DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010
April 30, 1998, Proceedings

Agenda Item: Developing Objectives for 2010. Reports by the Lead Agencies

PCPFS
SAMHSA
HRSA
CDC
NIH
OPA
FDA
AHCPR

Agenda Item: Reports by the Lead Agencies. PCPFS.

MS. PERLMUTTER: Good morning, everyone. I hope everybody took a very healthy stretch break for the last five minutes. I thought that was what you were doing out there.

I would like to introduce -- although she is not there at the moment, I think she is still out in the hall -- Christine Spain, on the staff of the President's Council, who is our Healthy People guru. Also, Dr. Bill Dietz with the CDC. The CDC is the Presidential Council's scientific advisor on objectives. The Council, in fact, is the lead agency for the physical activity and fitness areas, as the CDC is our scientific advisor.

The draft you have is actually a draft for the next decade. The objectives reflect the progress that we have made in the previous decade. We are pleased that we now have revised and updated data sources, such as the 1996 Surgeon General's Report on Physical Activity and Health, recommendations from consensus conferences, review of public comments and numerous work group discussions.

Our goal, simply, is to improve the health, fitness and quality of life for all Americans through the adoption and maintenance of regular daily physical activity. Our thematic focus is simply to change behavior.

Our objectives are presented logically and concisely for diverse audiences reflecting an exercise and physical activity prescription. An example of that, for those who don't engage in any physical activity during their leisure time, is to take first steps to begin to do something, and then work toward more. We are looking to improve access and availability of opportunities, of facilities, and improve the quality of life.

Our objectives, we believe, are understandable, appealing, and portray the relationship to everyday Americans. The subjects we have covered are the following: the adoption and maintenance of physical activity participation for those who are sedentary; the adoption of some physical activity participation progressing to sustained activity for a minimum of 30 minutes a day at least five days a week; and moving to vigorous activity for cardiorespiratory endurance. That is an additional 20 minutes a day, at least three days a week.

The second subject we cover is the enhancement of fitness components, to improve the components of muscular strength and endurance and flexibility, especially for seniors, to enhance their participation, for less injury and, ultimately, to improve the quality of life.

We emphasize physical activity in youth to encourage healthy behavior. We chose to emphasize this particular category especially in grades nine through 12, when we see that the amount of activity has declined, especially in young girls. We continue to recommend quality daily physical education, as well as recommending its incorporation into health education.

The availability and accessibility of facilities is also very important, and to continue to stress the employer-sponsored programs as well as to advocate the use of school facilities in off-hours. Increase the number of primary and allied health counselors in counseling people to be more physically active. Encourage professionals to ask the right questions.

We have 12 measurable objectives, three developmental objectives covering the life span. Our greatest successes, at least in Healthy People 2000, have been in our work site fitness program. We far surpassed our goals.

We are showing some movement in the physical activity participation area, enhancing physical activity components, although we are really not getting the message to those who are not participating in any leisure-time activity. We are emphasizing youth, as I said, because we are losing ground on the amount of quality physical education, as well as encouraging primary care physicians to ask and counsel their patients.

Unfortunately, we have no data available on community facilities or data for younger children. Any questions?

DR. SATCHER: Comments, questions? I am convinced that next to getting people to quit smoking, physical activity probably has the greatest potential for improving health in this country in all age groups.

Sandy, are we specifically recommending anything in terms of K-12? You said we were going to focus on that?

DR. PERLMUTTER: The problem with the younger grades is really the data at this point.

DR. SATCHER: But we know that there is only one state in the union that requires K-12.

DR. PERLMUTTER: Daily, yes.

DR. SATCHER: I think to a great extent that is where we are losing the battle, the inactivity among young people.

At the other end of that scale is older people, where we are underestimating the benefits of physical activity -- and we are learning more every day, of course, about disability -- to prolong independent life style and improve quality of life, even decrease pain in people with arthritis. I think we have underestimated that.

DR. PERLMUTTER: So, tomorrow morning, everybody get out there. Thank you.

DR. DUVAL: David, let me just ask one question for my own edification. On page 1.6, your physical activity participation -- this is recommendation number one -- increase to 90 percent the proportion of people age 18 or older engaged in any leisure-time activity. What are you trying to convey in the term leisure time? This is not a criticism. What do you mean by that?

DR. SATCHER: That is a very good question.

MS. SPAIN: Actually, what we were looking at is sedentary behavior, and other than work site -- when we are at work. The rest of the time is leisure-time. That is the time that we feel that people can devote to participating in some type of physical activity.

We have actually contemplated changing that terminology to any type of physical activity, so that we can include occupational physical activity also. The problem once again is data collection. There is no valid, reliable data collection for occupational physical activity.

DR. DUVAL: If you mate, for instance, this objective with some of the ones that are going to come up later -- for example, that come up with health in the work site, as you move into companies that have larger and larger numbers of employees -- many of them are going to find that companies are quite willing, for long-range purposes, to permit people to get good, solid exercise at the work site.

MS. SPAIN: Absolutely, and that has been our one success.

DR. DUVAL: All I was concerned about is -- if you look at construction workers and a lot of others who get physical activity on the job, I didn't want to see them obliged to say, oh, I have to do 20 minutes three times a week.

DR. SATCHER: This is where I would disagree. I really think we need to separate activity in the work place and leisure time, psychologically and otherwise. I really think it is important for people to have physical activity beyond their work. I would argue that leisure-time implies that we really want people to plan a program of physical activity that is separate from their work.

It is a very good point you make, though, about the fact that many work sites have now set aside facilities and time for their employees to be physically active. I spoke yesterday in Boston to the American Association of Occupational Physicians and Nurses. I think I got a greater response from the whole point about what they can do at the work site to provide opportunities for physical activity, not as a part of the work, but having the facilities there and even in some cases allowing a half an hour more for the lunch break. It is going to pay off for the company and for the employees.

I would just be careful because there are so many people who say, I don't need to exercise -- that is the word they use -- because I get so much exercise in my work.

I think there is a danger in that, even for construction workers. Some of these construction workers they are sitting there all day with a jack hammer. That is a lot of exercise but you don't want that to substitute for the kind of physical activity that we are talking about.

MS. SPAIN: We do touch upon occupational justification; we have looked at it, but this is not our focus. We do want people to get up and get out there and do more than just during their work.

DR. SATCHER: I think it is the psychological benefits of physical activity, in terms of getting away from the grind, if you will. Other comments?

MR. HARRELL: Just one. It is a disappointment, again, to reach the next decade and still not know more than we do about the children who are younger than, I think, ninth grade. We studied that back in the mid-1980s. We had one study that told us some pretty bad news, as a matter of fact, about physical activity patterns among children in the elementary school grades. We have dropped our capacity to survey that.

I just want to put it on the table that I think that is a big challenge for us. We know about the weight predicament of children in that range, and it is getting worse.

DR. SATCHER: We do have some data, don't we, about at least the great decline in the percentage of children who are taking physical education, whether it is required or not, and it has gone from what, 45 percent to 21 percent?

MS. SPAIN: It is 28 percent, I believe, is where we are at. The problem is the type of data -- the definition of whether it is national, whether it will be repeated, does it fit the definition of the data that is needed for these objectives. We are still striving to see how we can possibly move toward gathering some additional data in order to incorporate those age ranges.

DR. SATCHER: We ought to move to do that, between what Ed is doing with NHANES and other data systems and what CDC does with youth risk behavior. We ought to just talk about how we are going to move to do that.

DR. SONDIK: I am making a long list -- unfortunately, I think it is going to be long -- of what we need. This is certainly one. I thought the point that Clay made this morning about data was just critical. We didn't really talk about it at all, but this is just another example of that.

DR. SATCHER: I agree, and I hope we have a chance today to talk about it more. I think it would be good to have more discussion about that whole approach and perspective on data.

We are going to move now to the next presentation. Earl has agreed to allow Paul Schwab from SAMHSA, I guess, to go next.

Agenda Item: Reports by Lead Agencies. SAMHSA.

MR. SCHWAB: Thank you. I am pleased to report on two areas, two focus areas, substance abuse and mental health and mental disorders.

First, let me just mention briefly that in town will be the walk to focus attention on mental health. We are pleased that Dr. Satcher and my boss, Dr. Chavez, and many others will be joining in that effort. If you are in the area Saturday morning at 9:00 o'clock, if you are in town, we would welcome you to join with what we hope to be thousands of people who will be focusing attention on the need to reduce stigma and focusing public attention in terms of mental health.

In the two chapters here, there are two areas of focus. One is on mental health, as I mentioned, where the goal is to improve the mental health of all Americans by ensuring appropriate high quality services that are informed by scientific research.

The other is to reduce substance abuse to protect the health and safety and quality of life, especially for the nation's children.

Let me first note quickly the significance of collaboration in the work of these chapters, first in terms of input from constituents, special meetings, consortia of consumer, consumer advocates, but as well in terms of interagency collaboration within the Department. With regard to mental health, actually the National Institute of Mental Health within NIH is the co-chair with SAMHSA. HRSA and the National Center for Health Statistics of CDC and ODPHP also are active participants.

In substance abuse, we have worked closely with two NIH institutes particularly -- NIDA and NIAAA -- as well as CDC, HRSA and other PHS agencies, on the chapter and actually established an inter-departmental working group to both work on that and our upcoming progress review, which is scheduled for May 6.

With regard, first, to the mental health area and focus, as I mentioned, it is shared with NIMH. So, I am in a sense presenting with them as a co-lead. Mental illnesses affect all ages, all ethnicities and racial groups, both sexes obviously, and people from all educational and socioeconomic strata. Still, approximately 40 million Americans, ages 15 through 54, experienced some type of mental disorder in the last year, a striking statistic. The chance of developing a diagnosable mental illness over the course of one's life is approximately 35 percent.

The focus here is on a number of issues of national significance, as well as 2010 issues. Mental illness costs the nation nearly $150 million a year, and lost productivity due to illness or premature death accounted for nearly $75 billion. The World Health Organization study, the Global Burden of Disease Review, indicated that four of the leading causes of disability are mental disorders, with unipolar major depression heading the list of all causes of disability by the year 2000.

Here we now have two objectives that address disabilities: one on reducing the number of lost years of healthy life due to unipolar depression, and a second one on reducing disabilities associated with mental disorders in women, generally.

One of the key problems in addressing the mental health prevalence is that a vast majority of individuals needing mental health services do not receive them. So, access becomes the keystone to any strategy to provide preventive or treatment services. Here we are addressing that in several objectives. Three objectives ask if respondents who indicated that they needed mental health services didn't get them because they couldn't afford them.

For our most vulnerable population with serious mental illness there are objectives here that need to be involved in treatment to increase the rate of employment and to decrease the rate of homelessness.

For mental health as well, the primary care setting continues to be an important setting in which to identify children and adults who need mental health services. So, several objectives included here call for primary care provider screening for adults and for all children from babies to adolescents. Actually, one of the projects that we are involved in within the agency focuses on ages zero to seven, and looks at integrated health services in terms of mental health and substance abuse.

One developmental objective in the mental health chapter here calls for a nationally representative survey to assess the incidence and prevalence rates of mental disorders for children and adolescents, speaking to the point that Ed just raised in terms of the data needs and the inadequacies.

Also, there is an objective to address the needs of the elderly, in that instance, to have protocols for providing mental health services that focus on the elderly population.

Finally, in a very important area, the mental health area contains objectives on comorbidity, which is looking at mental health and substance abuse. In fact, I have been kind of new to this area, and visited several treatment centers recently, to learn that comorbidity in the minds of some of the people I met with actually extends to substance abuse, mental health, HIV and domestic violence.

The focus here is really specifically in terms of mental health and substance abuse.

That leads me now to turn briefly to the substance abuse chapter. The chapter really reflects, as presented, the ultimate goal of a policy in this country for preventing substance abuse among youth. That is a major focus in terms of the emphasis here. It is to increase the percentage of young people who reach adulthood without using tobacco and illicit drugs, including alcohol. In that regard we have proposed here a new objective, to increase the number of high school seniors who report that they have never used tobacco, alcohol or illicit drugs.

In addition to youth, and focusing attention on, again, the full life span, the chapter also addresses the problems of older Americans, including an objective calling for screening of alcohol and drug abuse by the elderly, especially in combination with prescription drug use. In my sense, and ours, a lot of the historical work in the substance abuse area has followed kind of a model focusing on the adult male. Increasingly, attention to issues focusing on women, as well as looking at the whole life span from the early years to the elderly years, becomes a very important dimension of the policy focus here.

The chapter also has objectives that seek to reduce the costly and often tragic consequences of alcohol misuse and abuse by adults, calling for lowering alcohol consumption by adults, and decreasing cirrhosis-related deaths. We have a developmental objective calling for alcohol and drug treatment for all ages and all cultures. The underlying fact here is that substance abuse treatment becomes a sound investment. One of the sources cited speaks to a documented 40 percent reduction in health care costs to participants two years after substance abuse treatment. We had some very important results this past fall, as part of the National Treatment Improvement Evaluation Study, that really clearly demonstrated, with a number of the substance abuse treatment programs, what kind of positive outcomes can occur.

In general, as far as the substance abuse chapter is concerned, it does retain many of the key Healthy People 2000 objectives, including reducing deaths due to substance abuse-related motor vehicle crashes, cirrhosis and drug use, reducing drug-related hospital emergency department visits, reducing past month use of illicit substances by adolescents, and reducing binge drinking on the part of high school seniors and college students. We have recently been engaged with Education and some other agencies focusing attention to the whole dimension of binge drinking on campuses. It includes increasing young people's perception of risk and social disapproval of substance abuse.

