Transcript of the Healthy People 2010 Regional Meeting
Seattle, Washington
December 2-3, 1998

U. S. Department of Health and Human Services
Office of Disease Prevention and Health Promotion

Session II:
Improving Systems for Personal and Public Health and Preventing and Reducing Diseases and Disorders

DR. SLOAN: Good morning, again. I am Hugh Sloan, Regional Health Administrator for Region VIII in Denver. We will be hearing comments on Chapters 14 through 26.

As I have said earlier to assure -- can everybody hear me all right? Okay, to help assure a fair opportunity for everyone to participate in today's hearing we will be using the same procedures that were used in the opening session.

First, each oral statement will be limited to 3 minutes so that we can hear from the greatest number of participants. The light will turn yellow when 1 minute remains and red when your time has ended.

Third, we will allow for 20 minutes of comments for each focus area. That means we will hear from six to seven people for each topic. At the end of the session the floor will be open for comments for focus areas and other general comments. I will ask each of you to introduce yourself by name and your state of residence.

Also, please let us know if you are commenting on behalf of an organization as opposed to you as an individual. We will begin by hearing comments on focus area, the first one will be on the Public Health Infrastructure.

The federal representative for this is at the far left end of the table, Pom Sinnock. His role in being here today is to listen to your comments and invite any clarifications that are needed.

I invite those of you with comments on the public health infrastructure to queue up behind the microphone. For anyone with special needs please raise your hand if you prefer to use a hand-held microphone. I would ask for the first commenter, please?

MS. METZGAR: My name is Beth Metzgar. I am here representing the Montana Department of Health and Human Services and, also, the Montana Public Health Association, and I have comments both broad and specific on some of the specific objectives.

First of all, Chapter 14 offers and excellent opportunity to address public health with a systematic approach. We do, however, recommend that summary measures include broader determinants of community health beyond health status.

Summary measures need to include prevalence of policies, environmental supports and conditions and availability of resources supportive of public health. The overview section's first paragraph should add wording such as healthy communities, community capacity and improved community public health and wording such as effective translation of research to practice and vice versa.

More specifically in the overview of Paragraph 1 in addition to promoting and encouraging healthy behaviors which implies a focus on the individual we recommend the addition of a statement on improving community health or improving community capacity for health improvement and promoting public policies conducive to health promotion and disease prevention.

In the overview of Paragraph 2 regarding the statement on research we suggest adding a statement to the effect of efficient and effective translation of research to practice and in turn practice to research is critical.

In draft objective No. 2, Paragraph 1, we suggest adding behavioral sciences, community organization and development and intervention design and improvement to the skills listed in Lines 6 and 7 of that paragraph.

In draft objective No. 6, Paragraph 1, we suggest adding such processes as community-based assessment and assets mapping.

In addition, community participation in the assessment process itself is critical.

Draft objective No. 13, Paragraph 1 is too limited, referencing only epidemiology. We recommend that it, also, include behavioral research and other evaluation.

In draft objective, again, No. 13, Paragraph 2, we believe that the team described is not a comprehensive epidemiology team. It is instead an interdisciplinary data epidemiology evaluation and research team of which epidemiology is a part. Epidemiology does not subsume the other parts.

It is, also, critical that newer evaluation models that include community level indicators and policy change indicators be developed and disseminated. It is, also, recommended that an objective be added to reflect the need for increased linkages between health departments and academic research to accelerate translation of research to practice and vice versa.

Finally, we feel very strongly that the entire chapter needs to be more sensitive to the unique infrastructure needs of rural and frontier counties and states.

Thank you.

DR. SLOAN: Thank you for your comment. I appreciate it. I did want to say that Pom Sinnock is from the Centers for Disease Control. I didn't mention that, and was the chair of a work group who essentially wrote the chapter on public health infrastructure.

Could we have our next commenter, please?

MS. REYNOLDS: My name is Melanie Reynolds, and I work as the state coordinator for the Turning Point Initiative in Montana.

I am pleased to have the opportunity to share some brief comments from the state Turning Point coordinators from Oregon, Alaska and Montana.

Our states are three of the 14 states funded by the Robert Wood Johnson and W. K. Kellogg Foundations working to improve public health systems. Among us we work closely with 10 community projects in these regions. These projects are as diverse as Fairbanks, Kenai Peninsula, Northwest Borough of Alaska, Will Josephine County, Portland County in Oregon and in Montana the Northwest Counties, Gallatin County, Fort Peck Health Coalition and the frontier county of Sheridan.

We really are a national laboratory working on improving on public health systems. As many of you know the goal of the Turning Point Initiative is to help states and local communities respond to the challenge to protect and improve public health into the 21st century.

One key way to do that is build links between public and private public health systems. The effectiveness of our future public health largely depends on the ability of many organizations to form strong collaborative relationships among all interested public and private parties.

The Turning Point Initiative serves as a catalyst for the development of innovative partnerships bringing together academic institutions, businesses, community groups, elected officials, health care providers, hospitals, managed care representatives, environmental health and a variety of others.

We have two main statements that we would like to share with you today. First, we strongly applaud the inclusion of the new objectives related to public health infrastructure as part of the Healthy People 2010 document.

These objectives provide a menu of options that state and local communities can use in developing a framework for a healthy public health system.

Secondly, we understand the statement in the overview for the public health infrastructure section that states, "Although public health services are no longer delivered solely by governmental public health agencies, government is ultimately responsible for the health of the public.

Our experience so far with the Turning Point Initiative has shown us that this responsibility can best be realized with an investment from many stakeholders to create a system that has the most desirable impact on the health of the entire population.

DR. SLOAN: Excuse me, ma'am. We find our yellow light is not working. You have about 30 seconds, and could we somehow see what is going on with the yellow warning light while she finishes? Excuse my interruption.

MS. REYNOLDS: Would you like me to continue?

DR. SLOAN: Yes, please?

MS. REYNOLDS: Leadership has started to, and I am going to finish. Leadership has started to develop and needs to be developed outside the traditional public health community. We need to develop much larger and diverse constituencies who are actively involved in supporting public health.

This represents a change in the way we do business, how we look at public health and in all likelihood would bring new changes.

I would just like to say that we will be providing detailed and further comments through the Internet as well.

Thank you.

DR. SLOAN: Thank you for your comments, ma'am.

We will at this point give you a hand signal for when you have 1 minute for the yellow light until we get that fixed.

Could we have the next commenter, please?

MS. WOODWARD: Good morning. Jennifer Woodward from Oregon. I am speaking on behalf of the Oregon Health Division. The Oregon Health Division would like to commend DHHS for including a separate set of objectives related to public health infrastructure. A strong and efficient public health infrastructure is vital for achieving Healthy People 2010 objectives.

As was pointed out by the IOM in its first interim report on leading health indicators for Healthy People 2010 the framework for the entire document is conceptualized around visions for healthy people in healthy communities. So, too, must this vision be conceptualized around a healthy public health infrastructure. To make this very important chapter reality several key points need to be addressed.

First, we feel that as public health officials we must own up to the fact that public health as it currently exists and will exist in the future cannot accomplish these lofty but laudable objectives on its own.

We must strive to form meaningful partnerships with our sister agencies such as HCFA, HRSA, managed care, other private health related entities, community coalitions, private non-profits and our customers.

