Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010

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DR. BOUFFORD: Also for immunology, the Office of Disease Prevention and Health Promotion and the staff that have worked there, Debbie Maiese and certainly Michael McGinnis' leadership.... So everyone's tenure really did keep the work going on this.

Let me invite other colleagues maybe to just kind of briefly--because I would like to be able to do a little bit of back and forth this morning--just touch the high points of has Healthy People made a difference in terms of your own policy making program organization. If not, what would you suggest might make it more helpful to you, understanding that we will get into some of the details on the future activities this afternoon? Paul, do you want to start, because mental health and substance abuse have been areas that have been fingered as being particularly, sort of relatively at least, underdeveloped in this area up until now?

MR. SCHWAB: Yes, we're pleased that--actually it was only this past year--that the number of State organizations, thanks to Dr. Lee's participation in both mental health and substance abuse, now have been added to the Consortium. I have only been at SAMHSA 2 months, but in that 2 months I've already been, at least in one session, focusing in on substance abuse treatment, for example, with a number of State representatives. They were very proud--Washington State, in their January 1997 report, focusing in on where they were relative to Healthy People 2000 and how that, in fact, was used for them as an effective enabler in terms of some of the issues they've been focusing on.

In talking with some of the folks in SAMHSA--and let me highlight Ann Mahony and Gail Ritchie as two persons among others who have been very active in this process--but over the last couple of weeks, one of the areas that has struck me where the Healthy People process has either been an important silent partner, or perhaps a very active partner--and it's still not totally clear in which way--is on a policy basis. I would say, as we reflected, there are at least three areas that seem to be particularly relevant.

One is actually, to use a term, providing policy parity for substance abuse and mental health issues, putting them on the table along with all of the other important priority issues, where each was considered, really, in the sense of equity, in terms of consideration. I think we can look at behavioral health issues, for example. Obviously, the term parity is frequently used in terms of mental health specifically, but policy equity is terribly important.

A second area on the policy side is actually giving some legitimacy to illicit drug use as a public health issue in some ways and looking at that dimension of substance abuse. We've noted, for example, this past year increasing references by General McCaffrey as part of the Office of National Drug Control Policy in looking at drug issues as a public health issues. That's been a tension, and I gather a historical one. I think in some respects Healthy People has provided a policy context for moving that discussion and that dialogue with regard to drug use and focusing on it as a health issue.

Thirdly, it's not been an area that's been well developed with regard to data and quantitative measures. In that regard, I think Healthy People has provided an important contribution in emphasizing the importance of data, emphasizing the importance of measurement. One of the observations that I would just bring to the table is that it struck me that the Healthy People process was indeed a trailblazer in terms of focusing attention in terms of measurable objectives and data.

Now, that is something that is about in the environment. Everybody is into outcomes, everyone is focusing in terms of quantitative measures and the importance of that. So in this environment, does that place new or different challenges to the Healthy People process? For us, for example, as we see the Office of National Drug Control Policy developing performance measures, as we're focusing on performance measures for the Government Performance Results Act, with Healthy People moving now into another iteration with the year 2010, with the managed care sector being quite active in different ways with HEDIS and other related measures dealing with outcomes and outputs, does that create a different kind of environment in terms of coordination issues and the relationship between the different measures?

Those would be my comments on the policy side. There have been a number of more specific activities that I could comment on as we go through the discussion.

DR. LEE: Jo, can I just comment on that also? Mike Wald, who was here in the Department in the General Counsel's Office, and then was involved in San Francisco in social service and poverty issues, has spoken--and actually was very helpful in convincing the mayor--about the pervasive impact of substance abuse on the welfare population and multiple others, including incarceration. The mayor has recently indicated a willingness to add $20 million to the substance abuse budget in San Francisco, with the goal of having treatment on demand by next April.

The only trouble is, we don't know what treatment on demand is and how you define it. How do you measure it; how do you evaluate it? But the need for ACF and SAMHSA to be working together, like HRSA or like CDC and HCFA, seems to be extremely important just because of this pervasive impact and this kind of collaboration. Of course, obviously Sally, it affects the Medicaid population very substantially as well.