In addition, there are several critical objectives that have been added, one on reducing inhalant use and several developmental objectives.

Further, in terms of Healthy People 2010, in terms of some additional ones, we have included reducing the percentage of drowning victims intoxicated at the time of death, to broaden the scope of focus in terms of some of the issues around alcohol, particularly, increasing the referrals to counseling of children whose parents have been admitted to substance abuse treatment programs, and school identification of students at risk for appropriate mental health, substance abuse screening and treatment, very much dramatized by recent events in this country in terms of what has happened among our youth.

In conclusion, both chapters emphasize that these disorders do not occur in a vacuum. To prevent these problems, to reduce their harm, not only are prevention and treatment services needed, but also those key services that help people get and stay on the right path, whether it is job training or employment or parenting training or education.

To address both problems, coordinated efforts by all parts of society are needed, by families, by schools, by providers. We were pleased to see this summer the National Physician Leadership Group, for example, with some very strong statements focusing on drug abuse and the role of physicians in that regard, by both the public and the private sectors and by the faith community. Our agency, SAMHSA, working in collaboration with both public agencies and private agencies, will continue to focus attention on these respective matters.

Let me just stop. Here is Peggy Gilliam, who has been very actively involved in the development of our work here, with staff from several of our centers and at the agency level.

DR. SATCHER: Comments, questions?

DR. BRANDT: Back to the issue of 16.6, reducing deaths caused by alcohol- and drug-related motor vehicle crashes. It seems to me that, even though you say so in here, that we ought to have a goal for reducing injuries caused by those. Many of these injuries result in people with significant disabilities and other -- those data are fairly readily available nowadays.

A second thing to consider is arrests for DUIs, DWIs, whatever your state calls them. I really have a feeling that one of the reasons why deaths have gone down is because of air bags, and more people using seat belts, and other kinds of things. I think at least in our part of the world, we are seeing an increase in injuries, apparently, due to drunk or impaired drivers.

We also have another problem that is going on and that is the issue of drugs, legal drugs, prescription drugs, especially the use of sedatives and other kinds of things that people are taking that really impair their judgement. I don't know how to get a handle on that, but I am only commenting that I think that is a growing problem.

MR. SCHWAB: I don't know, in terms of the history, as to why consideration was not given, for example, to injuries and alcohol. Maybe it is a matter of severity of injury and measuring with the data system, but there clearly are some data sources there with regard to injury resulting. Do you have any --

MS. GILLIAM: I think that is certainly something that we can look at.

DR. SATCHER: How do we deal with the intersection of objectives for injury prevention and your objectives for substance abuse? How have we dealt with that in the past? These are very important objectives. The question is, how do we make sure that they sort of come together in the right way?

MR. SCHWAB: At this point, it is not clear to me that there have been any objectives, from, in fact, the substance abuse area, for example, that have been connected up physically, if you will, in that part dealing with prevention. I believe that our agency, NIAAA, for example, and CDC have had some work collaboratively together. At this point, I am not specifically aware of a particular project that we are jointly funding.

MS. MAHONEY: We have had discussions, and the intervention group from CDC is involved with us in these discussions, about our Healthy People chapter. We also participated in the unintentional injuries discussion last year with CDC, in their progress review surrounding fires and alcohol and drug use. We also did have a discussion -- this speaks to Dr. Brandt's point -- about the injuries associated with alcohol and driving. I think I am glad to have you bring that point to our attention and in the forefront again.

DR. RICHMOND: I would like to just relate some of our discussion to our earlier discussion on racial disparities. I know in some of your developmental issues proposals -- number 18, increase the percentage of juvenile justice facilities that screen every juvenile for mental health problems -- I think when we look at the numbers of African American young people coming to the attention of the courts and who are actually incarcerated, we come up with an unconscionable number of about 35 percent of African American young people coming to the attention of the courts or actually incarcerated.

If we think of preventive issues here, it seems to me that we have to think of what comes earlier. It seems to me that there ought to be some emphasis on improving the environments in children, particularly those growing up in low-income communities. There are emphases, of course, for the extension of child care currently that I am aware of. With welfare reform, we said mothers need to go to work if they are on welfare. Yet, we know the inadequacy of child care provisions.

In the Department, the Administration for Children, Youth and Families is doing a lot of planning in this context. It seems to me that there ought to be some cross-cutting here to build in the notion that all children deserve a nurturing and safe and secure early environment, so that when they are ready for school, they are ready to take the advantages that come with schooling. It seems to me that this is not something that NIMH or NIDA alone can do. It seems to me that by linking with other agencies in the department, and even across government, one could move in the direction of providing that.

MR. SCHWAB: That is an excellent point. In fact, the irony is, the only way they can get attention is if they are in a correctional institution. For some families, it almost forces them to be in a situation where you have got a mother indicating that the only way that her child can get any kind of attention with regard to drug abuse issues, for example, given the status today of adolescent treatment, is to have the child locked up and maybe that way getting attention.

What I mentioned briefly before, the program focusing on ages zero to seven, which we have called Starting Early, Starting Smart, actually is working together with ACF, with Education, with HRSA. There are right now 12 sites, of which six are in Headstart sites, and six are in primary care settings. They are to, indeed, focus attention starting out right at the beginning, starting out with zero to seven.

We are also working collaboratively to look at children of substance-abusing parents, and also looking at issues around teen mothers and kids. We couldn't agree with you more. So, we will look in terms of how the objectives are configured to capture some of that.

DR. BRANDT: The other comment I would make is that -- again, to drive you and CDC together, or at least the Center for Injury Prevention -- there is a relationship between drugs and violence, alcohol and drugs. I am not arguing that it causes it, but there sure are a lot of drug-related, drug-dealing violent crimes.

I wonder if we shouldn't begin to address that. I sit on the Physician Leadership, whatever it is called, for a National Drug Policy. I know that we are talking about the fact that, if you can get treatment as opposed to, or in addition to, the courts, that maybe we could begin to reduce that rate. I would just comment that maybe that ought to be looked at, at least.

DR. SATCHER: We are going to have to move, so let's make these short.

MR. HARRELL: Nothing has been said about mental health. I am still concerned that we are not looking at, I guess, risk factors, in terms of mental health. I think there are data sources that would get at some of the things. We have proposed, for instance, and it did not get in here, the children in foster care we believe to be at risk for mental health problems, just because of what they are going through. I propose that you push SAMHSA to look harder at some of the things that are outside your particular stove pipe in terms of risk factors for mental health problems.

DR. JONES: I would just like to get on the record and just say that we should not continue to ignore young girls and the evidence of eating disorders, perhaps, increasing. Something like 60 percent of girls grades 9 to 12 report trying to lose weight, as many as one in six, perhaps, by binging, purging, using other methods.

This is thought to be a rich white girl's disease anecdotally by people who treat these young women. That is less and less the case, and boys also have increasing evidence of this behavior. I would hate to see us, 10 years out, continue to ignore and write off a group of very labile young kids engaging in eating, which is socially acceptable, and yet which has many of the features of an addictive, substance abusing disorder.

DR. SATCHER: There are a lot of other topics here, but that is a very important one, and suicide, suicide prevention and what is happening with that. We are working on a Surgeon General's report on mental health that should be ready in the next year to year and a half. Some of the points that have been brought up here, we are bringing attention to.

You know, one of the problems in this area is just the attitude that people in this country have toward mental health and mental health problems. It makes it very difficult to even provide the services to the extent that we need to. So, we have got to raise awareness and sensitivity at the same time.

Thanks a lot, Paul; okay. Earl?

Agenda Item: Reports by Lead Agencies HRSA.

DR. FOX: The Maternal and Infant Health area is under the Improve Access part of your book, which is the last part, and it is the next-to-last blue sheet, if you want to turn and look at those.

Dr. Audrey Nora is here today. They say about MCH, either, like most things, you have never done it or it has been so long since you have done it, you have forgotten how. I am in the latter category. If we have any questions, Dr. Nora is here to help me out.

We have 30 objectives. Eleven of these are developmental. I don't know if we have told you what a developmental objective is. It is one that we don't have any data for. I think it is a feeling that they are things that we need to look at; they are important, but we clearly recognize that there is no data, and the thought is they will be put in a separate part of the document, apart from the objectives where we have data.

We basically have done a number of things in the MCH objectives. One, we tried to be more specific. For instance, in the area of infant mortality, we have focused on things now where the technology or the evidence base has moved us: by moving kids on their back to prevent SIDS, using folate in the prevention of neural tube defects. The objectives reflect that. They also cover a broader range of health topics than the last go-round, particularly in pregnancy and infants through the first year of life

As I said, there are 11 that are developmental. We have 10 themes. I will run down them quickly, and I will try to be brief in my comments to leave time for some discussion. The first is infant mortality and, again, we have added specific objectives around SIDS and birth defects that were not there before. In perinatal and fetal mortality, we have an actual objective on perinatal mortality that was not in the last go-round.

For maternal morbidity and mortality, we have actually added objectives around issues of morbidity and mortality, like eclampsia, ectopic pregnancy and others.

In the area of pre-conceptual, prenatal and post-partum care, we are now looking at things in addition to what we had before. The initiation and adequacy of prenatal care, the use of childbirth classes, and the receipt of a post-partum visit were not in there the last go-round. Obstetrical care -- we are looking, in addition to some of the things that we have already looked at in risk appropriate care. We are looking at the issue of very low birth weight in infants born in level three hospitals. I think this is going to be very interesting, particularly since we don't really know what is happening around our regionalized perinatal care in light of what is happening with managed care. In the area of risk factors, we have added objectives on the rates of pre-term delivery and, again, the proportion of kids that are put to sleep on their back.

Perinatal substance abuse -- we have separate objectives on the individual substances, like alcohol, tobacco and illicit substances. Those were lumped together previously. We also have an objective on reducing the rate of fetal alcohol syndrome.

Neural tube defects -- again, I have already mentioned the use of folate, increasing the level of serum folate among women of child-bearing age.

Breast feeding -- we have actually extended it in two ways. One, we have an objective on exclusive breast feeding, and we have an objective that extends breast feeding up to one year.

Then, finally, newborn screening and primary care

-- we have added an objective on newborn hearing screening, because technology has gotten us to the point now where we need to be able to do that. Finally -- looking at appropriate primary care for children under age 18.

So, that is it in a nutshell and I will be glad to answer any questions. I will try. My brevity does not at all indicate the importance of the MCH objectives. I hope you understand.

DR. SATCHER: Are people having trouble finding the objectives in the book? It was just pointed out that if we use a number like 25.13 --

DR. FOX: Did you find the MCH objectives?

DR. SATCHER: Let us know if you are having any trouble.

DR. DUVAL: I think if each person standing up and making his presentation would say, this is chapter 25 or chapter 17, that would be very helpful.

DR. FOX: Again, if you have any comments later on the MCH objectives, feel free to give them to me, Dr. Nora or Debbie Maiese.

We also did preventive services, but John Eisenberg is going to make that presentation.

DR. SATCHER: Let me just say one thing, and it gets back to a point that Dr. Julie Richmond was making earlier. Focusing on what happens to children early is something that I think is a very important strategy for us, whether you are dealing with teenage pregnancy or drug abuse or whatever. When you focus on the developing child, it seems to bring into focus a lot of things, even in smoking. The more you point out what happens to children who are exposed to cigarettes or in early childhood -- in SIDS, for example, or smoking and asthma.

I think this area is very important, because we can all get together and agree, hopefully, that every child deserves an opportunity for a healthy start. I think we should all get together and agree that we are going to tackle that. I think it is an important strategy.

DR. RICHMOND: I would just again come back to the focus that -- it is no surprise that I would focus on early child care because of my involvements with Head Start. I think that when we established Head Start, we didn't succeed in enrolling the entire population that was in need, and we still haven't. The President, as you know, has put forward a proposal for $21 billion additionally for child care. It seems to me that this is where those of us in the health sector intersect with people in early childhood education and social services. Foster care was mentioned earlier as one example.

I think the point we were making earlier is that health services alone can't do the job if we are going to provide the appropriate environment for children in the preschool period. We do need comprehensive services, and this bespeaks the need for the Bureau of Maternal and Child Health to be interacting. ACYF and other agencies, and certainly the Department of Education will be having heavy involvement in early child care programs.

I would just emphasize that we in health can't do this alone. It takes comprehensive child health services -- and it is in the document under community-based services -- and we need to have this kind of cross-cutting emphasis to make sure that children get all the things that they need, and not exclusively just the health services.

DR. FOX: You all know Jim is one of the few points of institutional memory for Healthy People. He was in ODPHP 12 years, and probably knows more about Healthy People than anybody else here.

DR. SATCHER: Okay. Next, Dr. Claire Broome, CDC.

Agenda Item: Reports of Lead Agencies. CDC.

DR. BROOME: I have a somewhat daunting task, because CDC is the lead for a fairly large number of chapters. I would really like to work with our distinguished chair to do this in a way which really lets us get some input from the Council. I think it would probably be best if I stop after each chapter for discussion and make fairly brief comments.

DR. SATCHER: That assumes that you are not going to take too much time on each chapter.

DR. BROOME: That, of course, is the Chair's responsibility. [Laughter.]

The first chapter I will discuss is tobacco use, which is chapter three. It is under the first part, Promoting Healthy Behaviors. We are actually -- the title of the chapter is Tobacco Use Prevention and Reduction. The goal of the chapter is to reduce death, disease and disability due to tobacco use and exposure to second-hand smoke. The ways we have organized the chapter are the approaches to accomplishing the goal.