The importance of building and maintaining partners outside of the traditional public health sphere should be a developmental objective in this chapter.

Second, we must acknowledge that a healthy public health infrastructure cannot be attained unless we have adequate and sustainable funding. A developmental objective related to funding should be included in Chapter 14. We suggest the following. Increase the investment in public health so that the ratio of spending on medical care and public health infrastructure is proportionate to the health benefits of each sector.

Third, to build partnerships and obtain sustainable funding public health officials must do a better job marketing public health. Most Americans have little or no understanding of what we do in public health. Our best work focuses on prevention and maintaining a healthy community. Therefore, we are relatively invisible to the general public.

For example, no one really notices that their drinking water is clean or that they don't have a food-borne illness or that their children get immunizations on time. Essentially public health is doing a good job when nothing happens.

It is very difficult to market the invisible. We must do a better job of marketing our strengths and showing the public how public health affects their daily lives. Therefore, we recommend a developmental objective related to marketing public health in this chapter.

Thank you.

DR. SLOAN: Thank you for your comments, ma'am.

Next commenter, please?

Ma'am, could you please register at the back and sign your name?

MR. RUBIN: I am Dan Rubin from the Washington State Department of Health. This is a very brief comment to remind the panel of some comments that were made at other times. First, Mary Selecky yesterday in her address at the infrastructure session spoke at some length about both what infrastructure looks like from a local and state perspective and some implications for federal action to be consistent. I am not going to repeat those comments, but we will submit them in writing again under the proper chapter title.

Second, this morning Eric Slagle, our Assistant Secretary for Environmental Health also made some overall comments which were very emphatic on infrastructure issues. We very much support the specific inclusion of infrastructure issues in this edition of Healthy People, and we are looking for various approaches to flexibility in the use of resources that are available in the system now as well as the increases which surely are needed.

Our written comments which you will receive before the deadline will expand somewhat, but just to repeat very briefly a couple of things that Mary Selecky said yesterday she stressed the need for flexibility in those federal funds that now flow. She made the point that it is important not to let good concepts in Healthy People 2010 such as health improvement plans become bureaucratized as implemented. This isn't so much about the words in the document as what flows later as programs pick up the ball and convert the ideas into requirements and informal advice and finally, we can set objectives related to infrastructure and flexibility in finance, and it is very likely that our written comment will include a specific suggestion.

Thank you, that is all.

DR. SLOAN: Thank you for your comments, sir. I remind all of you again if you do make a public comment, if you could just sign the book in the back after your comments, so we know who you are? Thank you.

Next commenter, please?

MS. GARCIA: My name is Gimi Garcia, Gimi Remedios Garcia, and I am from Colorado, and I am speaking on behalf of myself as a woman of color, and my suggestion is short, obvious and not often implemented, but I am asking for an overarching commitment by Healthy People 2010 to include representatives from target groups in the planning, development and evaluation of programs to address health disparities. Who better knows what the problems are and what will best work for their groups than the people who are members of these groups?

Thank you.

DR. SLOAN: Thank you for your comment, ma'am.

Next commenter, please?

MS. SANCHEZ MARTIN: Hi, my name is Barbara Sanchez Martin, and I am with the Latin American Research Service Agency in Denver.

Just a couple of quick comments. I didn't get the document in time to go through it, but I did read the first section of it when I was on the plane. So, I don't know how extensive the idea of cultural competency is in the document, but I know the section that I did read talked a little bit about cultural relevant strategies in the community, and from my limited experience I am feeling that is not sufficient in terms of addressing the issues of cultural competency in terms of delivery of services, be it prevention or treatment, and I would like this group to consider looking at it more systemically, looking at cultural competency more as a paradigm shift versus an offering of an activity which tends to be more of a discrete kind of an activity. I think our world view needs to shift a bit to understand more of the world view of the people that we are serving, and I don't know you would do that in the document but maybe some more objectives, maybe 502.

(Laughter.)

DR. SLOAN: Thank you for your comment, ma'am.

Next commenter, please?

Are there additional comments on public health infrastructure, anyone?

Hearing no further comments we will take just a short break to test our equipment here before we move to the health communication focus area. We could all still be seated. Would you like to go ahead and test that?

(Brief recess.)

DR. SLOAN: The yellow warning light on the microphone is not working. We will give you a 1-minute signal. If you could please acknowledge that, I am sorry to disrupt your presentation but I think it will work out okay.

We have closed off the comment for focus area 1 on public health infrastructure. I would like to open comment on focus area No. 2, Health Communication and to hear your comments on that is Tom Eng who is from the Office of Disease Prevention and Health Promotion in the immediate officer of Dr. Satcher.

I invite the first commenter, please?

MS. WOODWARD: Jennifer Woodward from the Oregon Health Division. I am speaking on behalf of the Oregon Health Division. We have one very short comment on this chapter. We feel that there is an important attribute of effective health communication that was overlooked in the chapter, and feel that public and consumer participation should be added to the effective communication attributes.

Public and consumer participation is essential for framing the content message and delivery strategies to improve clarity and effectiveness of the health message, and this would be a fifth strategy and we would need to incorporate into Pages 15-5 through 15-7 and then all the other associated chapters where they are talking about other focus areas and communication.

Thank you.

DR. SLOAN: Thank you for your comment.

Next comment?

MS. REYNOLDS: Hi, my name is Melanie Reynolds and I am representing the Montana Department of Health and Human Services, and these are comments submitted to Bob Moon, our Health Promotion Specialist.

Chapter 15 references an important element of health education and health promotion. The definition of health education, however, is too narrow and not consistent with state-of-the-art health education and health promotion. The definition that we would like to see included is health education should be defined as any combination of learning experiences designed to facilitate voluntary actions conducive to health.

Also, media advocacy, we recommend that that be added as well. It is an important approach to promoting health and improving public policies conducive to health.

Thank you.

DR. SLOAN: Thank you for your comment, ma'am.

I didn't recognize, Tom, could you raise your hand so they know where you are? Okay.

Next person, please, comments on health communication?

Just let the spirit move you.

Going once? This closes the focus area discussion then on health communication. Thank you for your comments.

Our next focus area will be arthritis, osteoporosis and chronic back conditions. We will have two people hearing. That will be Reva Lawrence from NIH. Raise your hand? Thank you, and Frank Vinicor from the Centers for Disease Control.

May we have the first person's comments, please?

With 2 days of sitting here there are no chronic back conditions?

(Laughter.)

DR. SLOAN: Okay, if there are no formal comments to be made, we do invite you though if you think of something later to submit those in writing. We have someone.

Go ahead?

MS. BEFUS: I am Nancy Befus, and actually I am here representing Arc. of Denver which is related to people with disabilities, but when I get up I do have a little bit of a trick here that is arthritis, and I, also, what I was reminded of as you were speaking is that I have been so concerned with osteoporosis and I think anybody that heads towards 60 starts to think about that, and so I am really avid at taking my calcium, but I work with many people with disabilities in the community who are going to have the same problem, and these people of all age and especially elderly have no knowledge of needing to take calcium to prevent osteoporosis which then leads to a secondary condition.