MR. SCHWAB: Actually, with the impetus of not only Healthy People, but the Secretary's initiative in terms of substance abuse, it has in fact enabled us even faster to work with ACF in a number of areas.

DR. BOUFFORD: I think two things would have been interesting in introducing the Healthy People, the performance measurement issue. SAMHSA has really been a bit of a test case trying to sort of reframe some legislation last year, which we weren't able to get quite as far as we had hoped. CDC has really moved in some of the block grants. But in this area of substance abuse and mental health, they have raised the issue that Dr. Richmond alluded to earlier, of the resistance of the audiences and populations, including the professionals that are first confronted with this idea, and the anxiety and the difficulty and does this need to be measured--if we don't meet it we lose our money. I think this is very much alive and well out there, especially if we think about sort of broader applications and the sort of traditional public health ones.

The other issue which you raised Paul, which we probably will need to come back to this afternoon, is the issue of, with the stress on performance measurement in the government, through the Vice President's initiatives as well as the Government Performance and Results Act, so-called GPRA, there are a lot of models for performance measurement floating out there. The fact that this one has been around for a while may or may not--I think it's somewhat at risk in relation to our own sort of searching of is this where it needs to be and should we stay with the prevention agenda. Should we try to go more broadly? How do we kind of impress on people the sort of value perhaps of building in at least complementary activities with Healthy People. When it comes out of a budget framework, as opposed to a programmatic framework, it's a real challenge, but I think we are really where the rubber hits the road on this. What's going to be the nature of performance measurement, for the government going forward over the next year or two, and the fact that this has existed? We have to figure out how to communicate that and link it up to folks that are working forward on this kind of general stuff.

What about other comments? Bill.

DR. HARLAN: I have some from the perspective of NIH, in fact I even had some notes, it's the pedantic in me, I guess.

DR. BOUFFORD: Pass the notes out and maybe you can give us a thumbnail sketch.

DR. HARLAN: Well, one reason for passing out the notes is I am going to be very brief. I will just say at the beginning that the prevention research at NIH really is integral to Healthy People 2000. In fact, I think what we do is to develop the science base, the information base for Healthy People 2000, both the goals and the actions are taken.

I would like to point out that we have an extensive research program in prevention research that takes about 25 percent of NIH's budget as an investment. That also is spread across all of the institutes, where virtually all of them do have a prevention program. Most of the work is involved in identifying the risks to health, or the determinants of health, as Dr. Lee has called it. We also test interventions that modify this risk or modify these determinants. These become, I think, the base on which Healthy People 2000 is based.

One can go back I think to look at the remarkable changes in cardiovascular disease, for example, and see the research base that was created about the risk factors for heart disease, about the risk factors for stroke. The interventions are tested, the ability to modify this risk, and to lead to a change in the mortality and morbidity associated with stroke.

I might say, among the trends that we see at NIH in our prevention research, is an increasing focus on morbidity or function impairment and changes in that, rather than just on mortality. I think the emphasis on mortality is probably waning a bit as we get a little more competence in the measurements we can make of morbidity.

I would say, too, that we are seeing an extension across all of the institutes. As you know, we have 22 institutes and centers and they have a very categorical interest. It's become apparent that, when one talks about prevention, you're talking about something that's very holistic, very global. The attempt now to bridge the interests of the institutes in looking at behaviors as determinants of health, I think, is apparent from a lot of the projects underway.

I will just mention one that I'm involved in, the Women's Health Initiative, which had the involvement of about 12 of the institutes and centers in its development and does look at a number of different diseases, using the modification of the particular behaviors that are of interest to each of those institutes and will modify the development of more than one disease.

Quickly, we also, when we put out program announcements, requests for applications, requests for proposals, mention Healthy People 2000 goals. Most of our research is supported by investigator-initiated grants, and very frequently now we're seeing that the Healthy People 2000 goals are used in initiating those.