First of all, preventing the initiation of tobacco use as measured by the prevalence, and decreasing that prevalence, and particularly use among young people. This is under the tab, Promoting Healthy Behaviors, and then it is the third blue sheet behind that tab.

So, the four areas are preventing initiation of tobacco use, promoting cessation of tobacco use, reducing exposure to second-hand smoke, and changing social norms and environments that support tobacco use. We have 18 measurable objectives and six developmental objectives that are proposed for the chapter.

As you know, we have been making progress in some important areas, such as the declines in cardiovascular heart disease, but we obviously have some major challenges, particularly in the rates of youth smoking. So, a lot of the objectives focus on that outcome and accomplishing it through school health programs and general tobacco control programs. I think I will stop at that point and ask for comments on the objectives for tobacco.

DR. SATCHER: How many chapters do you have?

DR. BROOME: I think 14.

DR. DUVAL: I would ask one question. It happens to be referenced on page 3.3 at the top, but it is important. Last year when we met, the Secretary made a rather strong point that I was terribly attracted to personally, having to do with the role models, heroes, et cetera, possibly making connections. In fact, my recollection was that she implied strongly that she was going to be meeting with producers of entertainment shows and so forth, to try to slam home the importance of modeling.

I notice that that is referenced again on this page. I wonder, did anything happen?

DR. SATCHER: The most outstanding one, of course, is Boyz-2-Men. The group came here. They have developed several posters. My understanding is that before every one of their performances, they talk about the danger of smoking. They try not to allow smoking in any of their performances. That is the big one. Anyone else want to comment on that? I know we were very excited when they came on board.

DR. DUVAL: I think that is great. Of course, I realize that there are First Amendment issues that are involved here.

Maybe I am terribly biased, and I acknowledge that up front, but I think what we see in our athletic heroes and their behavior -- my own Charles Barkley says, I am not a role model. I think frankly this stinks. I am sorry, but I just think people in the culture of celebrity take on a responsibility that is a little different from others. I don't want to extend that too far, but I think that if you are going to talk about people's behavior in terms of health, you have got to find some way to connect to the entertainment industry.

DR. SATCHER: As you know, one of the problems we have now is that, in movies, we are seeing more smoking instead of less, but we are trying to work on that, too. The Secretary is committed to this area, and she is going to use her influence broadly in this area. So, we will hear more about that. It is a very important point.

I should have mentioned the U.S. soccer team, the women's soccer team that won the Olympics. They have also been very active with us in this, trying to discourage smoking. That is very important, especially for young girls. The U.S. soccer team has been very active. They have made TV spots and some other things dealing with it. Some of them are very good.

DR. BROOME: I think the very serious concern that the way smoking is portrayed, particularly in movies, gives teens the sense that the norm for being cool is to be a smoker. We have been, as Dr. Satcher mentioned, in discussion with the entertainment industry about how smoking is portrayed in movies, sort of avoiding dwelling only on the PSA approach and trying to address actual content of entertainment.

DR. DUVAL: The comment, if I was clear -- I am in my own mind -- I may not have been quite as articulate as I think I am sometimes, but I am going beyond smoking. I was trying to make the point that, as long as you are going to discuss behavior modification, et cetera, et cetera, in terms of health, the entertainment and sports industries are incredibly important, and that includes but goes beyond tobacco. That was my whole point.

MR. SCHWAB: I just want to comment on that. One of the areas that the Secretary has promoted in the Department is Girl Power, focusing on behaviors beyond just smoking. For example, one of the role models there has been Dominique Dawes, who has been one of the Olympic celebrities to focus in on younger women, to focus in on healthy behavior.

DR. SATCHER: There are obviously a lot of other things happening in this area. There is so much discussion going on about it that we probably don't need to spend much time talking about it. Go ahead.

DR. BROOME: I would call people's attention to the fact that there are a number of objectives dealing with smokeless tobacco and cigar use. We have seen that, in addition to cigarettes, these aspects have become an increasing problem in our young people.

The next one is sexually transmitted diseases. This is under your tab for Reproductive and Sexual Health. It is chapter five.

I would like at the outset to say, in terms of the organizational framework, as I mentioned earlier, we would either be very comfortable with folding reproductive health and sexual health into the earlier chapter, as Dr. Richmond has suggested. If it remains as a separate organizing entity, we think it would be important to change the title so that it was Promoting Reproductive Health and STD/HIV Prevention. We think that permits an STD chapter followed by an HIV chapter, but maintains the inter-relatedness between them. That is just one comment on the framework.

In terms of the STD chapter, the over-arching goal of this is to arrive at an adult society where healthy sexual relationships, free of coercion and infection, are the norm. The vision for reproductive health is that every pregnancy should be intended, that sex should be free of coercion and infection, and that every birth should be healthy.

The measurable objectives for the chapter, there are nine of these and 15 proposed developmental objectives.

I think the developmental objectives particularly address the changing environment in which we deal with STDs, rather than focusing only on STD clinics.

We think it is increasingly important to look at the whole range of settings in which STDs may be detected. Some of that can be seen in the chlamydia objectives. As you notice, we focus not only on STD clinics, but also family planning clinics, Job Corps, areas where we have been reaching out to identify silent asymptomatic cases, and be sure that treatment is offered, so that we prevent the latent, long term serious consequences of chlamydia, such as infertility and PID.

We also have developmental objectives that look at how we have managed care interface with the STD prevention model, i.e., how you deal with a partner who is not in your managed care organization. There are some suggestions that it may be possible to address reimbursement mechanisms between health departments and managed care organizations, so that we can do not just effective treatment, but also prevention of transmission.

We are, I think, making some substantial progress with the bacterial and chlamydial STD prevention. We are not in as good shape with the viral STDs. I think we can't forget that in addition to HIV, we also have continuing problems with herpes and papilloma virus as STDs that we need to focus on.

I think that the overall objectives really focus on greater access to high-quality clinical services. This also needs to be considered in the context of youth and disenfranchised populations, which are at considerable risk for STDs.

The new objectives are: reducing to less than 500,000 the number of childless women with fertility problems who have previous STD history, and decreasing to zero the percentage of sexually active young women who have ever had sex whose first experience was not voluntary, in response to the new data suggesting substantial coercion in young women.

DR. SATCHER: That is a very important one. I think the chlamydia experience is really important for us in the future. It is such an excellent example of prevention research actually carried out in the community setting, at least the setting of family planning clinics, and also involving managed care. I think that is a model that we have got to really build on.

DR. KNOUSS Maybe a question and maybe it would be classified as an observation, but there are a lot of very disease-specific objectives here within the whole context of STDs. It would seem to me that a lot of the prevention issues, the detection and prevention issues, the primary and secondary prevention issues around those diseases are going to be very similar.

The question, then, in my mind is whether or not it really is important to focus on the specific diseases, or whether it is important to focus on the strategies and interventions to deal generically with STDs. It is just a broad question and it comes up in a variety of different places throughout Healthy People. It gets in part to the issue, as well as the complexity, that Healthy People is coming to at the present time. I don't mean to focus just on STDs, but it is one where it is so clear.

DR. SATCHER: That is a very important question, because it relates to eliminating disparities. How many objectives we are going to have when we get through? There are some common risk factors and the question is, how are we going to deal with those common risk factors as they relate to disease, versus risk factor-related behavior?

DR. BROOME: I am delighted that Bob raised that. I think that is one of the reasons why we feel it is important to have HIV and the STDs together, just because so many of the sexually risk-related behaviors are common. What we have tried to do is have not only disease-specific objectives, but also some of what we call community-protection objectives.

If you look at 5.21, we are looking both at clinic availability and at school curricula, which obviously address behaviors relating to all kinds of STDs. We are looking at health care financing policies which obviously are generic for a whole range of STDs.

DR. SATCHER: Okay, Claire, we have to move on to your next chapter.

MS. DONAHUE: Just one question, a very short one. Page 5.24, looking at number 17, broadcast media -- increasing to 100 percent the number of principal television networks that accept condom microbicide advertising, et cetera -- My question about that is, does this also include cable networks?

DR. BROOME: I don't know. I think it is a very good point.

MS. DONAHUE: Yes, because so much of what the youth particularly are watching will be on cable networks.

MR. KRING: I would just say that at family planning we would agree with your rewording of the chapter to include HIV and STDs along with family planning. A lot of the objectives in all of ours overlap and we have left out a lot of things out of ours because it is in yours. It would make sense if we could rework them and have all of them together.

DR. SATCHER: Okay, very good.

DR. BROOME: In line with that proposal, I would like to discuss HIV next. However, in your book it is under Prevent and Reduce Diseases and Disorders, and that is chapter 15. So, it is the second blue sheet after that tab.

The strategies that we are looking at overall for HIV are, first of all, ensuring that every person at risk for HIV infection knows their serostatus, ensuring that those persons uninfected with HIV remain uninfected, ensuring that those persons infected with HIV do not transmit HIV to others, and ensuring that those infected with HIV are accessing the most effective therapies possible. So, we are hoping that meeting these objectives will result in a reduction in the incidence of HIV/AIDS, increasing people's awareness of their HIV serostatus and reducing the mortality due to HIV infection.

There are six measurable objectives and seven developmental. Of the Healthy People 2000 objectives, three have met or exceeded their targets and progress has been made on an additional seven objectives.

However, two of the objectives are moving away from their targets and obviously need more attention. One of the most disappointing ones is, in fact, the percentage of schools with HIV or STD education in grades four through 12. It has actually decreased recently. That is a situation of concern. Obviously, it is relevant not just to HIV/AIDS but also to the STDs and other sexually transmissible infection issues.

Another major area of concern is the increasing proportion of cases that are related, either directly or indirectly to injecting drug users.

We think that our ability to track the epidemic as it evolves and changes is very key, that these objectives do need to be based on what we are observing and the surveillance of HIV infection.

I am not sure if any of the others would like to comment. Obviously, this is an area which shares activities with many of our fellow agencies.

DR. SATCHER: Okay, then we move on. This is obviously a very important area that was given a lot of thought.

DR. BROOME: The next chapter is a new one and it is one that we have already had a lot of comment on, and that is the public health infrastructure. We find that back -- it is chapter 6. It is under the tab, Promote Healthy Communities, and it is the first blue sheet after that tab.

This new chapter incorporates the Healthy People 2000 data and surveillance chapter, but it also expands on the proportion of people serving on local health departments.

The organizing principles that we use are the essential public health services. This chapter focuses on the systems, the competencies, the relationships and the resources that enable the performance of essential public health services.

This is not in any way to diminish the importance of surveillance and data. I think anybody who knows me knows that I see that as an absolutely key part of what we do. It is an attempt to extend an understanding of what is needed in public health infrastructure in order to meet many of the other objectives that we are talking about today.

There are 16 developmental objectives. It is an area where we have had a working group that is across ODPIVs, in terms of the development and review of this chapter. I would be very interested in your perspectives on the chapter's organization and utility.

DR. BRANDT: A couple of points. One is that we talked about using the OMB breakdown of racial and ethnic categories. The issue of trying to get that into the local health department -- local and state health departments -- is something that needs to be addressed.

For example, in our state, all the Indian people will tell you that you are born Indian and die white. Recently our state health department has begun to look at that question by relating it to tribal roles. It is amazing. We rarely have an Indian die in our state. They always die white, even though they are born Indian.

I think the issue of getting accurate data by racial and ethnic group is something that local and state health departments are going to need a lot of help with.

DR. FOX: I was going to ask Claire -- what is the plan for the next revision of the U.S. standard certificates? Of course, states are not mandated, as you know, to adopt those, but a lot of them do. That is one way of getting the revision in the definitions that OMB has laid out. I know there is generally a 10-year cycle on that.

DR. BROOME: Are you talking about the vital statistics?

DR. FOX: The vital statistics.

DR. BROOME: Ed is probably closer to that.

DR. SONDIK: We have a panel, actually, that is meeting over a year and a half to look at those. We will be seeking information and input from a variety of sources and taking a very hard-nosed look at it. I told them to think very expansively about what we can get from this system, not solely about what we have had in the past, but to think in terms of the use of this information. This document should be input to that.

DR. BROOME: Earl, in particular, was asking relative to the racial/ethnic issues. I think it is going to be helpful, the policy that the Data Council has adopted, essentially mandating that, whenever the department collects data, that they collect it to include that information.

I think another thing that is going to be useful is the Health Insurance Accountability Act of 1996. The administrative simplification provisions are in the process of being worked through by HCFA and the Data Council.

I think it will be critical that the core data set require specification of race/ethnicity. At this point it is a reasonably voluntary option for most health systems. This is getting back to the point that you are making, Ed, about local availability.

I think there are different ways of doing that. You can certainly take the survey approach. But when you want to know, for Oklahoma on a local level, what is happening, I think you are also going to have to look at existing administrative data from hospitals and clinics.

I think you also have to think about these state-based surveys like the Behavior and Risk Factor Surveillance Survey, which frequently has a much larger sample size and can tailor to local needs.

I think this does mesh with the 2010 objectives, because I think we need this infrastructure chapter. We are going to need to be creative about where the data sources are, and look at all of these inputs to come up with the data that we really need to make a difference on a local level.

DR. SATCHER: This issue of integrating data from the local and state level is such a critical one. We have the Public Health Functions work group, that includes the National Association of County and City Health Officials and the state people. We are working very hard trying to make sure we do that.

Plus, there is a major initiative, I guess, from the Robert Wood Johnson Foundation. I always get these confused. One is at the state level, and Kellogg has one at the local level. Is that the way it goes, Debbie?

