program, but it is done so without getting payment for service. It is done because that is the right thing to do.

When you are going through and looking for further comment of what you can do with family planning, you have to include the male, male mentoring, going into the high school, teaching young males what it means to be a father, and then having them link with their partners and say, what does that partnership mean.

That is real important. It is a vital aspect of any family planning program, and I don't really see that too much in the literature. Thank you.

MR. ERICKSON: Keith Erickson, director of the Lynne County Health Department in Cedar Rapids, Iowa.

I want to address first of all the electronic access to health information. I would like to see this in terms of increasing the percentage of local health departments that have a home page, not just access to the Internet.

Second of all, I would like to see this document and the leading health indicators of 2010 put into an electronic format, a template, if you will, and supplied to every local health department.

We have got to be able to track these indicators in real time. It is not enough to get a document with two or three-year-old data because it is finally put together and printed and disseminated. We have got to do this in a much more rapid turn-around.

I wanted to address the objectives under the GIS. Yes, we want to increase the use of geo-coding. It is important that diverse data sets are put in a format that allow geo-mapping, geo-coding.

I am suggesting the justice system has databases, EPA, the social services. In Iowa we have four major departments that provide health services, not just the health department.

We have DNR, we have the department of inspections, which handles all food inspections, we have the Department of Agriculture responsible for, for instance, milk sanitation.

We have to be able to communicate. So, the geo-coding should be in a format that is compatible for diverse data sets.

The last is the legal basis for public health. I would like to see the roles and responsibilities of local boards of health articulated in state codes.

It is not enough just to have model statutes to define the central services. This should be articulated in the code itself. I would put it in the framework of essential health services. Thank you.

DR. WILLIS-FILLINGER: Thank you.

MR. HAVERKATE: Hi. My name is Rick Haverkate. I work with the Inter-Tribal Council in Michigan. I wanted to make comment on objectives 6 and 7 under public health infrastructure, the idea of making health data acceptable to small populations in communities of color.

The objectives don't clearly state any responsibility for making the data acceptable, or who is going to provide it where communities of color may obtain that data.

It may exist in health departments and vital records, but by the time you go through 12 or 15 desks and offices in trying to find where that data exists, and knowing the right question to ask, it is very confusing and disheartening for the communities.

While we are trying to plan for healthier communities -- 100 percent of the tribes, by the way, in Michigan adopted Healthy People 2000, so it is a wonderful document and we very much enjoy following it.

When it comes to planning for the future, we don't know where we have been, because the numbers always say not available.

We have a big problem because of small numbers, that they won't report rates because they are not statistically significant.

We still need to know a number. So, if we can have the numbers made available to us, we can decide then what we want to be able to do with it, and to be able to aggregate the numbers based on our tribal service areas.

So, the big problem with the objectives here is that it doesn't give the responsibility of who is going to make this data available and where we can access the data from. Thank you.

DR. WILLIS-FILLINGER: Thank you. Our lines are continuing.

DR. WIEGMAN: Janice Weigman. I am an associate professor of nursing at McKendrick College in Lebanon, Illinois. My comments here today do not represent the college. They are my personal comments.

I would like to reiterate the comment made by the individual from Cook County. I personally believe that family planning needs to include more family life education, and not just focusing on pregnancy and preventing pregnancy, and include the fathers as well.

Conflict resolution could possibly impact family violence issues, and decisionmaking, all those kinds of things would be involved in family life.

Also, I would like to make a comment about -- oh, it is on page 10-26, the developmental objective about assuring that every person with long-term care needs has access.

One of the things I have noticed in our southern Illinois rural area is that, with the changes in Medicare reimbursement, regarding home health reimbursed visits, I am concerned about the number of elderly who will no longer have their visits for routine lab work.

One of the things that I think, as part of potential data sources, could possibly be looking at is there an increase in the acute care admissions because of complications from some of the conditions that previously were monitored by home health. Thank you.

DR. WILLIS-FILLINGER: Thank you. I think some cursory reading of the document may have generated a few more issues. I won't press the issue of time. We have lots of time.

I will tell you, though, that some of the other sessions have ended. What they have done, they are starting to gather in the Regency Ballroom where there is sort of an open mike, open session for comments on any of the different sections that you would like to.

It is up to the group here. If you have a few other comments, I would like you to approach the mike now, and we have another comment. Okay.

MR. WILLIS: My name is Nate Willis, president of the Council for Biomedical Careers in Chicago. I want to make a comment on the suggestion that we have a report care for physicians.

I am against the report card because it would put a damper on the physician's actions, to the extent that they may tend to err on the side of procedures that get few or no adverse criticisms.

DR. WILLIS-FILLINGER: Thank you. Okay, it looks like we are going to adjourn this session and join our colleagues in the Regency Ballroom.

I want to thank you all for your comments. They have been very valuable in guiding the panel. I want to thank the panel for your listening as well.

Remember that there are alternate ways to enter your comments, through the Internet and in written form, and we very much value those comments.

So, take time to do your homework. Read all the chapters that are appropriate for you.

MS. BAYOU: Is there a deadline for submitting comments?

DR. WILLIS-FILLINGER: Yes, December 15 is the deadline for comments. Thank you.

[Whereupon, at 10:45 a.m., the session was adjourned.]

Chicago Transcripts and Summaries