I would make one other mention of the lag period. We need, if we're going to do research that's going to be useful in Healthy People 2010 for example--we need now to identify those things that need to be investigated, those things that need to be tested. The reason we need to is that the time between the initiation of an idea and the publication of results is somewhere between 5 and 7 years. So, if you want to use the information, we need to initiate the studies now to have it still in use.

There are a lot of good examples that were published last week of work that started 7 to 10 years ago. I think all of you saw what happened with ASSIST, the 10 percent decrease in the ASSIST-related communities with respect to cigarette smoking. There was the study also of fruits, vegetables and grains and the effect they can have on blood pressure. When I was in Heart, Lung and Blood, I initiated that program. So, in looking back, it started about 7 years ago. But that gives you some idea of the lag that we have built into it and the fact that we need to identify these issues early on. We have issues identified in the area of nutrition now, particularly with respect to obesity and dietary intake.

We support a lot of training, and I won't go into that in detail, except I hope you will note that we support about $78 million annually in training.

Information dissemination is an important part of what we do, and I've listed for you a number of the activities that we have--consensus conferences. The institutes, I think now almost without exception, have programs that are involved in disseminating information that can be useful to the individual with respect to changing behaviors into a more healthy pattern.

We also have input into clinical preventive services and into community preventive services. We have executed, through my office and many of the institutes, cooperative agreements with CDC. That's working extraordinarily well, I think, from all of our perspectives--where we, I think, have demonstrated that we can work together, both in terms of development of research, the evaluation of the research that's conducted, and the dissemination of the information that comes from that research.

So we have an extensive program of collaboration that goes on across the institutes, across the different agencies. We have a considerable investment in it, and I would just say that, having watched this over the 10 years that I've been in government, we have a change in attitude, I believe, at NIH in terms of the involvement and investment of the emotions and the interests of the people at NIH. I'm very proud of where we've been, and I'm even prouder of where we're going, because we have a lot of interesting activities underway that will have an impact on 2010.

DR. BOUFFORD: NHLBI is going to lead in this area, especially involving really important work in understanding minority populations and cardiovascular--

DR. HARLAN: Yes, I should have mentioned it. They have a large contingent of people, to see whether I got it right--

[Laughter.]

--to demonstrate their interest and support.

DR. RICHMOND: Just a very brief comment. When we initiated this process, we knew that NIH had a lot of work going on in prevention, but nobody had asked the question quite that way. It's sort of illustrative of Jim Thurber's old quip--it's better to know some of the questions than all of the answers, because when we started asking the question we then brought out all that NIH was doing, but they've never really classified it that way. It took quite a lot of work to really put it together, but this is a very exciting report, because this, of course, is the engine for change. Programs won't get better if we don't have research in prevention.

DR. LEE: Bill, could you comment on Julie's earlier question about the genome project and the potential impact and how NIH is beginning to think about that?

DR. HARLAN: We actually have included, when I say prevention-related research--we take about 10 to 15 percent of the Human Genome Project and count it as prevention- related research, because it's directly related--identifying the earliest risk, that is, genetic risk.

One of the other things that we have been interested in is trying to identify the risk that may come from a genetic environmental interaction, which includes personal behavior. I think as we get a better handle on the risk that's genetic, we can get a better handle on the environmental interaction that facilitates the development of disease as a result of that genetic risk. Their interest in this, I think, is rather considerable. In fact, I would just mention, if you talk to a lot of people in the Human Genome Project, they think they're working on prevention exclusively. That's their view of it, because they are looking at risk at that earliest stage.

I look at it more as it will help us to get a fix on the genetic risk but, more importantly, those things that we can do to overcome that risk by altering personal and general environment, because I think that's where we at least for the immediate future will have the greatest impact. I don't think we will be changing people's genes.

DR. LEE: But we're also seeing some problems when you say, Bill, right away with, for example, the breast cancer gene, and people commercially advertising it, saying it's a service, not a test, so FDA has no jurisdiction, and sort of hustling it to at-risk populations. So there's a big potential, I think--

DR. HARLAN: There's also a potential for trying to set the record straight. The BRCA-1, for example, probably only accounts for one percent of the breast cancer that develops and we need to have that kind of epidemiologic, population-based information that allows us to make it clear that this is not something you must have. This is something that people with a family history and a particular circumstance may want to have, and what they should do after they find they have the gene, because that's the environmental part of it that I think we need to sort through.