They are really helping us, I think, in that regard to work with counties and state health departments to try to improve the public health infrastructure. So, it is something that we are going to give a lot of attention to.

DR. RICHMOND: Just a question. Did I hear correctly that IOM is doing another study of public health services?

DR. FOX: They are doing a safety net study for HRSA, looking broadly at the safety net, that is going to be pretty inclusive. They are just in the early part of that. I don't know exactly what is going to be in it.

DR. RICHMOND: I was just thinking -- if they are, you know, it would be useful -- if they are on the time table, their data and recommendations would be useful for us to tap into.

The other point is just one by way of emphasis. I would hope that we would keep a very high emphasis on the public health infrastructure at a time when almost all the attention -- in terms of policy makers across the country at all levels -- relates to managed care and, particularly, financing issues related to personal health services. It is very easy for support for the public health infrastructure to be dropped, as has been happening, unfortunately.

I think that we should try to use this report to emphasize the significance of maintaining that. It could be quickly eroded and almost impossible to rebuild.

DR. SATCHER: I think, within the Department, that is a major challenge. I think the working relationship between HRSA and HCFA -- and HCFA extending 1115 waivers and other waivers to states and working with the program -- and the extent to which we are really preserving the public health infrastructure in all of this is really critical.

I know the first concern that everybody had was to get control of the finances. I really think we could miss some real opportunities here to strengthen, as opposed to weakening, the public health infrastructure, and we have got to do that.

DR. KNOUSS: One of the things that I have looked at as I have been paging through these prior to this meeting and during this meeting is the relationship of the objectives to the goal. One of the things that one assumes is that if you meet the objectives, you have accomplished the goal.

DR. SATCHER: Is that true?

DR. KNOUSS: That was going to be my question.

DR. SATCHER: I think obviously there can be several objectives working toward one goal, and you might meet some of the objectives and not others. So, you have not necessarily reached the goal.

DR. KNOUSS: I was asking it the other way around. In the structure of this, do we intend -- the way the goal statements are written and the objectives are structured, if we were to accomplish all the objectives, that meant that the goal would, indeed, be fulfilled. The reason I raise this question here -- I think that, in discussing the structure of our public health system, it may be a particularly germane question. The goal statement I am not sure would be fulfilled if the way the objectives have been worded in their totality -- that if we met them -- we could assure ourselves that we had accomplished the goal.

DR. SATCHER: Let's look at that, but I don't believe we should take the time now. I think the steering committee should certainly look at that.

DR. TAKAMURA: Actually, I had a specific suggestion for Claire. Based on my experience in the department of health -- on page 6.4, item C-3, I would actually suggest that you consider changing that objective, so that it calls for an increase in the number of employees trained, as opposed to increasing the number of agencies providing. I think it presents a very different outlook.

DR. SATCHER: Training is a very important part of this infrastructure, development and maintenance. I think we are making some progress. We could probably have leadership institutes and moving to different levels, but we still have a long way to go in terms of the work force issues. Okay, let's move on.

DR. BROOME: The next one is the next chapter, chapter 7, within Promoting Healthy Communities, the chapter on educational and community-based programs. The goal of the chapter is to increase the quality, availability and effectiveness of education and community-based programs designed to prevent disease and improve the health and quality of life of the American people.

The objectives represent the importance of preventive approaches that are community-based, and focus on both individual behavior and environmental, policy and societal influences. I think, over our experience with Healthy People 2000, we have made substantial progress in determining the qualities of a healthy community and what is involved in meeting the health and quality of life needs in this country.

The difficulty that we have had, again, has been in monitoring and evaluating educational and community-based programs. I think we still have six developmental objectives that reflect that complexity. We have found that progress in the areas of family discussion of health and have a number of, I think, very positive experiences with work site health promotion, for example, the campaign with business response to AIDS. You would still need to have a more comprehensive aspect in being able to assess work sites that offer comprehensive employee health promotion programs to their employees.

There are no new objectives in this area, but we do feel that we have a lot of work to do just on the developmental objectives.

DR. SATCHER: It is interesting. We started the healthfindertm program a year ago, and we just introduced healthfindertm two days ago. It has been averaging about -- what? -- 5,000 hits per day, 1.7 million hits the first year. So, the desire for more information on the part of the public about health issues is really strong.

We have got to find creative ways. One concern there, of course, was access for people who didn't have computers in their homes, and working with libraries and schools and churches to make sure that more people have access. This is a very important issue and we have got to look for strategies.

DR. DUVAL: One question quickly. On page 7.13, your number 5. I guess I would -- my own instinct would be to increase the percentage -- where it says increase the proportion of employees who receive a comprehensive health promotion program from their employers, rather than dealing just with work sites. There are so many, many work sites with very small numbers of employees that you don't reach large numbers of people by focusing on the employer.

To me, it is a better objective if you try to get all the employees, particularly of the bigger companies, to participate. That would be the fastest way to reach the largest number of employees as opposed to the number of work sites.

DR. SATCHER: Could you do both?

DR. DUVAL: Yes, you might do both, and in a way you are doing it with number six, because you are increasing to 50 percent the number of employees who actively participate. That is good. When you start looking at the way employees are distributed across companies in the United States, if you want to reach a large number of people, you start with the big employers.

DR. BROOME: The next chapters are also in Promote Healthy Communities. There is unintentional injuries, and then that is followed by the violence and abuse section. Chapter 11 is the unintentional injuries. The objective of the unintentional injuries chapter is to reduce the incidence and severity of injuries from unintentional injuries, non-occupational, among all people of the United States.

There are 23 measurable objectives and five developmental. The new objectives are reducing emergency room visits due to unintentional injuries, reducing non-fatal injuries due to motor vehicles, reducing pedestrian injuries, and extending to 50 the number of states with primary enforcement laws for safety belt use, reducing the number of emergency room visits for non-fatal dog bites in children under nine.

I was struck by the earlier discussion about the importance of integrating substance abuse issues with injury prevention. In fact, we focused very much on the injury prevention aspect, as you can tell, in the objectives. Obviously one of the key risk factors for many unintentional injuries, as well as violence and abuse, is alcohol use and then other illegal drug use. I think we need to work more closely with SAMHSA to figure out a way to effectively cross-reference those activities and possibly develop some additional objectives that would reflect that.

DR. SATCHER: We are not looking for more objectives, if we don't have to. By working together, I think you could well reduce the objectives and still achieve the goal.

DR. BRANDT: I just want to make basically the same comment I made about motor vehicles. That is, I think, all the way through here, where you are talking about reducing deaths, let's reduce injuries as well.

DR. BROOME: I think it is worth underlining the success we have had with motor vehicle fatalities. I am not sure people remember that we set the target in 1988 for the year 2000, and it was actually achieved in 1991. It was further lowered in the mid-course review. I emphasize that partly because it is always nice to remember that we have successes, but also that this includes both engineering and behavioral interventions, that we can have successes in behavior change.

The next chapter is chapter 12.

DR. DUVAL: I would point out one minor thing, lest somebody fail to pick it up. There is a very, very important typo on page 11.17, item number 24. You have left out the word "no", which rather changes the total meaning of the objective. Just so someone doesn't slip. I am a compulsive editor.

DR. BROOME: Thank you. Any other comments about that?

DR. SATCHER: That is pretty important.

DR. BROOME: At this point, I should recognize Chuck Gollmar, who is our person organizing what obviously reflects work from throughout CDC, from all of our CIOs, essentially, and Chuck has coordinated all of this. He and Theresa Rogers have done a tremendous job.

DR. SATCHER: You notice they are recognized at the point of this error. [Laughter.]

DR. BROOME: The next chapter is chapter 12, violence and abuse.

I should say there have been some suggestions that these two should be combined, as both reflecting injury prevention. We certainly would have no difficulty with that, but it has been raised. Since a number of the underlying risk factors, co-factors of sexual abuse, for example, are the same, there might be some benefit of that.

The goal of this chapter is the reduction of injuries, disabilities and death due to violence and abuse for all people of the United States. The chapter focuses on the prevention of youth violence, family and intimate violence, suicide and firearm injuries. There are 14 measurable objectives, two developmental.

We have had some success in a number of year 2000 targets, with reduction of instances of weapon-carrying and physical fighting. There are definitely some areas where we are actually moving away from meeting the year 2000 targets, particularly in physical abuse, assault injuries.

DR. TAKAMURA: I think one of the objectives that perhaps could be added would be work pertaining to elder abuse, which is really on the rise.

Then, with respect to suicides my understanding is that, although the data may not be massive, the number of suicides among older Asian women is very high.

DR. BROOME: I think suicides among the elderly are recognized as an increasing problem in that particular group.

DR. SATCHER: They have increased by about 30 percent in the elderly, in general, since 1985 -- 13, I guess per 100,000 to 19 per 100,000. It is a very important area.

DR. BROOME: The next chapter is chapter 13, which is occupational safety and health, regarding promoting worker health and safety through prevention. The theme of the chapter is improving national work place injury, illness surveillance, increasing the number of states that code work-related injuries and illness so that we can more effectively detect, monitor and prevent work-related injuries.

There are 11 measurable objectives. There is a new one that focuses on reduction of work site assaults, and five developmental objectives.

I think there are two major concerns. One is that we focus sufficient attention on preventable occupational illness, injury and death, and we are very pleased with the launch of the national occupational research agenda, which we think will provide a lot of the tools that we need to meet the objectives.

Then, the other big focus is the current lack of data. There is a developmental objective proposed to begin to address the absence of data for tracking national occupational injury and illness trends. That will also help us target prevention programs.

DR. BRANDT: I would just like to comment that I think you need a good definition for what a work-related injury is. You had a lawsuit in our state; somebody was suing because they were driving home from work and were in a car wreck, and they want worker's comp. It is not work- related; they were going home. I really think it would be worthwhile to talk about what is work-related.

DR. SATCHER: CDC had an experience like that. That is a very good point.

DR. DUVAL: That has been settled in some cases, and the courts already -- we have an instance, for instance, where an off-duty policeman in Arizona, not too long ago, was killed when he came to the rescue of somebody who was a victim, and he was off duty. It went finally to court, and they decided that this was work-related, interestingly enough. What I am saying is there is a history of this issue being addressed.

DR. SATCHER: For police, isn't it -- I don't know what the rules say, but it is almost like they are always on duty. They are almost like the Surgeon General.

Seriously, they often get involved in things where people expect them to come to the rescue because they are police and they have on a uniform. That is interesting. It makes a point, though, that we need to look at the definition.

DR. BROOME: Okay, the next chapter is chapter 14, immunization and infectious diseases. This includes prevention of death, disease and disability from infectious diseases, including the vaccine-preventable diseases. This focuses on the developmental and measurable interventions that are effective, and that can be shown to be effective, in preventing infectious diseases.

I think one point I would like to make in regard to our earlier discussion is that, with childhood vaccine-preventable diseases, we have had a real success story in this country. It has been successful not just overall, but also for many minority populations. So, the objectives for 1996 were really met in essentially all racial and ethnic minority populations. That doesn't mean that we don't still have a lot of work to do, particularly in some urban areas, but I think it is a demonstration of what can be accomplished in eliminating disparities, although obviously this was a very intensive national program.

DR. SATCHER: Claire, the question is, do we and should we have global objectives in this section? I ask that because, as you know, we have been working on a global strategy for surveillance and response to infectious diseases.

I think you recently met with Gordon Douglas and Ralph Nader about tuberculosis and malaria. These are problems that, on a worldwide basis, are major problems. Forty percent of the cases of tuberculosis in this country are now from outside. This is an area where it is very hard to separate domestic objectives from global ones. How do we deal with that?

DR. BROOME: I think you are absolutely right. For example, in addressing -- our agency strategy for dealing with tuberculosis does include international work outside the borders of the United States, as a substantial number of cases are in the foreign-born. Certainly we think of the 2010 objectives as ones that are not just for federal agencies to do.

Now, expanding that beyond just the United States community to the global community is certainly a challenge.

For at least some of these diseases, unless we enlist our global partners, we are not likely to be successful. So, I think that would suggest that we need, at least in certain instances, to do that. It is also an issue for importation of emerging infections. Unless we have effective surveillance and investigation capacity, we are likely to have a much greater challenge in preventing emerging infections.

DR. SATCHER: In fact, during the upcoming World Health Assembly, we are having a meeting with our partners to talk about each country making a commitment to the control of global infectious disease. I think we are probably going to need some shared objectives or shared goals to put into place, to recognize that we share these with other nations, as the only way we are going to be successful.

DR. TAKAMURA: I had some experience with this in Hawaii with TB. It seems to me that we could craft some objectives to enable communities to do some self-monitoring and education. Sometimes the screening tests that are used to detect TB in one country versus another use a different level of sensitivity, and the populations are not aware of that.

I actually think we can do some things internal to the United States. I would be happy to work with you on that.

MR. SCHWAB: I was just going to comment, there may also be a kind of infrastructure analog to this. When we look at work that is going on in the drug area, for example, going from bilateral to multilateral approaches -- maybe there might also be the view of promoting as an objective more multilateral agreements and shared objectives dealing with a number of the different areas. It has both a content aspect, like immunization, and also a process infrastructure aspect that might be worth thinking about.

DR. RICHMOND: I think historically the Public Health Service clearly has been active in this arena and collaborated with the WHO and other United Nations agencies and with ministries of health around the world. I wonder whether we oughtn't to concretize this in terms of a specific objective for continuing this collaborative activity. It could be phrased in some solicitous way, but it seems to me it would also, as this report gets to ministries around the world, show that the United States is on record as being active in this collaboration.