So, that probably is in the line of education, helping to educate people in all walks of life in all racial and ethnic backgrounds, disabilities, everyone that calcium is so important and they think I nag at them about it, but it is important. So, I am going to let you know that.

DR. SLOAN: Thank you for that reminder.

Additional comments on this focus area. The focus area is arthritis, osteoporosis and chronic back conditions. Are there additional comments you would like to make?

Okay, hearing no further comments, this will close the formal comment session on focus area No. 16, arthritis, osteoporosis and chronic back conditions.

We will now address focus area No. 17, cancer, and the federal panelists are, again, Reva Lawrence from the National Institutes of Health and Frank Vinicor, from the Centers for Disease Control.

Could we have the first person's comments, please?

The topic is cancer. Comments, please?

Okay, hearing no additional comments, we again invite your written comments, if you would like to, and again, we have 12 days left to comment on this, and it is on the Web site.

The next focus area is focus area No. 18, diabetes. We will have the same two federal panelists, Reva Lawrence, National Institutes of Health and Frank Vinicor, from the Centers for Disease Control. The focus area is diabetes.

Yes, ma'am?

MS. CLAYBROOKE: I am Charlotte Claybrooke, and I work with the Washington State Department of Health, and I have one main issue to bring up regarding objective No. 23 about diabetes education, and I will read what it says here.

The objective should have the wording changed to read, "Increase to 52 percent the proportion of persons with diabetes who have received formal diabetes education within the last 5 years," and here is the rationale. Given the changes in diabetes knowledge, it is not enough to give diabetes education once as implied in the original wording of this objective.

The baseline data for this goal is highly suspect that 43 percent receive formal diabetes education. The National Health Interview Survey is clearly self-report and should be compared to administrative data for billings for the service.

The diabetes control program in Washington will have a population-based evaluation of education delivery from our Washington Multi-Health Plan Study by the end of this year. That information could be used as a reference as well.

Thank you.

DR. SLOAN: Thank you for your comment, ma'am.

Next person, please?

Yes, could you please remember to sign in after you have made your statement, please, so we can credit you with your remarks? These will be posted on the Web site. So, this will be part of the official record.

For those of you who are joining us maybe from the other session, we are on focus area No. 18, diabetes. If you have missed commenting on 14 through 17, we will probably have time at the end for some other comments that we can include, anything that you might have in those areas.

Diabetes, any further comments?

Yes, ma'am?

MS. TOM-ORME: Hi, I am Lillian Tom-Orme from Utah but from my native land Navajo Nation in New Mexico. I represent myself as well as Native Americans who are suffering and dying from diabetes throughout the country. I believe that there is not a single American Indian, Alaskan Native who is not affected by diabetes.

We have very close relatives, friends who have diabetes and over 20 years of research has been taking place in our population looking at issues of diabetes, and we are not any better off after all these years.

What I would like to see reflected in the objectives for diabetes is a major paradigm shift particularly in areas of health communication which is not listed as a related objective, cultural competence and health education programs, really emphasizing healthy behaviors which of course, includes incorporation of traditional ways of thought, practice, so forth and culturally competent health care professionals.

We have over the years experienced very high turnovers of health professions from various, well all walks of life, people who are prepared maybe at the best schools and it seems like every time they come on to our reservation the pattern of care has changed according to that person's individual beliefs and therefore we don't have standards of care that are observed and our mortality, morbidity continues to increase, and as Dr. Satcher noted yesterday diabetes in American Indians, Alaskan Natives is not anywhere near reaching the 2000 objectives. So, I would really like to emphasize a very different way of approaching diabetes interventions in American Indian, Alaskan Native populations.

Thank you.

DR. SLOAN: Thank you for your thoughtful comments.

Next person, please?

Oh, ma'am, could you sign the book in the back, please?

Additional comments, please on diabetes focus area, No. 18?

Going once?

Hearing no further comments, then we will close the comment period for focus area No. 18 and move to focus area 19, disability and secondary conditions.

Our federal representative to hear your comments is Don Lollar from CDC. Don?

Do we have the first person's comment, please?

MR. PATRICK: Donald Patrick, the Center for Disability Policy and Research, University of Washington and, also, representing my own family like all families in the United States that have experience with people with disabilities. I would like to make five points.

First, the operational definition of disability needs standardization across federal agencies and at least the Centers for Disease Control in the Public Health Service.

Thus, a core set objective of three to four screening items is necessary for achieving the Healthy People 2010 objectives for people with disabilities.

Two, reductions in absolute health status measures such as those in objectives 2 to 6 of reducing days of depression, anxiety, increasing emotional support and satisfaction are not useful, as useful as elimination of disparities. These measures are available on persons without disabilities and should be used in setting objectives and the objectives are eliminating gaps and disparities between people with and without disabilities rather than absolute reductions in health status measures.

Three, evidence is limited on the effectiveness, let alone the cost of health promotion and disease prevention programs for people with disabilities. The specific intervention goals related to HPDP promotion should be evidence based and where evidence does not exist this evidence needs to be gathered.

This is best done through incorporation of disability concerns in clinical and community level studies and the review process that is conducted by the Public Health Service on the evaluation of clinical and community-based preventive health services.

Four, promoting increases in the percentage of children with disabilities in regular classrooms is an admirable goal of inclusion but like the deinstitutionalization of the persistent severely mentally ill without adequate support the rights of inclusion are reduced to individual responsibility and duress. Thus the support should be added to support children with disabilities in regular classrooms, and lastly, fifth, addressing environmental barriers to full participation for people with disabilities is an important and laudable goal.

It is important to include educational settings in this particular objective and to monitor participation using the Harris Poll indicators that have been conducted over several decades and indicate that the gaps and disparities between people with and without disabilities are not closing very rapidly.

Thank you.

DR. SLOAN: Thank you for your thoughtful comments, sir.

Next person's comments, please? Focus area No. 19, disabilities and secondary conditions. Could we bring a microphone up, please? One minute, we will bring a microphone up, please?

MS. VINCENT: I have got a very serious disability that however has not kept me down. First of all you think of education being for children. When we graduate you don't have involvement with disabilities. This is something I cannot understand. We do not want to be only symptoms. They give you $495 a month to live on. I can tell each and every one of you to live on this, and second of all, we got the ADA which I feel is where people come in. People in Washington don't seem to care about this.

I worked 12 years going over 500,000 miles to get the ADA. Why don't you guys make Washington defend this? I got here today with Jane Logan(?) who I very highly recommend, but most of you could not bother with me. What you are trying to promote is a Healthy 2000. No one who needs it the most cannot tell you because of money and all kinds of big problems. You need to work on this. Okay. Thank you.

MR. LOLLAR: Excuse me. Could I just make sure I understood the points? Would that be okay?

MS. VINCENT: It is fine. You ask it.

MR. LOLLAR: I wasn't sure whether this was going to be in writing. So, I thought I would make sure I got it.

MS. VINCENT: Oh, good.

MR. LOLLAR: Education, it doesn't help a lot if you get education, if you don't have work afterwards?

MS. VINCENT: No, it doesn't.

MR. LOLLAR: Four hundred and ninety-five dollars a month doesn't go very far.

MS. VINCENT: You can try it.

(Laughter.)

MR. LOLLAR: I have. ADA ought to be the core of anything that is going on around Healthy People 2010 when it comes to people with disabilities.