I can't help but just comment that this really takes us into a very exciting area talking about lead time. One of the reasons I brought this up is that the Genome Project is unfolding, and it's going to give us a lot of information, and it really leads us into an era of predictive medicine that is almost going beyond prevention. I think we have to recalibrate our thinking about this. It's kind of like after the Manhattan Project, when Einstein said everything in the world is changed except the way we think. I think we're in a situation now, as you point out, where we're really starting to think very differently about these issues.

DR. SATCHER: There's a major effort in CDC, and this is coordinated with Frances Collins and the people at NIH, looking at the public health impact of the Genome Project and what it means in terms of our ability to target prevention interventions, things like that. So a lot of potential, but we're also concerned about the risks.

DR. BOUFFORD: Yes, I think we should come back to this this afternoon when we talk about the plans for the future. It's really an important issue.

Michael, do you want to say something quickly about FDA? I'm trying to get everybody to make some key points statements here.

DR. FRIEDMAN: The agency has been very supportive of and active in this initiative, at least since the late 1980s, when the food and drug safety objectives were added. A lot of people in the agency have been involved--Sharon Holston, Peter Rheinstein, Stuart Nightangale--a number have been active in trying to participate as meaningfully as possible in this effort. When I asked the question, how important has this been in agency actions over the past several years, it was really impossible for people to tell me if it was the framework that set the agency agenda, or were the goals so cleverly constructed as to be entirely consistent with what the agency did. In a sense, I think, that's really something to think about for the future. If you pick the right goals, they will naturally fall as the key items that one will want to focus on.

So, while we can point with some satisfaction but no complacency to certain successes that have occurred with this current set of priorities, it leads us to think about how to do things in the future. We've been primarily responsible for food and drug safety priority areas. We've shared responsibility with NIH for the nutrition area, which has been very important, but we found ourselves very active in certain areas where we had neither the lead nor the co-lead, for example, with tobacco, where I think some useful activities have occurred as well.

There are a lot of specific areas in which I think we've made some progress which helps to tell us, sort of inform, what we think about for the future. I think a real focus on food safety has been characteristic of the past but needs to be much more expanded in the future, and I'm sure we will talk about that this afternoon. I think that providing information to people to allow the accomplishment of certain goals is a really key item. We've talked about the need for generating good data so one can assess where you're going with things, and so that one can identify the best ideas to track, but there's a third component, which is that that information is communicated and provided in the proper way. Then, in fact, we can achieve the public health goals that we want because the public will be involved in this.

I know of nothing more effective in that regard than nutritional labeling, which has turned out to be, I think, a very happy experiment, allowing people to make choices in a much more informed way. I think that much the same can be said for providing information about medical interventions and medicines. It's a very active program in the agency for MedGuide, for the future, to allow pharmacies to provide the most effective information to those people who take their medication to use it in safe and effective ways. I think, for the future, there are going to be a lot of other opportunities for us to discuss how we can be even more effective in that regard.

If we look at one of our roles as providing good information, useful information to practitioners, to consumers, to others, I see that as a means to attain certain goals that we establish for ourselves.

In trying to think about what the next set of goals in the 2010 framework should be, we see a very important opportunity for us to collaborate even more closely and more carefully with CDC, with NIH, and with other parts of the Department. We've been struggling to think about what the right metaphor is for this. It seems that at least one that makes sense is thinking about rock climbing, actually. How one climbs a rock face really depends upon picking the optimal route. You can work very hard and if you've picked the wrong route, you won't get anywhere at all. So part of what we're charged with now is to pick the right route, and then to use the data as those devices which allow us to gain purchase, to climb it and to keep from falling. So I think that will be the key for the future.

DR. BOUFFORD: We want to hear from the Administrator of HRSA, because your role obviously puts you into direct relationship with the underserved, under- represented population.