DR. SATCHER: Let's do it. We could think of tobacco in a similar light, but let's work toward that.

DR. KNOUSS: There is an emphasis in here on surveillance in relation to emerging infectious diseases or other outbreaks. I am just wondering whether or not -- I didn't see it here -- there is some standard that should be established for being able to deliver an effective immunization campaign when you have a specific outbreak, so that you get the prevention action objective as well as the surveillance objective.

DR. SATCHER: Pandemic planning.

DR. KNOUSS: Exactly. That was what was going through my mind.

DR. SATCHER: We have a special group that is working on a pandemic plan. Claire, do you want to react to that?

DR. BROOME: I think it is an interesting idea. It is also relevant to meningitis. It is a sort of prevention capacity. It probably belongs most appropriately in the infectious disease chapter, rather than in public health infrastructure. At this time, I think those kinds of -- I would say that it is contrary to the work of the group that is focusing on the pandemic plan to build as much as we can on strengthened infrastructure that is also useful for your annual influenza shot or your meningococcal vaccination. We will definitely look at how that might be worded.

DR. SATCHER: All right, we are going to move on.

DR. RICHMOND: Just one quick comment. Here is an opportunity also for us to take into account some of the great progress that other countries have made. The New England Journal of Medicine, three or four years ago, carried an article on their successful program of elimination of all the childhood infectious diseases for which we have immunizing agents. I think how we can translate what they have already accomplished into our goals would be a useful thing to contemplate.

DR. SATCHER: We have a lot to learn from them.

DR. KNOUSS: While she is finding the place, let me just, apropos this last chapter, having been a member -- no longer a member -- of the Partnership for Prevention --

They are totally committed to this chapter. I would use every possible tie to that group. They represent a fairly broad number of industries that are prepared to step in and help address this problem.

DR. SATCHER: We are going to hear from a representative from the Business Advisory Council.

DR. BROOME: The next chapter is the diabetes one. It is chapter 19. It is the fifth blue tab under Prevent and Reduce Diseases and Disorders. We are working on this with NIH and I am going to let Bill Harlan make some comments in a minute, just to change the presenters, change the pace.

The overall goal of the chapter is to reduce disease and economic burden for all persons with, or at risk for, diabetes mellitus. The theme focuses on the societal burden of diabetes, why this condition is increasing, and what the factors are that are important in prevention and control, and interventions to reduce the serious morbidity and mortality related to diabetes.

There are 19 measurable objectives and seven developmental. The framework tries to focus on getting more accurate measurements of the societal burden of diabetes, and the disparities that exist among various populations. As you are well aware, diabetes is a serious issue for Native American populations, American Indian populations, as well as other racial and ethnic minorities.

There are new process-oriented objectives which emphasize the behavioral components of diabetes prevention, which may be more useful as sort of intermediate indicators, rather than looking only at the outcome variables such as mortality.

DR. HARLAN: I would probably just add that the increase of the prevalence of diabetes perhaps has been there for a long time, but certainly it has increased to a major degree over the past 10 or 15 years. A good part of that is related to increasing obesity. A lot of the efforts that are being made now, I think, at the primary prevention will be directed toward obesity.

There are significant changes that have been made in the management of diabetes to prevent the complications, and they are reflected in such things as the HEDIS measures for Medicaid, where one tries to recognize early retinopathy and take appropriate actions. We have studies now that represent the effect of tight control or good control on diabetic complications, and a number of studies that are looking at the whole issue of reducing body weight in populations, particularly Native American, Hispanic and African American populations that, in fact, are putting themselves at tremendously increased risk of diabetes.

This links in with the other things of interest. In fact, diabetes now is recognized, I think, as a major contributor to other chronic diseases, most specifically, coronary heart disease. Some of the racial/ethnic disparity may, in fact, relate to both the overweight and the diabetes. They are linked together quite closely.

The NIH group has worked very closely with CDC, and I think we have a good working relationship.

DR. BRANDT: I guess I have a problem on page 19.7, with the number two recommendation. There is increasing evidence of the genetic nature of diabetes, type I diabetes. I guess to reduce the prevalence of diagnosed diabetes, to achieve that goal, the simple thing to do is to have a reduction in the diagnosis. I just wonder how in the world you are going to reduce the prevalence of type I diabetes. That is the question I have. Type II I can understand.

DR. SATCHER: What proportion of diabetes -- just for the sake of people who might not be --

DR. BRANDT: About five percent, less than 10 percent for sure.

DR. HARLAN: Actually, we convened a conference to look at the research implications of that. Since it is very clear that there is an inherited susceptibility, plus an infectious principally viral component, one of the things that one might do is, in fact, be sure that we recognize those individuals who are at high risk by virtue of the genetic susceptibility and then also recognize or try to identify all the infectious agents that, in fact, precipitate the development of type I.

DR. BRANDT: Also the development of type II.

DR. HARLAN: It is an area of very great interest, I think, with NIH. It fits in with our great interest in genetics, obviously.

DR. BRANDT: But most of this reduction would be in type II.

DR. HARLAN: Most would be in type II, which of course is the most prevalent.

DR. SATCHER: I think we said, based on pretty sound data, in the physical activity report that we could reduce by 30 percent the onset of type II with physical activity and nutrition. I think that is going to hold up.

DR. HARLAN: There might be opportunity for siblings of type I diabetics, might be another area to focus.

DR. SATCHER: Let's move on.

DR. BROOME: Very rapidly -- there is also a controlled trial that is being done jointly by NIH and CDC to look at drugs and physical activity in preventing pre-diabetics from moving on to diabetes.

DR. SATCHER: It is one of our best models, really, of cooperative research. You are doing physical activity and diet, or just physical activity?

DR. HARLAN: Both. It is actually trying to control energy balance.

DR. BROOME: The next chapter is other chronic conditions.

There is actually an issue that I think it would be helpful to have the Council comment on, in terms of how we would address the understandable desire for many other chronic conditions to want to see themselves in Healthy People 2010. We have been -- we would actually like to see, maybe, the focus just on osteoporosis and arthritis as their own chapter, and then ask ODPHP to maybe consider a process whereby other clinical conditions are considered. It would not be having an infinitely expandable chapter for every chronic condition that might be of interest. That is a suggestion for the Council to consider.

With regard to osteoporosis, which begins on 20.1, the goal of the chapter is reducing the prevalence of osteoporosis and resulting fractures by increasing calcium intake and counseling men and women about interventions to reduce the risk of the disease. It focuses on the major health consequences and preventive measures associated with osteoporosis. This is a new area. So, we have three new measurable objectives and two developmental objectives.

I think it is important as a new addition because of the largely preventable nature of the disease, and by treating the objectives where we can place a greater emphasis and draw attention to the prevention capacity. The reason for concern is that, in fact, calcium intake is declining and hip fracture rates, in fact, are increasing. So, we think there is some urgency in getting attention to this area.

NIH is also co-lead on this chapter.

DR. SATCHER: I don't know where we are on those studies, those clinical trials with raloxifine.

DR. HARLAN: Well, raloxifine is licensed for use in treatment of osteoporosis. Like the other estrogen receptor modifiers, it actually has the result of increasing the bone mass.

I don't know if you want to make other comments. We actually agree; osteoporosis was not covered previously and is extraordinarily important, particularly as the population gets older. It is the leading cause for hip fractures, which are a leading cause of disability in older people.

The other point about this, I think, that is very important to recognize is that the prime time for laying down bone is in the teen years and the twenties. That is particularly true for women. It is a little bit like money in the bank. The more you put in, the more you can draw on as you go through the post-menopausal years. It is not just talking to post-menopausal women or to older men, but it is also speaking, I think, to younger individuals as well.

DR. BROOME: That feeds back into the physical activity chapter.

The other chronic condition that is new this year and that we think is very appropriate is arthritis. That is on 20.9 of your book. It really has become even more so an important chronic disease for the upcoming decade. Arthritis affects more than 40 million Americans, making it one of the most prevalent chronic diseases in the United States. This is one of those diseases which doesn't show up well when you use mortality as an outcome.

When you look at disability-adjusted life years, arthritis clearly comes to the front as a major public health problem and a major clinical problem. It is currently the leading cause of disability for Americans. We estimate that by 2020, almost 20 percent of the population may be affected.

So, the goal for the chapter is reducing the occurrence, and also the impairment and functional limitations associated with arthritis, and the disability associated with arthritis and other rheumatic conditions.

The chapter focuses on reducing the burden. Furthermore, widespread use of currently existing public health interventions which have been shown to be very impressively efficacious -- there is a self help program for arthritis, which has shown some very impressive impact, that clearly needs to be more widely available, as well as continued research and evaluation.

There is a national arthritis action plan being developed by CDC and the Arthritis Foundation with input from many other organizations. We think that this will provide support and direction for achieving the objectives. NIH is also co-lead on this chapter.

DR. HARLAN: I don't think I want to add anything more, except the close relationship with health disparities, which are really very great with arthritis, and are particularly disabling, of course, to older individuals. It becomes an issue of greater and greater importance. Some of this relates to overweight, as well as not seeking care at appropriate times or not receiving appropriate care. To eliminate those disparities, we are going to have look at all of those issues.

DR. SATCHER: Again, physical activity is most important.

DR. HARLAN: Yes, actually as you look at it now, one of the increasing reasons is, in fact, recreational activity.

DR. SATCHER: Let's go on to the next chapter.

DR. BROOME: I have got some notes here that are focused -- I am not sure. Earl, you will have to clarify. There have been a number of proposals that there be a chapter with birth defects, genetic disorders and developmental disabilities. Currently, I think, they sort of fold into the physical and mental impairments and disabilities chapter. I think it is just important for the Council to be aware that there has been substantial interest from the March of Dimes, and I think the American Academy, in having some separate emphasis on birth defects as being somewhat different from a lot of the other disability areas. I will just mention that, for people to be aware of that.

The chapter is designed to monitor progress in the area of birth defects, genetic disorders and developmental disabilities and includes eight measurable objectives and 14 developmental. This is part of chapter 21. It starts on 21.11. Since we are short on time, I would just bring it to people's attention.

DR. TAKAMURA: Can I mention one additional area, and that is vision impairment and hearing loss. They are very big problems among older adults. I don't see any mention of this.

DR. SATCHER: That would go into this chapter, in disability, in 21. I agree that it is a disability that can be ameliorated, sometimes.

DR. BROOME: You will be happy to hear, my final chapter is oral health, which is under Improve Access to Quality Health Services. It is the fifth blue tab under chapter 24. I think I will just mention that this is both prevention and control of oral, dental and craniofacial diseases. Objectives for this chapter include both behavioral and environmental and also health services approaches to promoting oral health, 14 measurable objectives and seven developmental.

I think there are some issues in terms of how this chapter meshes with others that would be worth our looking at in terms of things that are health service access issues. Some of them need to be cross-referenced with the cancer chapter and, obviously, with the tobacco chapter.

DR. SATCHER: I would mention there is, again, a Surgeon General's report on oral health. NIDR is, for the most part, working with Caswell Evans, I guess is the person, full time. I forget the time line, but it is going to be within the next year that we are going to have that report. So, there needs to be some interaction.

Let me just thank you for working so hard this morning and for all the very valuable presentations. We are going to break for lunch. We would still like to come back at 1:30, because we built a lot in. I think we are in pretty good shape for this afternoon in terms of time, but we will pick up this afternoon with Bill Harlan and Tom Kring and then go to Michael Friedman and John Eisenberg. I think we will be okay. Thanks a lot.

[Whereupon, at 12:42 p.m., the meeting was recessed, to reconvene at 1:30 p.m., that same day.]

AFTERNOON SESSION

DR. SATCHER: I thought Claire did a great job of getting through all those objectives.

DR. FOX: She is not through. She missed two.

DR. SATCHER: She did 13. I think we should let her do number 14.

DR. BROOME: Thank you. As I was racing through all of those, I did pause at one point. That was because I thought we probably did have the whole disability chapter and not just the genetics and birth defects. I was right.

So, if I can just take two minutes, this is chapter 21.1, which is in the Prevent and Reduce Diseases and Disorders section.

This is actually a very important chapter, we feel. The objective is to promote health and prevent secondary conditions among persons with disabilities in the United States. It proposes another angle on the disparities issue, and that is that we should eliminate disparities between people with disabilities and the United States population. I think that is an important objective, and the chapter proposes a number of developmental objectives to make that goal a reality.

I think I will just stop there. I think all of us are aware of the importance of disabilities and the need to have an increased focus on those throughout the public health and medical care system.

DR. SATCHER: Claire, you mentioned that arthritis is the greatest cause of disability. Do you think we have a good handle in this country on depression as a cause of disability?

DR. BROOME: No, we don't. I think SAMHSA alluded to that in their presentation, the absence of good data on population-based incidence of mental conditions. However, the analysis that Chris Murray suggests the disability- adjusted life years due to depression are also right up there as an important thing.

DR. SATCHER: Okay, we are going to move on to Bill Harlan from NIH.

Agenda Item: Reports from Lead Agencies. NIH.

DR. HARLAN: Thank you. I passed out some notes. These are the crib notes that you will need for the exam. I learned two things from lecturing to medical students at Duke University and the University of Michigan. One is that you must hand out the notes that contain the exam questions. Number two, at the University of Michigan I learned if you hand them out in advance, they don't come to class. That is why you got them just now. That is exactly what happens.