MS. VINCENT: By the way, yes, by the way I got a very nice birthday gift when I was visiting you. They signed the ADA on my birthday.

MR. LOLLAR: That is great, and finally, you are and I have a feeling have been and will continue to be a strong advocate for the disability movement.

MS. VINCENT: Yes, until the day I die, I will be going on with ADA.

MR. LOLLAR: Thank you. The only thing I would say is that our office is in Atlanta not Washington.

DR. SLOAN: Thank you very much for your very thought-provoking comments. Do we have another commenter in the back here? Okay, please take the mike back?

Excuse me, sir, we have one comment here in the back and then you, okay?

MS. MC DEVITT: My name is Lauren McDevitt with the North Carolina Office on Disability and Health and I, again, also, represent myself as a person with a disability and I have three main points that I wanted to make about the disability chapter. One is just to commend the inclusion of this chapter in Healthy People 2010 objectives, and I do support all the current objectives in that chapter, and with regard to this I, also, support the broader definition of disability that is included in this chapter, and I think it is really important to note here the individuals with disabilities really define disability and perceive themselves as people with disabilities very differently and often very differently than human service agencies or government agencies or whoever may be defining them actually define them, and so I think it is important to include this perception of disability as individuals themselves see themselves as opposed to how others will define them, and I feel like that is incorporated in this broader definition of disability and so I would support this definition, and, also, again as I stated in the previous session I feel like again it is so important to include disability and other chapters within Healthy People 2010 that this chapter does a good job to really address some of the environmental barriers in participation and some of those issues that are specific to persons with disabilities but so many of the health issues that exist for the general population are, also, for people with disabilities and we cannot address all of these health issues within one chapter. It really has to be incorporated in all of the chapters, and the third point is if this chapter is really going to affect the health of people with disabilities it is vital to improve the collection of data on disabilities in all surveys, government and more clinically based or local surveys and measurement tools that will look at these objectives and measure the outcomes of these objectives.

It is really important that we begin to identify disability as a demographic variable in all federal data collection.

Thank you.

DR. SLOAN: Thank you for your comment, ma'am.

Sir?

PARTICIPANT: I am Floyd, an investigator for the Department of Health and Human Services, Office of Civil Rights located here in Seattle. I am representing myself today. Having cursorily read the definition of persons with disabilities I suggest that the definition more closely track that at the time of the ADA, the American Disabilities Act of 1990, because what I saw did not include working as a limitation. So, I would suggest you go back and look at the regulatory definition of a person with disabilities.

DR. SLOAN: Excuse me, sir, do you have that definition with you?

PARTICIPANT: I don't have it with me, no, but I can certainly see that you get it by the date.

DR. SLOAN: We would invite you to submit that, maybe with your written comments so that we have that for the record.

PARTICIPANT: Okay, thank you.

DR. SLOAN: Thank you, sir.

Next person's comments, please?

Yes?

MS. BEFUS: As I mentioned, I am Nancy Befus. I am employed by ARC of Denver. As an employer of ARC of Denver actually what I do is work as an advocate for people with developmental disabilities. These folks who have a problem with direct care services or with services by the system come to us for help. So, what I see very often, and I wanted to mention that I really didn't see mentioned in the document was the drastic shortage of quality direct care staff for people. When I say, "Quality," I am sure you all know what I mean. It is very difficult to find people who are paid minimum wages to come in and take care of people who are not able to take care of their personal needs themselves.

I think that this directly contributes to secondary conditions. Many, many people that I see in the community that have disabilities have depression as mentioned. I feel this is directly related to the type of service they get from the system and from their direct care staff, and I felt this was important to look at and wanted to mention that.

DR. SLOAN: Thank you very much for your comment, ma'am.

MS. BEFUS: There was something else I wanted to say. Kathy didn't introduce herself. So, I will introduce her. Kathy Vincent is here representing the Colorado Cross Disability Coalition. It is a coalition that is trying to bring groups together in Colorado that have all kinds of disabilities and work together to have more power. So, that is who she is representing. She, also, is on the board of the Developmental Disability Planning Council of Colorado and another board, I could probably name three or four that is the Governor's Board in Colorado.

Thank you.

DR. SLOAN: Thank you for adding that important information. We appreciate that.

Next person's comments, please?

MS. JACKSON: I am Emma Jackson from Colorado, and I wanted to ask if, since I work with the schools, and we have students who are diagnosed with ADHD, is that included in the 2010 area?

MR. LOLLAR: May I answer that?

DR. SLOAN: Yes.

MR. LOLLAR: Yes, and I think the issue of schools and children with disabilities is part of what folks are talking about in terms of inclusion across chapters because you see kids who have learning disabilities or behavior problems, etc. When they are in special ed classes, we are concerned that those chapter include special education as well as the regular education.

MS. JACKSON: Okay, thank you.

DR. SLOAN: Thank you, ma'am for your comments. Could you please go to the back and register your name?

Thank you.

Next person's comments, please?

Any of you who might have come in late we are addressing focus area No. 19, disability and secondary conditions. Are there additional comments, please?

Hearing none, I will close off the official comment section for this focus area and open up comments for focus area No. 20, heart disease and stroke, and our federal representative hearing your comments will again be Reva Lawrence from the National Institutes of Health. Reva?

Thank you, may I have the first person's comments, please, heart disease and stroke?

Any comments at all on this focus area, on heart disease and stroke?

Reva came a long way, as I am sure you did.

Sir, will you come to the microphone, please?

DR. RAMEN: I walked in late. I don't know what extent, what scope of the discussion of this particular area is. I am Dr. Ramen. I am an educational consultant. I am a first-generation immigrant having lived in India for 30 years in Calcutta, and I am living 34 years in this part. I am 67 years of age today.

The reason why I am saying this is we need to have a certain perspective on how to prevent many of these things because in our culture we have been patching up lots of holes. We need to do some preventive things. In terms of heart conditions, I think the first thing to start with is the school lunch program. Many of you have probably heard about a lot of rhetoric going on about it, but if you look at the school lunch program in any school district in the 50 states, it is almost an embarrassment to nutritional science.

So, the first thing we have to do is to make sure we have some very definite preventive measures to see we don't fund a school district when it is making the children butterballs. We have to be extremely strict about it. We have got so many resources in this country. We can produce the entire Monica Lewinsky tapes overnight. Why can't we do something to make a fundamental change in terms of addressing this particular issue of the high-fat content of food that children are ingesting?

The second thing is we need to have a comprehensive nutrition education program for the medical colleges. In fact, I have more degrees than thermometers. If anyone wants to have the curriculum vitae I am willing to send it to you.

I did a survey of the nutrition education curriculum at 40 American medical institutions, and you wouldn't believe it, it is so embarrassing to state while there was no preventive nutrition involved, that only 40 minutes of the entire 5 years in spent in preventive nutrition. Most of it is on therapeutic nutrition. So, I thought I would make the major comment that heart disease can be prevented by early onset of proper nutritional attitude.

Thank you.

(Applause.)

DR. SLOAN: Thank you, sir for your thoughtful comments. Are there additional comments on heart disease and stroke, please?

Sir?

MR. BAILEY: I am John Bailey, director of a multi-county health department in Northern Utah. I am representing myself on this. This is really more in the way of questions rather than comments.