DR. FOX: I will keep my comments fairly brief since I have two times on the agenda this afternoon to comment. I have seen this box from several sides. When I was State commissioner, we were one of the first States to issue a Healthy People 2000 document in 1990. I was running the State MCH Program when the 1990 document came out, so seeing it there. Then, when I arrived in ODPHP and was charged with the 2010, and got started and, kind of, have seen it from the agency standpoint.

So I guess the real question, and you've said it Mike, is how do we really make this a part of our daily operations and how do we make this a part of the way we do business for the next decade. I think that really to me is the challenge of the Department.

I think it is, in most agencies, and certainly in HRSA, somewhat a part of the way we do business. HRSA has been very engaged in Healthy People as many of you may know. I will just comment briefly about some of the data issues. Certainly, NCHS has been the main data driver for Healthy People, but HRSA has been involved with ODPHP and looking, for instance, at the 1992, and now the most recent rendition of the provider survey, that is the contract with the American College of Preventive Medicine to look at, really, what are the preventive practices of providers in this country? I think it's been quite a surprise in the 1992, and I think it will be interesting to see what happens in the survey that's just beginning right now. We, along with NCHS, know there are obstacles in that.

As Jo just said, in trying to think about HRSA, somebody said, what's the role of HRSA? If you had to say in one or two words what HRSA is about, I think HRSA is about access and HRSA is about vulnerable populations. Certainly, the Healthy People 2000 had as one of its goals looking at access, at least for preventive services, for all people. I think one of the things we don't--and we really don't know what's happening out there--so we have a series of instruments, MCH block grants, HIV/AIDS, the cooperative agreements with community centers, so we look at what's going on at the State level.

I think one of the challenges at this point is to try to integrate those, not only within the agency, but integrate them with HCFA, for example, with other agencies in what data is being collected that we can all use, not only for our program planning, but for where we go with Healthy People 2010. I think that kind of data certainly needs to be interfaced and there are some projects underway that we can do that. It also would entail having some idea about the underserved populations, as well.

We have looked at recently, as an activity that was started when I was at ODPHP and tried to continue at HRSA, a subexample of that, in looking at the maternal and child health data. You know the block grant is in HRSA. We don't really know for sure what's happening to MCH populations around many of the issues that are dealt with in Healthy People. One of the things we're discussing is the idea of how we can interface State vital statistics data, data that State Medicaid agencies might have, that CDC has for the plans, that we have in other sources, and put that together in a way at the State and federal level that really gives us an idea of where we're headed. I think there's more opportunity there to do this across agencies. It's something we should take advantage of.

HRSA is the co-lead for two priority areas, the one in clinical preventive services and education and community-based services, and is the lead in the maternal and infant health priority area. In fact, there have been progress reviews held in a couple of these areas since I was at ODPHP and a lot of activity there.

I was really surprised--and I guess maybe I knew it David--but the first week I was at HRSA, I signed five Federal Register notices and every one of them had in it a requirement for the grant applications to address the applicable Healthy People 2000 objectives, and to submit work plans that were consistent with Healthy People. It didn't hit me until I signed those Federal Register notices and I was looking at it, how pervasive that is in the way that HRSA does its business.

The Maternal and Child Health Block Grant, like the Preventive Block Grant, has as a part of its reporting requirements Healthy People objectives. That's built into the statute. Also, there's a lot of this going on there--the HRSA strategic plan, the literature, our Web page, our Home Page, all have Healthy People integrated as a part of that. Healthy Schools, Healthy Communities, again, in looking at references to Healthy People 2000, in particular, schools and minority populations.

So there's a lot going on. I think that the opportunity is there again to try to think through all the providers that we deal with in the community health center movement and the States and other grantees. How can we make this a way of reaching business and what do they think about it?

I will tell you for me, having worked at a number of levels, the value to Healthy People is that, one, it made us think prevention at a time when I think our thoughts about prevention were rather diffuse, and it made us think prevention in objective terms. I think, for me, if I had to say what value had been done at the State level and other components of the system--that to me is the value of Healthy People.