The first area is nutrition, and it is chapter two. What I have outlined here are the number of objectives for nutrition currently, that is 18, the goal statement and the themes. I would just note some issues about past experience with nutrition. First of all, nutrition has gone on a diet and in fact dropped or moved 13 objectives, with only four being added. So, the original total of 27 is now down to 18.

The direction that Healthy People 2000 objectives went is shown with a general movement toward targets, except for some very important movements away from the targets and very strongly away from the targets. I will just mention these very briefly as important background.

First of all, nutrition, I think is probably second only to cigarette smoking as a cause of chronic disease, death and disability, as an attributable cause. It is associated with a considerable amount of angst, in terms of the way the country proceeds to eat. So, we have had good news and bad news occurring.

The bad news, I will tell you first, is that overweight in this country is now epidemic. It was endemic. It is now epidemic. We are the fattest country in the world. We are getting fatter and fatter. It is increasing at such an alarming rate that more than 50 percent of the United States population is over the standard weight of the BMI that was selected as the former definition of obesity, which is over 25.

DR. SATCHER: Why don't you increase the standard weight?

DR. HARLAN: It's good you mentioned that, because it increases in 2010 to over 30. Even if you increase to 30, we still see an epidemic because it is actually the very extremes of weight gain that we are seeing, rather than the modest populational movements. It is a movement of the upper area of the population. That is the bad news.

The good news, for those of you who have looked at the consumption of foods is, that the qualitative elements of the diet have actually improved in the country. We are eating less fats. We are eating more fruits and vegetables. An indicator of that is the nice fall in serum cholesterol levels, which we believe contribute to diminished risk for coronary heart disease.

There is an important part to all the bad news, though, and that is that the change in children's weight is even more alarming, since weight tracks very strongly through the years. We can predict very safely, I think, that, if we don't do something, all of these kids, as they become adults, are going to be fatter and fatter. So, you see a lot of emphasis on that.

The other thing that is important about the weight issue is the very major disparities across racial/ethnic groups and socioeconomic groups. So, it is a target that we really must deal with.

In going over the highlights, I do note that we have changed the cut-point. It doesn't change the problem that much, however.

We have some other issues that we would like to see improved, and that is to really improve the quality of fruits and vegetables. It turns out that, of the fruits and vegetables eaten by kids, about a third are french fries. When one talks about fruits, it is generally fruit juices and not solid fruits themselves. So, there is a good bit of work to be done, even on the qualitative side.

There is the inclusion of a new objective on food security, based on the premise that it is not food safety. It is food security, based on the premise that, in order to eat appropriately, you need to have available to you the right foods and in the right amounts and have them readily available to eat. There are still pockets of malnutrition or under-nutrition in this country, and poor nutrition in this country.

I won't go through any of the other pieces in any great detail, except to note that one other thing that has been done as we worked on the chapter is to move some of the risk behaviors from chronic disease areas into nutrition, and to try to coalesce them into objectives about food, based around the notion of risk reduction and meeting the dietary guidelines for the country. So, it is one attempt to have an economy on these objectives.

I will stop there.

DR. SATCHER: How are you doing in the interaction between nutrition and physical activity?

DR. HARLAN: Well, what people want to talk about, I think, more than anything else is energy balance, and point out that it is not just what you eat, but it is also what you burn. Most of the efforts toward obesity, I think, want to deal not only with food intake, but also with physical activity.

I think it is almost impossible to sustain a weight loss with just diet alone. Clearly, all the indicators are that we are not only less active but, as we sit in these less active activities, as we sit and watch television, we sit and eat more. The two are linked together very closely.

DR. SATCHER: If I remember correctly -- and Mike McGinnis is here -- but in looking at the leading behavioral causes of death, I believe, they put physical activity and nutrition together, as second to smoking only.

DR. MCGINNIS: That is substantially for practical reasons. It was very difficult to separate out these things and measure them independently.

DR. HARLAN: We do know that the food intake per person has gone up in this country and the number of calories has gone up as activity has gone down. It is a combined process.

DR. FOX: Bill, we have an objective in the current set that relates to the quality of school meals. I think in the schools that my kids went to the quality was pretty abysmal.

There is not one proposed in the new set of objectives. I know USDA has expressed an interest in having that. With HRSA's and CDC's involvement in school health, I think it obviously is a major factor in what these kids are getting during a big portion of the day. I just think we ought to, maybe, think about working at having some kind of an objective in there that addresses it. I know it is difficult to get that kind of information, but it is a big factor in kids' overall nutritional intake.

DR. HARLAN: We know it can be done. Actually, in Montgomery County we have done it, where they changed the 30 percent fat intake. That is a good suggestion.

DR. SATCHER: Other comments, questions?

DR. HARLAN: I will move quickly to environmental health. Environmental health is chapter 9. This is a chapter with 35 objectives and actually you will see that we have a gross addition of objectives to this. The experience has been that we have been moving toward the targets in the previous objectives that were there.

This has seven sections. We have joint development of these. Incidentally, I should mention that I show you at the top the coordinators from the agencies who have worked on this. They have done an outstanding job in all instances and work very, very well together. These are based largely around exposures in the home, exposures in the ambient air, waste, agricultural waste, water.

We had some comment about developing nations and international cooperation. I will just call your attention to the last paragraph and the highlights in which we discuss the importance of having international collaboration and international surveillance as it is related to environment and to movement of goods across countries.

The number of objectives here is quite sizeable. If you have been through the chapter, I think you are struck by the large number of objectives. I think we need to work to try to edit down to a smaller number of objectives, because it has grown rather considerably. Nonetheless, it is an extraordinarily important area with impact, I think, on most of the disease areas.

DR. DUVAL: One quick question. On 9.9, number 7-A, I don't wish to overdo this. I touched on this a little while ago with respect to diabetic amputations. A reduction in asthma hospitalizations, no more than...et cetera -- I agree that that is a very desirable objective.

What I am not sure of is whether or not it is possible for us to lay down criteria like this where individual physician decisions about whether to hospitalize is the ultimate issue. I guess I wondered how you are going to address this kind of objective, plus insurance companies.

DR. HARLAN: Certainly, asthma objectives are going to be in lung disease, which I will take up in a moment.

I would just say quickly, it turns out that is a measure that one can take of serious asthmatic episodes. If there is a preventive program that requires that they don't come to the emergency room -- if there is effective treatment in the emergency room, then presumably they don't get admitted. So, the approach to that is to work at prevention and to work at the handling of the aggravated attacks, and diminish the hospitalizations as a result of that.

DR. BROOME: We also think it is feasible to have more effective environmental interventions, in terms of reduction of exposure to allergens, that may be reflected in the reduced hospitalization rate.

DR. DUVAL: I am not quite sure that addresses it, but it is a concern I have in looking at it. I would say this, that the incidence of serious asthma attacks could go up and, if the treatment in the emergency room is improved, you get credit for meeting an objective that had nothing to do with the objective.

DR. HARLAN: We actually have objectives in the lung chapter on the development of asthmatic episodes and the number of people who have asthma. We could switch over to the lung chapter. Let me quickly tell you where it is. It is 20, and it is in the section that follows osteoporosis and arthritis.

By way of introduction, I would just say that, except for the one objective on asthma in Healthy People 2000, there were no objectives on lung disease per se. This represents a new chapter dealing with two issues -- one, the fourth leading cause of death, chronic obstructive pulmonary disease.

The second is another true epidemic that we have underway, which is the epidemic of asthma, with a tremendous increase. I think it is the last section. You will see that the prevalence has increased by 70 percent over the past 15 years, an extraordinary increase. There are 14.6 million Americans affected. The increases are greatest, again, in minority groups and those with lower incomes, and they are the most striking for kids. The asthmatic exacerbations result in these hospitalizations and deaths as shown here. I think one of the things that is particularly troublesome for people is that the number of deaths has increased rather markedly as well.

The notation is made at the bottom -- I am responsible for that -- that primary prevention of asthma has not been very successful. We appear not to be able to prevent the onset of asthma, the development of asthma. Most of the evidence focuses around the secondary prevention, as preventing the asthmatic episodes through appropriate treatment. That involves education of both physicians and patients. There is a national asthma education program that seeks to do that.

As you look at the development of objectives, you will see the addition, now, of asthma objectives, looking at the prevalence, as well as sort of the last stage of the severity of asthma attacks, and that is hospitalizations. I don't know if that answers the question that came up. It is a problem that perhaps needs a greater effort in terms of primary prevention. It is also a problem that needs much more secondary prevention and much more preventive maintenance to avoid even coming in to the emergency room.

DR. SATCHER: We have several things happening. We have the asthma project at CDC in Atlanta. It is another one of these community intervention things, evaluating the impact of it, training community health workers to go into the homes and help the parents to understand how to get rid of allergens and work with teachers. In a few years, we should know how well that works to reduce attacks and emergency room visits and things like that. Okay, let's go on.

DR. HARLAN: There is an objective on chronic obstructive pulmonary disease and one on sleep apnea. The one on sleep apnea includes sudden infant death syndrome as part of that. I believe that is the only place it is included here.

Moving along to -- I think heart disease and stroke is next. There are 18 objectives there. There were 17 before. It is chapter 17. The tally sheet shows that nine objectives have been dropped or moved and we are adding 10 more, and we are moving toward the target in most of them. These were fairly ambitious targets, I should note, last time. Again, as is often true in these situations, there is a very great racial and economic disparity with respect to mortality rates and with respect to incidence rates.

The aspect that was not properly recognized 10 years ago nearly as much as it is now is that heart disease is the leading cause of death for women as well as for men.

What we have failed to appreciate is that women may present differently. They misunderstand the symptoms that they have differently and they may be discounted by physicians.

Part of this is to engage in an educational early identification program particularly for women. Also, the early identification could lead to appropriate, I guess we could call it secondary prevention therapy of thrombolysis and angioplasty, and the rather remarkable changes, I think, that have occurred in initial rates that owe something to that early intervention as well.

Stroke is the third leading cause of death. As you, I am sure, recognize, we believe we also have an appropriate approach in terms of not only lowering the risk factors such as elevated blood pressure and smoking, but also thrombolytic therapy. We were talking earlier about getting immediate coverage. In fact, if you watch ER -- and most people seem to watch that -- you probably saw the episode about thrombolytic therapy and the individual who had an evolving stroke. That was arranged by the neurologic diseases institute.

I think the other part of this is to be sure that, as we look at heart disease and stroke, that we don't forget the importance of dealing with the risk factors. We have made good starts, but we still have a large number of people who are not effectively treated for elevated blood pressure. We still have people who continue to smoke. The lifestyle changes are extraordinarily important. Just because we have had some successes, I don't think we should move away from a good focus on dealing with those risk factors.

One other thing that I think is particularly important is to recognize that the risk factors for secondary events are the same as the risk factors for primary events. There is nothing more striking, I think, than the studies that have been done on individuals with elevated cholesterol or prior heart attack and the use of statin drugs or of diet, in decreasing the second events.

A lot of the improved survival that we look at now is a result in the improvement in heart disease mortality. It does give us a large number of people who have the disease, who are living with the disease, and who need attention to those risk factors to prevent second events.

I think I have highlighted the other issues that I put into the chapters, that I put into the notes. There may be other issues that you would like to bring up about heart disease and stroke.

It is a success story to date, but with a lot more work to be done, I guess is the way I would put it. Hidden behind all this is the new epidemic in heart disease, which is the epidemic of congestive heart failure, going up rather markedly, while acute coronary deaths, particularly in young people, have gone down strikingly.

DR. SATCHER: In reference to the cholesterol, how much of this is because of drugs and how much is just because of natural changes in diet and so forth? Do we know that?

DR. HARLAN: We have, from the national surveys, a good indication of the impact of dietary change, that is, a lower-fat diet, a change in the quality of fats that are in the diet. The serum cholesterol levels have dropped -- I believe they are given in the text here -- rather markedly, just from the dietary change.

The characteristics of the statin drugs being reserved for those at very high risk, that is, very high levels of cholesterol and all those who have had a prior event. I believe the new recommendations are, treat anyone with a prior event. We also now know something that we didn't know before, that lowering cholesterol with statin drug lowers the risk of stroke by a third. We never thought that cholesterol was a risk for stroke. So, a striking change.

I will cover cancer very quickly and then move to oral health. Cancer has 19 objectives basically. You would note the number of objectives has shown no net change. Several have been dropped because we actually have met them and don't need them any longer. There was an objective on oral cancer that was inadvertently omitted, and I would note that it is going to be in the current document. It was a negotiation between oral health and cancer as to where that particular objective would be. We tried to make sure there is not a lot of redundancy or overlap.

I think there is good news in cancer for mortality but, interestingly enough, as you probably have seen, the most recent reports indicate that there is a decrease in the incidence of cancer. I think one could say that we actually now have an influence on prevention and it is not just better treatment that has been decreasing the mortality.

It is still, however, the second leading cause of death. I think there are racial and ethnic disparities as you go across the different sites. It is not very clear, from the work that has been done, why there should be these disparities, whether it is a matter of poor prevention, treatment not directed toward cure, or election to follow up. We do not believe it is an inherent characteristic of any particular group.

I should have noted that -- all of these shifts we have looked at -- we don't think they are genetic shifts over the past two decades or decade. Sometimes we get accused of working on the genetic side only.

It is true that as the population gets older, the risks for cancer are going to be greater, and the opportunities for prevention, I think, are in fact going to be greater as well. There are tremendous costs involved with that.

The new objectives relate to prostate cancer, cancer survival and physician referral for high risk patients, and the further development of statewide registries. The NCI SEER program, I think, has provided a tremendous amount of information, particularly on the causes for racial, ethnic and income differences in survival. As we get more broad-based registries, we will get more information on that. I think we will get better information as well on the risks as they may be different across the particular groups, as we get better population-based registries.