With regard to the statements and the goals on hypertension elsewhere there have been clear definitions of what is hypertension and what is not. I don't see it in reading the material here that such definitions are there, and we talked elsewhere this morning about standardization from the federal to the state to the local level. Is there some reason that there is not a definition of what we should consider as high blood pressure in our goals in reducing it in certain population groups?

That is my first question. With regard to goals 10 and 11, is there some reason that goal 10 talking about cholesterol levels talks about serum cholesterol; goal 11 talks about blood cholesterol? Perhaps just a consistency in the use of terminology there?

I noticed on goal No. 8 that we are talking about increasing the percent of people with high blood pressure who are taking action to control their high blood pressure and No. 9 who have an actual knowledge of what their blood pressure is. Some consistency again as you talk about a comparable goal for people who have their cholesterol levels measured, if it could be, also, included there to not only have their cholesterol measured but to again know what their cholesterol levels are.

Thank you.

DR. SLOAN: Excuse me, could you wait right there, sir? Reva is the federal representative. Would you have any response to any of those questions here?

MS. LAWRENCE: No, I don't have a response, but I will carry your comments to those people who work on this section.

DR. SLOAN: Thank you very much. Thank you, sir, for those questions.

The next person's comments, please, heart disease and stroke?

MS. SANCHEZ-MARTIN: Again, my name is Barbara Sanchez-Martin, and I am with LARSA from Denver. These are probably comments relative more to the nutrition and physical activity, but they are related to heart disease.

I conducted a heart disease weight reduction program in the inner city of Denver and one of the things that emerged as our support groups progressed was sexual abuse and its relationship to obesity, and even when you talk, I mean I think there is a subgroup of the population where you can give them good nutrition education and they can respond to that, but when you are talking about persons who have more deep-seated psychological issues all of the nutrition education in the world I don't think is going to make a difference until the compulsive kinds of things that underlie that are addressed, and so, I don't know how you, again, would incorporate the idea of maybe some diagnoses in terms of an objective to try to get at what some of these problems are because I think we are spending resources, spinning our wheels spending resources, and we are not getting the outcomes that we want because we are not addressing the right problem.

Thank you.

DR. SLOAN: Thank you, ma'am for that thoughtful comment.

Next commenter, please?

MS. MARINO: My name is Martha Marino, and I am a registered dietitian working with the Washington State Dairy Council, and prior to that I spent about 3 or 4 years working with the Washington State Five-a-Day Program, and the comment that I would like to make has to do with diet and life style modifications for control of high blood pressure, and in looking at Page 20-14 where it talks about life style modifications like losing weight and then, also, eating a diet rich in fruits and vegetables I would like to add to that low-fat dairy products because there is good research through the National Heart, Lung and Blood Institute on the DASH diet which is Dietary Approaches to Stop Hypertension, and I think that calcium in dairy products is often overlooked, and I would like to see that added.

Thank you.

DR. SLOAN: Thank you, ma'am, for your comments.

Sir?

MR. FINGER: Reg Finger from Colorado. When I look at the chapter on heart disease you have a couple of objectives on deaths and then hop right into risk factors and more front-end type issues. I don't see anything there on the incidence or prevalence of heart disease.

Recognizing that that is hard to measure because you don't have registries like you have for cancer, etc., I think some consideration could be given to measuring hospitalizations or hospitalization rates for heart disease especially given the fact that they are expensive, and if you prevent hospitalization either by keeping people in the hospital shorter lengths of time, reducing numbers of admissions or by reducing the incidence of heart disease then that would be very important just because this dwarfs so many other things in terms of costs, and if an objective could be slid in there regarding either incidence or hospitalization rate that would be, I think a good thing, and if you need to avoid proliferation of numbers of objectives and you need to cut one out so that you have room I would say maybe No. 20-5 on awareness. There are hundreds of possible awareness objectives throughout the book that are just, we sort of assume that awareness is one method of achieving many of the other objectives, and if you need some more space that would be where I would suggest cutting.

Thanks.

DR. SLOAN: Thank you, sir.

Next person's comments, please?

Are there additional comments on heart disease and stroke? Some very thoughtful and provocative comments have been made, and I appreciate those. Hearing no further comments we will close this comment period for focus area No. 20 and move to focus area No. 21, HIV.

Could I have the first person's comments, please?

Oh, I am sorry, while you are coming up, go ahead. I wanted to introduce our federal representative from the Centers for Disease Control Eva Seiler. Eva, thank you for being here.

MR. HERRERA: Good morning. My name is David Herrera from Montana, and I do HIV education. In looking at the section on HIV I noticed that several populations at risk are covered and that is drug users, prison populations and youth. The one population that I don't see covered though that I certainly work a lot with and that happens to be gay and bisexual men and men having sex with men and so I would really like to see an objective that specifically addressed this population if, in fact, we are going to be looking at risk behaviors.

What I, also, don't see is we have information on the minority populations, African-American and Hispanic and again what I don't see here are other populations, such as here in Montana I am working with Native American populations, and there may be little data, and I think a lot of that is due to under reporting as we have seen with eliminating disparities, but I don't think that doesn't mean that the risks are not there or the incidence is not there.

Thank you.

DR. SLOAN: Do you have any comment to that, Eva?

MS. SEILER: Actually I think both of those are addressed in objectives 1 and 2 where it is HIV surveillance and AIDS surveillance for both Asian Pacific Islanders and Native Americans and, also, for men who have sex with men.

DR. SLOAN: Good. Thank you for that comment, sir. That is a good reinforcing comment. We appreciate that.

Further comments, ma'am?

MS. BOWMAN: Hi, my name is Darcy. I am from Plan de Salud de Valle in Colorado, also, Salud Family Health Centers and a population I deal with frequently and as a nation we do, and it is undocumented immigrants, and it hasn't really been addressed, but they are a part of public health even though it states that these objectives are for the American people. Remember we are a nation of immigrants and those health needs, also, need to be assessed and not much research has been done for HIV and STDs in the undocumented populations that migrate throughout the nation and probably a good focus of study which kind of leads to confidentiality, reinforcing confidentiality in testing and providing treatment because that is the biggest barrier for these populations, also is am I going to be turned in if I know I have an STD or something. Is that barrier going to mean that I am going to be deported? So, they are going to continue to have this life style if we cannot eliminate those barriers for the undocumented.

DR. SLOAN: Thank you for that thoughtful comment. We appreciate that. Is there any response, Eva?

MS. SEILER: The only response that I would have to that is we tried not specifically with HIV but with a TB survey to ask questions about persons' immigration status and our survey have to be approved by the Office of Management and Budget, and we were not allowed to ask questions about a person's immigration status. We were told that that was an invasion of privacy and really none of our business. So, it would be difficult I think for us to get that kind of approval related to HIV and STDs.

DR. SLOAN: Thank you for that comment.

Next person, please, with any comments on the focus area on HIV?

Ma'am?

MS. KOSTELECKY: Good morning. My name is Bonnie Kostelecky. I am the Director for Assessment in Epidemiology at Southwest Washington Health District. It is a two county health department in Southern Washington, and I wanted to make a couple of comments directly specific to 21-11, Item No. 2.