I again appreciate the opportunity to be here in this role and look forward to seeing us carry this along to its next stage.

DR. BOUFFORD: IHS has legislation driving it towards reporting on Healthy People objectives--just very quickly, Craig.

DR. VANDERWAGEN: It has great influence because it is--

[Laughter.]

I have to say that there are two pieces to that. One is that this process is about people and it's about moving people and shaping the way they do business. For us, in a very decentralized program, that means communities. The law--at some level, we educated the Congress too much, because the question that Dr. Lee raised earlier about how useful is a 319 priorities agenda is one that's raised consistently in the Indian community, and I think for most communities, really. So that question of how much is enough is raised by the law demanding that we report on essentially an undoable number for a community.

Secondly, and this is a question that I think Dr. Boufford raised earlier, and that relates to minority communities or communities that are disadvantaged or communities that have special problems. That is the question of how much should we identify them in terms of a potential rate of increase in improvement, versus defining on the front end how deep that hole is to start with, and potentially setting up some difficult challenges for those communities in addressing those goals.

It has advocacy benefits to set the hole as deep as you possibly can. That is what reality is out there in the community, but it does have difficulties in terms of providing and sustaining motivation for people at the ground level. It drives our organization and it has--and Dr. Richmond can relate to this. Water and sewerage are what have made the biggest changes in our mortality rates and the life expectancy in Indian people--that plus 90 percent immunization rates for children. But we're in the chronic disease environment now, and that's all about changing a different set of behaviors. Prevent diabetes by starting in Head Start.

The other concern I wanted to raise here, and this is about numbers, because right now we're in dialogue with CDC about numbers. Our communities are interested in primary prevention. Indian people believe in holistic health, and primary prevention is of high interest to them. How do we capitalize on their interest and yet provide a reasonable documentation and support in the form of evaluation and research about those kinds of things when that isn't the normative behavior for the average person out there in the community? There is a cultural concern here that many communities, not just American Indians, that many communities are going to struggle with in terms of implementing what intuitively makes sense. We start in Head Start with diabetes, as opposed to waiting until they're already diabetic and then initiating all the secondary prevention. That's where the communities are. There's a concern there about the tradeoffs between evaluation research, quantification and community understanding, willingness and enthusiasm for the process.

DR. BOUFFORD: They are very important points, we will come back to a lot, I'm sure, later on today.

Our newest--the last word, John.

DR. EISENBERG: The newest individual and maybe the newest agency, too. I will celebrate my second week anniversary tomorrow.

I think it's been very interesting, as the newest person, to listen to a stream of activities and interests that's gone back to 1979, and inspiring, to feel a part of that continuity. I was also inspired by Michael's reference to rock climbing, because it is an activity that's best done as a team, one where your friends help you climb, where they keep you from falling, and I guess they grieve if you do fall. But I am looking forward to the opportunity of collaborating with others in this initiative.

Let me just very briefly comment on the Agency for Healthcare Research and Quality's activity in the Healthy People agenda. In many ways, I suspect one could say that AHRQ was established for many of the same motivations that the Healthy People initiative was established, which was to try to bring the Federal government to improving the way in which people get their health care and in which they avoid needing health care. Since the agency wasn't established at the time, of course it didn't have representation at the beginning, isn't the lead agency, but we do ask prospective grantees to comment on the relevance of Healthy People to their grants, and we have provided data from the 1987 National Medical Expenditure Survey that helped to set some of the framework for measuring progress.

The four areas that I will mention briefly, Jo, that I think relate to what we're doing now as a connection to the Healthy People initiative--one of them is the modus operandi of this agency, which is to focus on evidence-based medicine, to focus on outcomes, to do what we can to provide information to the public and health providers to be sure that health care is at as high a quality as it can be and that the outcomes are as optimal as they can be. Of course, that relates to prevention and the healthy public in general.

I think Dr. Richmond's comments earlier about quality of life issues being important, as well as mortality issues, is fundamental to this agency as it has taken some of the lead in helping to measure outcomes and to develop new measures for health outcomes.