Tobacco use in general has been shifted over to the tobacco chapter as an economy. There are improved dietary habits that are in the nutrition chapter. Again, it is an attempt to have an economy in the citing of the particular objectives.

I guess I will stop at that point.

DR. SATCHER: Did you want to say something on oral health?

DR. HARLAN: Yes, I am just going to go to oral health quickly. Claire and I agree. We share this and I was going to cover that quickly next. Oral health is 24.

This is, again, an area that we share with CDC, NIH chairs with CDC. It has four sections. Because of the importance of behaviors in these, the groups feel very strongly that they would be much better suited in the health promotional rather than the services area.

You can see the tally sheet on the dropped and added. It is important that much of what will be happening, I think, will be predicated on the Surgeon General's report on oral health, which should be released in early spring of next year, and I think will give us a wonderful blueprint for making changes for the future.

The objectives that are shown here are very frequently picked up by the state health groups. So, I think it is very important to have the objective clearly outlined. The state-based oral health surveillance systems, I think, are an important part that has been put into this.

I would note one other interesting aspect of that. As we watch the shift in our thinking about the ability of infectious diseases to cause chronic diseases, based on Helicobacter pylori and peptic ulcer, it is interesting that the association that has always been noted between poor oral health and the development of coronary artery disease and other chronic diseases may have an elaboration if, in fact, there is chronic oral infection that may have an influence on the development of chronic diseases. A lot of the work on chlamydia and so forth, I think, addressed that. So, it is a very interesting kind of connection for those of us who have watched this over the years.

The objectives on cancer lesions, as I mentioned, and the use of a uniform screening -- the uniform screening is here. The actual use of tobacco and oral cancer is in the cancer section now. I think that is probably longer than I thought.

DR. SONDIK: The cancer chapter and particularly the objective having to do with prostate, that really raises several questions. One is disparities. One has to do with interventions that are actually going to make a change, since it really doesn't reference interventions.

Secondly, the disparity there in the rates is enormous. So, it does sort of question what an appropriate target is. The target was set at 17.1 -- right? -- from 17.3 in 1994.

DR. HARLAN: Yes.

DR. SONDIK: But the rate among blacks is three times as high as that.

DR. HARLAN: Yes. I think it is one of the issues that, when we say we will eliminate the disparities, you are going to see a tremendous change in a number of different facets, including primary prevention as well as the area of recognition and management.

DR. SATCHER: There are more questions than answers in both of those areas.

DR. HARLAN: Right.

DR. SATCHER: There is no real evidence yet that early detection reduces mortality.

DR. SONDIK: I think the paragraph is very straightforward in saying that.

DR. SATCHER: So, how would you set the goals?

DR. SONDIK: Even though it is straightforward in saying it, I wonder if it will implicitly endorse PSA, for example.

DR. HARLAN: I don't think there is any intention on the part of the Cancer Institute to endorse PSA.

DR. SONDIK: I realize that.

DR. HARLAN: I won't say they are doing the reverse, but they actually are quite anxious to remain on the sidelines for the moment until we have better evidence that it leads to a change in the mortality rate from a disease.

DR. SATCHER: I am going to call on Tom.

Agenda Item: Reports from Lead Agencies. OPA.

MR. KRING: First, let me say there are two numbering errors in our report. On the goals, there are two number 10s and no number 12. So, they just need to be renumbered.

The family planning goal statement we are quite happy with this time. It is just simply that all pregnancies in the United States should be intended. We have shifted the focus of this chapter from emphasizing adolescent pregnancy and adolescent behavior to reducing unintended pregnancy among all women of reproductive age, 15 to 44, and improving contraceptive use, although adolescents continue to be an important subset.

We have 13 objectives. We listened to Earl and cut down the number of objectives. We listened to Clay and, if you look at our statistics, you will see that there is wide disparity in the numbers, but we have used just one goal number for all groupings within our objectives. The objectives -- we do have four developmental objectives, and I will get to those in a minute.

We have emphasis on increasing male involvement as a key objective. We also have objectives addressing adolescent sexual activity, increasing dual method contraceptive use among adolescents, to both prevent pregnancy and sexually transmitted disease, as well as education.

There is also an objective on impaired fecundity. Although it is not a major public health problem, it is something that certainly relates to sexually transmitted diseases and we think it is important that it be there.

The four developmental objectives -- we have what we think will be means for measuring those as we go along. The male involvement -- the National Survey of Family Growth (NSFG) will include a male sample on the next round, so we will have that. The objective on emergency contraception -- there is a periodic survey of family planning providers that is conducted by AGI that may serve as a measure for this.

Repeat births is a measurable objective which can be calculated using data from the NSFG and vital statistics data. Pregnancy prevention education in schools can be measured using data from School Health Policies and Practice Surveys from CDC.

Most of our measurable objectives rely on the NSFG for their data. The next cycle, as I said, will include one on men. Several objectives focusing on that -- and this is an issue that we need to raise -- several objectives focusing on adolescent sexual behavior and contraceptive use can be measured using different data sets, notably either the NSFG or the Youth Risk Behavior Surveillance System, YRBSS.

The advice that we have been given so far is to not to have parallel objectives, that we should use just one measuring system. So, we have basically gone with the NSFG. It is something we would like to reopen the discussion of, because we think it may be wise to have parallel objectives using both the NSFG and the YRBSS, because several states are using the YRBSS and will use it in their monitoring of these same goals and same objectives. So, we think it would be wise to have parallel objectives using both data sets.

The family planning objective focuses on women of reproductive age, 15 to 44. The adolescent objectives focus on males and females aged 15 to 17, or aged 15 to 19. Since the next survey of NSFG will include a survey of males 15 to 49, we will have a wealth of information to include.

Several people have asked us that -- suggested that the adolescent pregnancy objective include those under 15. The adolescent objective does not measure adolescents under 15 because calculating such pregnancy rates is unreliable, number one. The actual number of pregnancies that occur in this age group is small, with two thirds of those pregnancies either ending in fetal loss or abortion.

Generally, there is consensus that pregnancies among this age group are inappropriate, period, and whatever the number is that occurs, the target number should be zero, no matter what we have there.

Successes -- in the past we have seen a reduction in unintended pregnancy according to the latest NSFG, dropping from 56 percent to 49 percent. That is still far short of our goal of 30 percent that we set this year, but it is substantial progress. However, even assuming another seven point drop between now and the year 2010, a target of 30 percent remains ambitious. A target of 40 percent for unintended pregnancies is probably more realistic.

We have seen reduction in sexual activity. Again, the NSFG indicated that the proportion of females aged 15 to 19 who have ever had sexual intercourse dropped from 55 percent in 1990 to 50 percent in 1995.

We have seen increases in adolescent contraceptive use, which is probably the most exciting thing. Sexually active unmarried females aged 15 to 19 who use contraception at first intercourse rose from 63 percent to 77 percent between 1988 and 1995.

Females who use contraception at the most recent intercourse also rose from 78 percent to 84 percent in that same time frame. Much of this is obviously attributed to the increase in condom use, which has also gone up substantially.

We are still nowhere near -- this is the final point -- we are still nowhere near the year 2000 goal of reducing adolescent pregnancy to 50 per 1,000 adolescents. The baseline for 1985 was 71.1. In 1990 that rate had increased to 75.5. It went down for a while, but it has gone back up again. It may be better, instead of using the figure we are using of 50 per thousand, to stay with the 1994 national average figure, which was somewhere around 76 per 1,000, and simply say that is where it is at.

It is interesting to note that while birth rates -- as you saw from the news release today -- while the birth rate for teens has gone down, the pregnancy rate has not gone down. In fact, it has gone up in the past few years, and that is a concern that we have.

With that, we will answer any questions on that. I do want to point out Evelyn Kappeler, who wrote this and did all the work on this, is sitting back here. Any mistakes in my report -- it is her fault. She can answer questions that I can't answer, but basically she should have done this report, because really, she is the one who did all the work on it.

DR. SATCHER: Are you saying the teenage pregnancy rate is going up?

MR. KRING: The teenage pregnancy rate itself has actually crept up a little bit. The teen birth rate has gone down.

DR. SATCHER: Are you implying that the abortion rate has gone up?

MR. KRING: There is fetal loss in there. There are other things in there.

DR. SATCHER: Spontaneous abortion?

MR. KRING: Spontaneous abortion as well. But there has been a slight creep since 1994.

DR. SATCHER: Okay, very good. We are going to move on, then. Michael Friedman, FDA.

Agenda Item: Reports from Lead Agencies. FDA.

DR. FRIEDMAN: I will do this very quickly. We have two sections. The first is 10. It has to do with food safety. It links, in a way that I didn't want to bring up at this time, to the nutrition section. At a time when we have more information about the need for diverse and balanced food intake, we have new concerns about the risks of eating the fruits and vegetables that are such a critical part. So, these two have to be sort of organically linked in that way.

This section really has an advantage -- has two advantages. The first advantage is that it builds upon a successful Healthy People 2000, where a great many of the goals either are being achieved or have been achieved. I think that is extremely positive.

The second major advantage here is that we have the benefit of the President's focus on food safety, new funding, new responsibilities, and really a new coordination between CDC, USDA and FDA, along with EPA providing some pesticide, and other environmental issues, input as well. We are very lucky to have that focus, those resources, at this time. What is being proposed here for 2010 is entirely consistent with the food safety initiative, as articulated by the President, and has been carefully vetted and evaluated by CDC, USDA and EPA. So, we have that advantage as well.

I like this section because it has both primary end points that are straightforwardly measurable and important and surrogates. The primary end points are the outbreaks of disease, which are being tracked in a more effective way than ever before, thanks to FoodNet and other activities of CDC.

We have shown demonstrable diminution in certain kinds of outbreaks over the past several years. Salmonella is definitely down, as are other important species. We will have the advantage of setting goals for each one of what we think are major pathogens during this period of time, and we will have direct primary end points to measure them.

In addition, there are surrogates that we think are important, or at least our mothers told us were important, such as washing hands, proper food handling, proper food storage, and so forth. So, we will have the advantage both at retailers and in the home of making those important educational statements, and I think that is going to be very satisfactory as well.

This is a very broad set of proposals. It really addresses issues from the farm through all the intermediate steps to the retail establishments, and to the home. That advantage means that there are multiple places for important involvement with relevant industries, important involvement with state and local authorities.

I think I will just stop there, David, in the interests of time.

DR. SATCHER: Comments, questions?

DR. FRIEDMAN: This is a really good one.

DR. SATCHER: I agree.

DR. FRIEDMAN: This is one that the public is focused on in a way that is very important. That is one of the things that is likely to make it succeed, is that the public is really keyed into this.

DR. SATCHER: I think the progress of technology is being applied in a very excellent way, DNA fingerprinting and all the electronic reporting.

DR. FRIEDMAN: I think that, luckily, the scientific sophistication and the commitments from different folks --

DR. SATCHER: As you said, it is one of the best examples we have of interagency cooperation, even in budget preparation.

DR. BROOME: The one challenge we do have is that we do need to have people understand that, as we improve our surveillance, we may actually see an increase in some important diseases. We are trying to work with the surveillance system so we can assess that and still meet the targets.

DR. FRIEDMAN: That is right, and we can barely predict what the economics of this market will be. We are getting so much food from abroad now that it is likely that by 2010 that will be even more.

Food tastes change, our population ages, and that will have characteristics that will affect us. The real ringer in this is that we know that bacterial genetics change and there will be new organisms emerging with new resistance patterns and new invasiveness patterns. So, all of those things will contribute to a really dynamic situation.

DR. SATCHER: That reminds me. We didn't really talk about microbial resistance when we talked about infectious disease. I think everybody should know that that is a major, major issue here.

DR. BROOME: There are some objectives addressing particularly the hospital setting and the development of resistance.

DR. SATCHER: It is one of the major challenges we face in infectious diseases.

DR. FRIEDMAN: Can I go on to the next one really quickly?

DR. SATCHER: Okay, yes.

DR. FRIEDMAN: It is on number 26. It is the last one, I think, in the book. This one is on drug safety. It is a new area.

In the interests of saving time, let me tell you that we are not entirely satisfied with how this reads at this time. That is not to detract from the considerable discussions that have been held and the work that has been done. I think it rather reflects a better appreciation on our part of how complex a set of issues this is and how we need to try to think of ways of addressing this.

None of us have any quarrel with a number of the objectives that are laid out here, albeit not developmental, albeit not getting numbers plugged in, because we are still getting the baseline data. As we thought about this, we thought there may be other ways in which to analyze and address this problem. I will do this very, very quickly, David.

If you think of drug safety being really four areas, four distinct areas -- most recently we have heard so much about adverse drug reactions that are expected, well documented, part of the label, but nonetheless account for a large number of illnesses and deaths. That is one kind of issue that we can address.

The second is those drug or device or other intervention effects that have not previously been described, absolutely novel. Phen/Fen is probably an example of that recently. We must be more vigilant. We must be able to intervene there as well and reduce those. As more products are being approved, as there are more novel products, as products are being used together, the number of interactions is unpredictably large. It is a major issue. We are all in the midst of a major ongoing toxicology experiment without even knowing it.

The third area has to do with misadventures, medical misadventures of all sorts, prescribing the wrong medication at the wrong dose to the wrong population; this is an important factor. There are a large number of people who suffer because of this. This is remediable with education. You can imagine how one would address this.