This objective talks about diagnosed HIV infection and I wanted to direct a question to the panel. Has this been discussion, whether this will be named reporting or will this be a unique identifier?

My second comment is specific to 21-13 which deals with the issue of increasing the percent and proportion of clients who are screened for common bacterial STDs. I would like to see a definition of that screening, please, to include laboratory diagnosis and confirmation. Screening is not enough to be done by history. What we see in local public health jurisdictions repeatedly is inappropriate treatment of undiagnosed sexually transmitted diseases and particularly this happens when women are asymptomatic particularly in Chlamydia and finally under your section No. 6 regarding inmates of federal and state prisons I would, also, like to see the term "county" added.

Some of our systems leave local prisoners in county jails for really long periods of time, and HIV counseling and testing should, also, be included in that objective.

Thank you.

DR. SLOAN: Thank you for your comment, ma'am. We appreciate that. Any specific response, Eva? You seem to be getting a couple of questions in this focus area, but I will try to pick on you.

MS. SEILER: That is okay. The last two about the definitions and including county, we will take that into consideration with the other comments.

Regarding HIV infection, CDC is getting ready to publish some draft guidelines on HIV reporting, and states will be allowed to develop either named reporting or unique identifier systems as long as they meet certain criteria.

DR. SLOAN: Thank you, Eva.

Next person's comments, please on HIV, focus area No. 21?

Are there additional comments that you would like to make?

Hearing no further comments, we will close the comment session then for focus area No. 21 on HIV, and we will open up comments for area No. 22, immunizations and infectious disease.

Our federal panelist from CDC is Martin Landry.

First person's comments, please on immunization and infectious diseases?

Ma'am?

MS. AZCAPOTZALCO: Hello, my name is Cherylle Azcapotzalco. I am a registered nurse, community health nurse and one of the areas I am really concerned with as I go into the community is tapping into various communities where infectious diseases seems to be pretty prevalent, and I understand that there may be some kind of funding cut as far as TB clinics are concerned. I know that the political refugee status is greatly affecting this state where, just various populations such as the Russian Ukranian population that I go and see, and it is difficult when you, also, have undocumented immigrants that you suspect are having some respiratory infectious diseases or other infectious diseases by the signs and symptoms they are exhibiting, and it is difficult to get them into a clinic or whatever and a source related to the funding where there are reports and statistics show that it is on the decrease, I don't believe so, not when I speak with my other nurse colleagues, and we are out there in the communities. We see this when we go out to various communities maybe coming across a neighbor's house of a client that may be full of immigrants, and there are suspicious signs and symptoms of infectious diseases and I think that for statistics perhaps the Federal Government needs to tap into the sources, excuse me, the resources of the home health nursing agencies or the other various community nursing agencies that can tell you what is really going out there because it is undocumented, and that is just the comment I had to make about infectious diseases.

DR. SLOAN: Thank you, ma'am for that thoughtful comment.

Next person's comments, please?

Ma'am?

MS. BOWMAN: I am Darcy Bowman, again, from Colorado. Regarding immunizations most of the measurements for the outcomes of increasing immunization rates have to do with how many vaccines or how your rates have been met according to your standards but rather maybe we can measure the attempts. How many times did you attempt to match your rates, because that is more measurable. I mean that shows the effort you have tried to get your population immunized rather than the rates that were met.

DR. SLOAN: Thank you for your comment, ma'am.

Next person's comments, please?

MR. FINGER: Reg Finger, Colorado. On the table of target immunization rates it is 90 percent across the board. There are three of the antigens where we are already above 90 percent, and I think that in keeping with the spirit of this document where we are trying to shoot for improvement I think it would be reasonable to try for 95 percent on polio, Hib and the three doses of DTP while maintaining the very challenging 90 percent goal for the series. It seems that we could do that especially in view of places in the United States that are already probably at 95 percent on individual antigens in certain states.

Thank you.

DR. SLOAN: Martin, is there any particular comment relative to those three areas?

MR. LANDRY: No, I appreciate those comments. I may just add that on the 95 percent issue I think some of the scientists will say that they feel if we can get to 90 percent and stay at 90 percent they are comfortable if we can maintain those levels we can keep the disease level down and that is the core thing I think they are thinking of.

DR. SLOAN: Thank you, and thank you for your comment.

Next person's comments, please, on immunization and infectious diseases?

Are there additional comments, please?

Hearing no additional comments then I will close the comment period for the immunization and infectious diseases focus area No. 22, and we will open up comments on focus area No. 23, mental health and mental disorders.

Ma'am?

MS. STEPHENSON: Hi, my name is Andrea Stephenson, and I am a mental health advocate. My statement would be what would you do if you have a mental illness. Adults and children with mental illness face numerous obstacles in life every day that range from access to care, education, getting a job, an occupation that provides fulfillment, housing, the public perception of persons with mental illness, stigma and related social barriers and numerous other barriers which people with mental illness face.

I, myself, deal with a mental illness of a bipolar and PTSD on a daily basis and have faced every one of the above issues in my lifetime. I lost my job because of lack of access to care when needed, felt stigma and discrimination at the level of getting an education and employment. All these have been painful experiences which no person or group of people should have to face.

People with mental illness face these challenges every day and more. The ability to get up every day and face these challenges that a person faces with mental illness is difficult but can be overcome with the following: Proper treatment, access to care, the support of friends, family and the public which can be difficult to get, access to a good education, changing the public perception of persons with mental illness which is stigma, advanced directives that can be considered legally binding and honored, treated fairly and the same as any other medical condition in health insurance and not be discriminated against, not have the media see people with mental illness as a joke but people with thoughts, feelings and beliefs that should be respected, medical providers who communicate effectively, involve persons with mental illness on an equal basis at all levels of the decision-making process, including federal, state, local insurance or any level. Respect and dignity go a long way. The head is connected to the body. The above things came from a survey of talking to about 150 people in Washington State.

Thank you.

DR. SLOAN: Thank you, ma'am for your very thoughtful comments. I neglected to introduce our federal panelist who is hearing these comments on behalf of the Substance Abuse and Mental Health Administration, NIMH, NIH, Winnie Mitchell. Winnie?

Thank you.

Next person's comments, please on focus area No. 23, mental health and mental disorders.

Ma'am?

MS. STAPLES: Thank you. I am a short person. I may have to pull this down here. Microphones always bother me for that problem.

DR. SLOAN: We don't have a focus area for that.

(Laughter.)

DR. SLOAN: I am, also, a short person.

MS. STAPLES: I am from Colorado. My name is Carol Staples. I have a background as a family member of an individual with a mental illness and served 8 years as Executive Director of the Colorado Alliance for the Mentally Ill. I, also, currently am involved in Northeast Colorado as director of consumer services in a service agency. So, I come from a couple of different kinds of backgrounds.

I have, also, served on the state mental health planning council for about 8 years. So, I am aware of a lot of the mental health services planning for the State of Colorado, and am trying to put this together with Healthy People 2010, run into some of the difficulties we have in Colorado in terms of getting this all together.

The mental health services under restructuring of state government in 1993, got buried in state government not as its own department at cabinet level where there would be equal discussions with general health services and all the other service agencies but got buried in the department of human services as an office.

So, anything to do with mental health at the state level gets filtered through other people, not direct comments from the mental health services itself.