Dr. Windom's comment about linking preventive medicine to the clinical community is one that's near to my personal heart, as well as to the heart of this agency, which has tried to bring to the clinical domain what several of the other agencies have brought to the public health domain. So we're looking forward to continuing to work in that area.

The second is the agency's adoption of the U.S. Preventive Services Task Force. AHRQ is now the home agency for the task force, which is in keeping with what I commented on earlier about our interest in clinical preventive services. And working with the CDC and HRSA and others, we're looking forward to taking the responsibility for helping the Preventive Services Task Force move to its next iteration and are beginning the planning for that now.

The third area is the agency's portfolio research that evaluates alternative strategies for delivering care. It's, in a nutshell, what works, when, and how well does it work? Trying to develop better measurement methods for quality and for outcomes, I think, will be important in trying to help us figure out whether we've made progress in the next iteration of the Healthy People program.

Then, finally, AHRQ will serve as the lead agency for the Secretary's initiative in quality. It will be, I hope, impossible to separate the Healthy People initiative from the quality initiative because the coordination of Healthy People 2010, I think, will, as the people have already mentioned, depend upon improved performance measures, accountability, the ability to be sure that the care that's provided is of high quality and has some impact on people's health. So, in that way, I look forward as an individual, and the agency will look forward, to working to be sure that there's integration between the Secretary's quality initiative and, frankly, the President's Commission on Consumer Protection and Quality in Health Care and what we're trying to accomplish here.

Much of that is continuity. It's hard to have continuity when you're a seven-year old agency, but I think there's a fair amount of continuity that will exist in our collaboration on the Healthy People effort to climb a rock.

DR. BOUFFORD: Thanks, John.

Just in the interest of time, I am going to wrap up the morning session. I think we've really begun to identify some of the key issues and will try to sort of lay them out when we come back from lunch.

Also, we have Susan Blumenthal of Women's Health, Clay Simpson of Minority Health, Tom Kring in Population Affairs and representation from international health as well. I think we will get into some of these cross cut observations this afternoon in relation to how some of these connections get made and some of the reflections that we may have on them.

So let me just thank everyone for their participation this morning and encourage you to have a healthy lunch and join us back here at 1:00. So thank you.

[Whereupon the meeting recessed for lunch, to reconvene at 1:00 p.m.]

A F T E R N O O N S E S S I O N

DR. BOUFFORD: Let's call ourselves to order. We want to be sure we have enough time for discussion this afternoon, so we're going to try to be prompt. We've invited all of our presenters to limit themselves to 15 or 20 minutes, and the gong will go off or something more violent will occur so that we have plenty of time for some back and forth.

Let me call to your attention--you may have seen something like this on your desk. This is the launching of the Healthfinders Gateway--we were talking about information systems this morning--Gateway into the Department, which was very successfully launched last week on a project led by the Office of Disease Prevention and Health Promotion. Debbie Maiese--I'm sorry, Debbie Maiese does lots of things, but she didn't do this--Mary Jo Deering led this one. I understand that, the first day, they had 400,000 hits, and the second day they had 300,000 before noon.

MS. STOIBER: And we're now up to two million.

DR. BOUFFORD: Two million since last Tuesday morning, so this gives you a sense of the public's thirst for information that we talked about a little bit earlier.

Let me also welcome Marty Wasserman who is the Commissioner of Health for the State of Maryland. We're happy to have him here and invite him to join us in this dialogue and conversation this afternoon.

Okay, our first presentation this afternoon is by Shoshanna Sofaer from George Washington University. She has, as you will have seen in the materials that you got in advance--I think it was the summary of the Healthy People 2000 consortium focus groups--has conducted a series of focus groups to look at what people's reactions were-- perhaps maybe dominated by the familiar users, but also some of the non-familiar users--reactions to Healthy People so far, suggestions for the future. We want to have her present and kick off the discussion on the issue of really getting a good sense from the public of where we have come over the last two decades. So, Shoshanna, welcome.

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