The fourth area really has to do not so much with drug safety as with proper administration of medication. If you do not take your medication properly, for the full time, in the right dosage, not while using heavy equipment, whatever it says on the label -- if you don't do that, either you suffer a side effect, or you miss the opportunity of benefits that that product would have had. You stop antibiotics early and you don't completely eradicate the infection, or you have resistance emerging and other things.

I know I am laying out a lot of large issues here, but I think one of the values of this exercise is that we get to think about it and refine it and focus it as time goes on. We think this is a good start, but we are not satisfied with where this is. We see more working on this over the next bit of time to make it more inclusive and refine it even further, and we would very much like people's input and suggestions about how to do that.

Let me stop there.

DR. DUVAL: I was bothered by the wording on 26.4 of your development number three. Maybe you can explain how you think it would work in the field, where you are asking that you increase by a certain percentage the number of pharmacies using drug alert systems which have fully updated those systems over the past three months. Now, over a 10-year period, this is not an easy one to operate, it strikes me.

DR. FRIEDMAN: Your concern is that it is not easy to do?

DR. DUVAL: Well, if you look at the nation's pharmacies, you are going to ask over a 10-year period that they improve the percentage of those which have introduced the alert systems over the past three months. That is the part that throws me. If they get it updated today, does that mean in the fourth month from now they are working against you? I would just look at the wording, that is all. It won't fit the way it is now.

DR. FRIEDMAN: I appreciate that.

DR. SATCHER: Very good. Thank you. Other comments, questions? Okay, thank you. We are about back on schedule. We are scheduled to take a break now, but if you don't object, I think I would like to go to health indicators with Dr. McGinnis.

Oh, John Eisenberg, you just walked in. We are delighted to see you.

DR. EISENBERG: I just threw you off schedule again. Do you want me to do this?

DR. SATCHER: Sure, go ahead.

Agenda Item: Reports from Lead Agencies. AHCPR.

DR. EISENBERG: I am sorry I had to break away. I had a reauthorization hearing before the Senate Labor and Human Resources Committee. It was sort of ironic. Sen. Jeffords said, don't you think we need a better information system to understand what is happening to the quality of care in this country? I was thinking, which meeting am I in? He sort of said it all, really.

This part of Healthy People is a break from tradition, and I think in that way it is a very important break from tradition. Sitting next to me is David Atkins who, as many of you know, is a member of the staff at AHCPR who is a physician who has been working on the clinical prevention agenda and working with CDC to bridge the clinical approach and the public health approaches to prevention. This part of Healthy People grew out of the clinical prevention part of the program.

We came to the conclusion, after a lot of discussion, that what we really need to do is to understand how we can improve access to comprehensive high quality health care across the continuum. All those words are important. Access, comprehensive, high quality health care, continuum, are all key words to this. In some ways, that says it all.

The group felt that we have in some ways in our enthusiasm for emphasizing the public health aspects of Healthy People -- we may not have paid as much attention as we should to the health care part of Healthy People. Even if you are one of those people who think that health is only 10 percent of health care and the other 90 percent is other things, we at least should spend some time on the 10 percent part.

This part was aimed at trying to figure out how we enhance the interface between the public health aspects of Healthy People 2010 and the health care parts of it. The group came to the conclusion that there were three principal interfaces. One of them is in primary care; one of them is in long-term care; and one of them is in emergency care. Those are three interfaces that are critical in order to enhance the health of the public

It also recognized the fact that access to care is an important part of health care. Even when people do get access, we need to be sure that the quality of their care is as high as possible. The President's Commission on Consumer Protection and Quality in the Health Care Industry addressed that in a very serious way, showing that there is a gap between what we know how to do and what we do, and we ought to close that gap, as well as the kinds of gaps that we have been talking about in this meeting.

So, the four areas including clinical services are the interfaces of primary care and Healthy People, looking at issues like whether people have a source of care that is regular, an adequate level of care, whether the supply of primary care providers in under-served areas is adequate, and reducing indicators of inadequate care like preventable hospitalizations.

For emergency services, the questions were those of improving access to emergency medical systems, access to emergency services in general, poison centers, looking at the needs of special emergency populations, especially pediatric, where in many cities the capacity to handle pediatric emergencies is limited, not to mention rural areas, and improving follow up for people treated in emergency facilities.

In long-term care, the agenda items that the group proposes be considered are issues including identification of long-term care needs, improving the appropriate evaluation and referral of people to long-term care, increasing access to a range of long-term care services rather than just thinking of long-term care as nursing homes, and improving the outcomes of nursing home care.

What the group has proposed is a set of measurable and developmental objectives. In many ways, there may be more developmental here than in other areas, because our ability to measure quality of care, as we know from the President's Quality Commission, is just starting, and I think that there will be a real important intersection between the activities that are being undertaken to follow up on the Quality Commission that the Secretary co-chaired and Healthy People 2010. In fact, there were several instances, in people testifying before the quality commission, in which they emphasized that Healthy People 2010 could be a barometer of how we are doing in quality and that we should be sure to link the two.

We have begun to have conversations with Ed about ways in which we can bring AHCPR and NCHS together to look at some of those parameters. There are going to be a number of challenges, not to mention the fact that we don't have very good data sources. HCFA, Barbara can tell us that HCFA can provide us some data. But we are struggling even with HCFA to get data, and that is only the people who are Medicaid eligible and people who are Medicaid beneficiaries or recipients. So, our data sources are skimpy. We have made some progress in developing better, more reproducible measures of quality, but we have a long way to go in that area.

In clinical preventive services there probably has been more progress made than in other areas. If you look at HEDIS, you will see that clinical prevention is a large part of HEDIS already, but we can do better. We can do much better with services other than the classic preventive services like mammographies and immunization, but especially these areas of primary care and emergency care and long-term care, we can do much better and we need to develop those kinds of measures.

Let me ask David if he wants to add to that. Knowing that your time is limited, I might just stop at this point and emphasize the fact that there will be measures that are available that are going to be proposed for Healthy People 2010.

A large part of this is going to be developmental, trying to measure things like patient satisfaction, patient participation in their care, in long-term care, primary care or emergency care, making sure that people not only have access to these facilities, but that the care is of high quality when they get to them, reducing health care errors and looking at issues like drug safety.

DR. ATKINS: I just want to remind you, we are co-lead with HRSA and CDC on this. Lyman Van Nostrand and Melissa Clarke from HRSA are here. Jeff Harris, the new co-lead with us wasn't able to make it, but it has been a very productive interaction.

MR. HARRELL: I just have a structural comment. I noted that particularly in, I think, mental health and maybe in sexually transmitted diseases, perhaps in physical activity and perhaps nutrition -- although I didn't see it

-- there are objectives similar to your developmental one about smokers and problem drinkers getting attention in the primary care setting. I am wondering if, structurally, these ought not to be brought to one place, especially because we could do surveillance of primary care that would put it all through one system, as opposed to having little bits and pieces scattered about.

DR. EISENBERG: Let me respond in my way and David might add to that. There is a lot in many of the different sections of Healthy People 2010 which may be measures that will reflect on this question. One could argue whether the clinical preventive services, like mammography and immunizations, should be here or in the other chapters. There has been a movement toward including them in the other chapters.

I personally think, as was implied in the first part of today's discussion, that we need to think about this as something bigger than just chopping up Healthy People into 20-odd chapters, but that there is going to have to be an integration of them. I personally would welcome the opportunity to look at measures that are in other chapters that will give us indicators of how we are doing in primary care, long-term care and emergency care. I think it would be a mistake to have this chapter serve as only that which is left over after everything else is taken. It has got to be more integrated than that.

One thing that was left out, and purposefully, was hospital care. The group might want to think about whether that is the right decision. I suspect it is because this platter is so full as it is. Taking on the issue of hospital care might be more than we want to take on. In theory, at least, the hospital isn't an interface with the public health sector, because people have to go through the emergency room, through long-term care, or through primary care in order to get to the hospital, although we all know that is not always the case. Hospital care was left as something that might be considered separate or later than this one.

DR. SATCHER: How do you describe the baseline for poison control and where we plan to go?

DR. ATKINS: We have a number of people from emergency medicine who worked on those objectives. The baseline, I think, is described as the number of states in which the access to poison centers leads one to a single 1-800 number. So, the objective is phrased as increasing the number of states that have adopted that.

DR. SATCHER: From where are we starting?

DR. ATKINS: I think it is somewhere in here.

DR. SATCHER: I tell you why I am asking it. It is because this is a pet peeve of some members of Shays' committee. Every time we go, regardless of what the topic is -- hepatitis C -- it always gets around to poison control. The last time they admonished me to come back with a plan for poison control.

DR. EISENBERG: As you probably said to them, David, we will get back to you with that. There are 74 poison control centers. I don't know how many states that represents. The unit is individual poison control centers. Some states have several.

DR. SATCHER: This is one that I know HRSA has a major role in, too.

DR. JONES: John, you mentioned hospital care was not included here. I would note as well that whatever care is provided through the correctional system is also ignored.

It is mentioned in the sections on STD, HIV and on mental health and mental disorders or whatever that chapter was called.

Nonetheless, there is a continuum of care when you are dealing with things like tuberculosis, HIV long-term care, mental and addictive disorders, of which public health may or may not appropriately be the continuum of care that perhaps reduces recidivism and protects the community in many ways, as well as helps that individual achieve a better health status. I don't know that it is appropriate. It might be outside the scope.

DR. SATCHER: It is very appropriate and I think it is a real challenge for us in the future. How do we relate to the correctional institutions in terms of health care. We are dealing with one community, really. When it comes to HIV, TB, people are in and out. If they come out with a greater risk of infection than before they went in, then it changes the community.

We do need a strategy. We don't have one yet, I don't think, but we have got to talk about that, as to how we are going to do it. Ken Moritsugu, I guess, runs a prison system. He is over in the Justice Department. I was talking with Ken the other day about that. We need to get together soon and talk about that.

DR. BROOME: I think it also just underlines the importance of cross-referencing. We discussed correctional health in STDs because that is such an important potential setting for high risk. You know, in terms of thinking about your chapter -- is it more a question of cross-referencing all the ranges of sites in which prevention or health care intersect?

DR. SATCHER: Okay, then. Monty?

DR. DUVAL: First, I would say I was personally very pleased with this chapter. My compliments to John and the others who have assembled these materials. I think this is a very important set of additions to the original Healthy People.

I have two comments. Specifically, on page 23.9, your A-1, I guess it is, and also 23.18, B-4. May I say, in case there is any question, that I am wholly supportive of both goals. I had to question, upon reading these, whether they belong in this document.

DR. SATCHER: Read the first one.

DR. DUVAL: Yes. The first one is reduce to zero percent the proportion of children and adults under 65 without health care coverage. As I said, while I am totally supportive of that, I am not sure that this is the right place to articulate that as a goal.

I have the same difficulty with respect to increasing the proportion of all degrees in the health professions and allied and associated health professions awarded and going to under-represented racial groups -- again, that I totally applaud. I am not absolutely sure that they belong in this. I am only asking that you consider it. I am not suggesting that you delete it at all. It is just that it tends not to be quite on the mark in terms of what this document is.

The second comment I would make is on page 23.29. It is objective D-4 -- reduce to 40 per 1,000, the proportion of nursing home residents with pressure ulcers. I would like to make a specific and a generic comment about that kind of objective, generic in the sense that it might be well to keep this in mind with respect to a re-reading sometime of all of the objectives.

I remember some years ago when Paul O'Neill left OMB -- and I notice, incidentally, he is on your Business Advisory Council -- and he went to Alcoa. Early in his experience, he mentioned something to me which I have actually never forgotten in a way. Alcoa uses certain preassembled things that they purchase in the open market and he was accustomed to having them turn up with flaws, as many as nine or ten per 100 of these devices. One of his vice presidents had made the comment, I think, that the Japanese could probably do this, and they might be willing to do it lower. So, they wrote a contract with a Japanese company to preassemble them and said they wanted two defects per 100. When they arrived, the Japanese said, the two with the defects are separately packaged.

I bring that up only because I would say that when you say to reduce to 40 per 1,000, et cetera, et cetera, that is not to me a good way to word that. I would suggest this is sort of generic also, because it has application to certain of the other objectives. You are not at all trying to achieve 40 pressure sores per 1,000. Point made.

DR. SATCHER: Do you want to respond?

DR. ATKINS: The first part of the question, the uninsured rate and the other -- those are actually retained from Healthy People 2000. I think the issue of the uninsured population in Healthy People 2000 was addressed as an important precondition to getting clinical preventive services to everybody. We felt it was still appropriate to retain. Now, whether zero percent is the right level -- it seems that is the goal.

DR. DUVAL: Zero percent is the right level. The issue is whether it belongs in here at all. I have raised the point and I don't care. Leave it in. As I said, I am for it. I just was a little uncertain as to whether it belonged in this document.

DR. ATKINS: Similarly, with the training -- that is an objective retained from Healthy People 2000, but we are open to comments about it.

DR. SATCHER: It is sort of an enabling objective, I guess, in a sense. I must say, I think we are going to make it. At least we are getting closer. We are going to have some trouble with, probably, the migrant population. I think, with the $24 billion in the CHIP program, we are making progress toward that. So, we can make it.

DR. SATCHER: HCFA, are you comfortable with that objective?

MS. COOPER: Absolutely.

DR. SATCHER: Thank you very much. These agency presentations have been very stimulating, very interesting. Obviously, we wish we had more time to discuss each one of them, but I think you gave us a really great flavor of what we are dealing with, and we appreciate that.

Okay, Dr. McGinnis, health indicators.

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