Also, in that restructuring mental health services were separated from hospitals. The hospital services went under health and hospitals and the services aspect got buried.

So, with all that in mind the comment is that it is going to take some dollars and some really hard work getting the state infrastructure on the same track, and that would be, also, what would be necessary at the local levels, too, and because Colorado is two-thirds rural not in population, whoops, sorry, okay, it is going to take a lot of work there.

Comments on No. 5 on homelessness, objective 5, we need a variety of alternatives. It is going to be hard to build those.

Six, in employment we need to consider non-paid employment to measure that and encourage that. Consumers do a lot of volunteer work and do a lot of self-help groups. This helps with the total general health of people and that needs to be supported, and this is outside of the medical model.

Under services we need to train peer counselors. We need to develop consumer-run, self-help support groups, telephone networks and other support services that are recovery based and make sure that those get in there.

We need to do a lot of education and empowerment.

Cultural competence, we need to consider consumer culture as a separate, sort of a separate culture as well as the mountain, frontier and rural culture however that gets incorporated.

Nineteen, jail diversion, we need to consider more than just up front jail diversion in that but, also, people coming out of prisons in transition settings. They come out with triple stigma because of perception of violence and so on. Community acceptance, they have a real hard time in the community, and it is a whole separate thing.

Okay, maybe I will have time later.

Thank you.

DR. SLOAN: Thank you for those thoughtful comments. We appreciate those.

Sir?

DR. RAMEN: It is highly commendable that the opening statement of this section says, "Ensuring appropriate high-quality services informed by scientific research." It is an excellent statement. Make sure we follow that right up to the T, until we do this work. In the year 2010 if the political condition doesn't change in Washington we may be able to do something here.

Let me just give a perspective in terms of the mental health situation. I think we need to have a complete paradigm shift in terms of how we train the people who are providing services right from the department of psychiatry to the counselors.

Most of us are unidisciplinary people. We need to have a multidisciplinary approach for the mental health problems because the brain is not only just a biological instrument, psychosocial and spiritual aspects are extremely important.

I was working for Aries(?) Laboratories in Canada in antidepressants for more than 20 years. I just gave up because I became very depressed after working in that because the whole paradigm of the industry is so and so is a mentally dysfunctional bipolar because he has no Prozac in his system. So, in other words we need to completely have a new outlook as to how to look at the mental dysfunction as, also, a biological problem. It is not just purely one. I was so heartened to read a book by Rosalyn Carter, Jimmy Carter's wife, and she is not a professional. She doesn't have degrees. She is just a wonderful human being, and that book must be read by every human being that is interested in the mental health situation, and we are discussing this focus of our concerns as if they are isolated areas. They are highly integrated.

So, I would like to have a new outlook in terms of the paradigm with which these people are educated in the institutions of higher learning, and, also, molecular psychiatry or biochemical psychiatry is going to be extremely critical in the coming ages, and Canada and Japan are doing more work than we are doing in North America. So, we have to look outside our borders to see what we can do.

I think that these are some comments that are seriously taken, and I think we can do a tremendous impact on mental health if you look at the biological aspects of t he brain and behavior.

Thank you.

DR. SLOAN: Thank you very much for those insightful comments. I trust you are feeling better now since you have gotten back here to Washington, back from Canada.

Next comment, please?

MS. SOULE: I am Susan Soule. I work for the Department of Health and Social Services in the State of Alaska. I used to work for the Division of Mental Health. I now work for the Division of Alcoholism and Substance Abuse with a large focus on suicide prevention.

I am concerned that suicide appears only in the mental health section of this document. For me the beauty of the public health model is that it allows us to address the health of populations and recognize that there are some social conditions that contribute to behavior and dysfunctional behavior. Placing of suicide in the mental health section allows a definition that says that people who take their own lives have a diagnosable mental or substance abuse disorder.

There are precursors to that disorder which are social conditions because I focus a lot with Alaskan Natives. We need to look at racism, discrimination, poverty and lack of opportunity as contributing factors to suicidal behaviors. Suicide is a behavior.

The mental health section, in addition seems to me to use mental illness, mental problems, mental disorders and mental health behaviors interchangeably. I think they are not interchangeable terms. They confuse the issue and contribute to the problem of stigma.

Finally, I think the whole area of cultural competence is handled inconsistently across the document and particularly in the mental health section.

Let me see if I can find the precise quotes? Belief systems in the mental health section, some individuals because of their age or cultural context do not experience symptoms of mental illness as a problem. That strikes me as a fairly culturally incompetent statement and yet in another section they talk about prevalence rates must consider the cultural meaning of mental illness.

Mental health behaviors need to be defined in the context of each individual's culture to determine normative behaviors. That is a far more culturally competent statement, and that approach should really frame cultural competence throughout the document. Cultural competence is not my learning enough about you to convince you that I am right. It is my learning enough about you to understand your world view and respect your own approaches, definitions of health and healing.

Thank you.

DR. SLOAN: Thank you. Before you leave, ma'am, could you come back to the microphone? I just have one question. I just wondered if you had a specific or two or three other focus areas that you would like to see suicide addressed in rather than just mental health?

MS. SOULE: I think certainly injury and violence prevention. Lloyd Potter at CDC has done a good job of educating folks and a gentleman yesterday when I spoke raised the question of environmental health, and I am not experienced enough at thinking about environmental health broadly enough, and I apologize to him and to you for not knowing that it should, also, be there.

DR. SLOAN: Thank you for those comments. I appreciate them.

Next person's comments, please?

MS. WELLS: Hi, I am Linda Wells, and I am a planner here with our local area agency on aging here in Seattle, King County, and we have recently been working in a multi-organizational partnership called Healthy Aging Partners, and it involves our local public health department, the University of Washington, our Area Agency on Aging and many hospitals, looking at the whole issue of suicide in the elderly.

The objective 6.2 on Page 23-9 on suicide attempts, I don't know if this is more detailed than you want. I have a feeling you are looking more at the macro, but we have been looking at the issue of nobody seems to follow up on suicide attempts through the emergency room.

It seems like often the elderly person or people in general are given a number to call. They are told to take some initiative to go find someone to help them.

We are looking at the idea of perhaps the emergency rooms can go back and contact their physician. As you know, often the person has visited their physician a month in advance of doing the attempt. Why not complete the loop? It is just something to consider.

DR. SLOAN: Thank you for those comments. I appreciate that.

Further comments on mental health, mental disorders?

PARTICIPANT: Could I get some clarification on the last comment? I am assuming that your comments to have a follow-up to ER suicide attempts applies not only to the elderly but to the population at large?

MS. WELLS: I think it could.

PARTICIPANT: Thank you.

DR. SLOAN: Thank you.

MR. MACDONALD: Steve Macdonald, Office of Epidemiology, Washington State Department of health. Just a point of information. There is an objective, in fact, targeted exactly at that. It is in Chapter 10 on access it is 10.17, also, numbered C.6 depending on whether you are looking at the book version or the Web version of these things, but it is specifically on access to follow-up mental health services. So, that may be covered.

DR. SLOAN: Thank you for that clarification, sir. He may get the award for having read --

(Laughter.)

DR. SLOAN: -- more specifically than some.

Ma'am, you had a comment?

MS. ROTH: My name is Sarah Roth, and I represent an organization called Eating Disorders Awareness and Prevention. We are a national non-profit organization headquartered here in Seattle, and I am here to offer my great support and commendation for including eating disorders in our nation's public health agenda. It is very satisfying for our field to see that included.

I would like to make three quick comments. One, I hope that the definition of eating disorders that is adopted is as broad a definition as possible including not only anorexia and bulimia but, also, binge eating disorders, eating disorders not otherwise specified and other borderline conditions.

I, also, think it is important to note that while it is included in the objectives targeting children and adolescents, it is, also, important to recognize that eating disorders occur among adults. It would be nice to see an objective, also, addressing adult populations who do struggle or continue to struggle with an eating disorder that perhaps developed earlier, and finally, it would, also, be nice to see an objective that focuses on the importance of prevention and early education, particularly in some of the other sections that focus quite a bit of effort on nutrition and dietary change.

It is important to continue to complement that form of education with education on keeping your body healthy, fueling it and making sure it has what it needs.

Thank you.

DR. SLOAN: Thank you for your comments.

Would you please register at the back? Thank you.

Next person's comments, please?

We have time in this section for one more.

MS. GARCIA: Hi, again. My name is Gimi Ramerioz Garcia, and my background is in counseling and human relations and I would like to again stress in terms of prevention the idea of cultural, inclusion in cultural competence throughout our country and all sorts of systems and organizations, and I think the failure of this to happen and the results in what we see as mental dysfunction or emotional problems is nowhere more evident than in our schools where in particular young people of color are often labeled as being dysfunctional, angry, depressed and even diagnosed with learning disabilities as a result of institutionalization and factors that permit them to fully engage in the learning system, and I think that this is really, these manifestations are really their best way of coping with the situation that they are met with because of the lack of cultural inclusion, and I think that maybe we need to look at the failures of systems to involve these kids and involve all of us really as people of color in the process where we are allowed to contribute to the best of our ability and really share in the functioning of all of the work that we have to do here.

Thank you.

DR. SLOAN: Thank you for your comment, and we appreciate your presence here today.

Next commenter, please?

I said, "One more," but she was short.

Sir?

DR. WILSON: I am William Wilson. I a physician in general practice here in Seattle, director of health development resources.

I appreciate the necessity in terms of management to address many of the health conditions in terms of disease prevention and treatment, but particularly in terms of mental illness and other related conditions, such as nutritional deficiencies I think we might want to consider addiction as a focus for management and prevention. Addiction is a broad-reaching nature of human beings which has negative consequences, but, also, positive, and I believe if we address more resources to understanding the primary qualities and aspects of addiction we may get some new perspective on management and treatment of specific conditions as well.

Thank you.

DR. SLOAN: Thank you for your comments.

I am going to close the comment period due to time restraints in that general area and move now to focus area No. 24, respiratory diseases.

We have with us as our federal panelist Ernestine Smartt, from the National Institutes of Health. Ernestine?

Could we have our first person comment, please?

The focus area is respiratory disease.

I don't hear much coughing in here, no smokers, no wheezing. I don't want to make too much light of it. Are there comments on this particular focus area?

Hearing none, we will close that focus area then and move to focus area No. 25, sexually transmitted diseases. Eva Seiler will hear comments as the federal representative from CDC. Eva?

Could we have our first person's comments, please on sexually transmitted diseases?

Sir?

DR. RAMEN: I thank you again for allowing me to come here because I am not always politically correct. I am the Ross Perot of this meeting.

DR. SLOAN: Let the record reflect so.

DR. RAMEN: I am so happy that the goal of this whole focus is society. There are healthy sexual relationships free of infection, as well as coercion, and unintended pregnancies are the norm. It is a terrific goal, and also, the second part of this it talks about changing sexual behavior and sexual norms will be an important part in any long-term strategies. I think that while the immediate short-term objectives are absolutely right on target, but from my point of view we miss the whole perspective on the moral and spiritual aspects of sexual relationships because we are not meeting the fundamentals because Moses did not give 10 suggestions or 10 options. He gave Ten Commandments, and America is a good testing ground to know whether they are options or commandments. So, we are going through a cultural testing of the ancient wisdom of all the religious practice of other cultures.

While we are doing it we must be very bold to say that there are certain values and norms that are important for a healthy society, and they are to be infused in particular spiritual education in our country.

Of course, our Constitution doesn't allow us to bring religion and state together but we can always have a back door method of putting things called values to education. We can bring it to, because if there is a will, there is a way, and now, we are at a juncture where we cannot be taking politically correct statements. We have to be morally bold and assertive to make sure we are going to have a society where spiritual values will be of great importance.

I travel abroad quite a bit. I am actually an American, first generation. They always say, "Look, you guys in the dollar bill you say that in God we trust. Why don't you apply it?" No, no, Americans are always in a great hurry. They forgot to put the g-o-l-d, you know, g-o-l-d? So, we have to say, "I am sorry, they forgot to put the g-o-l-d, in gold we trust." There is a printing error there. So, unfortunately I just say, "No, they trust in God," but what happens is there is not enough consensus among the people to make sure that becomes the whole paradigm of the culture. We need to reintroduce moral and spiritual values back to the very basis of all prevention of sexual problems.

We can have a happy, healthy sex life but not the way we are, promiscuous behavior. Of course, you know in a heterogeneous society like North America we can always question any values, but I am telling you there are some eternal principles in the universe. When we violate it, we are going to be victims of that.

Thank you.

(Applause.)

DR. SLOAN: Thank you.

MR. FINGER: Reg Finger, from Colorado. I would like to commend our most recent commenter and agree with the whole issue of needing to watch how we talk about those norms and I agree completely with what he said especially as regards the wording of that one section he referred to. It does come across sounding like openness and more communication is the answer to changed behavior. I think it is a part of the answer to changed behavior. I think that changing of norms in the society per se is very important to, also, address in that paragraph.

Thank you.

DR. SLOAN: Thank you for your comments.

Next commenter, please?

MS. KOSTELECKY: Again, Bonnie Kostelecky from Southwest Washington Health District. I think I might be so bold at this time to represent local public health nursing directors and health officers for the State of Washington.

In this section, STD objectives 13 and 14 you deal with financial policies. I have some very serious concerns about this. My local public health jurisdiction as do all of ours in the, almost all of ours in the state with the exception of Seattle, King County receive zero, no money, either federally or state for the treatment, follow-up, surveillance of STDs in general and specifically those that are in our STD clinics.

It is extremely presumptive at the federal level for you to suggest how we should be spending our money, and I am going to be extremely specific about this. When you at the federal level pass down dollars specifically related to the treatment of HIV or TB, you typically develop rules that are very specific about what must be done with the money in the surveillance and reporting guidelines.

What we have at the local level been doing for a number of years is treating, running clinics and following fairly strict guidelines about the treatment of STDs and surveillance as well as partner notification and partner treatment without a dime. So, as you are thinking about adding these two objectives in particular I would strongly suggest that you collect more information from other local health jurisdictions about the amount of money that comes from the federal coffers for the treatment of these problems.

Thank you.

DR. SLOAN: Ma'am, just one minute, please? We need a clarifying point of view here.

MS. WILSON: Were you commenting on objectives 13 and 14?

MS. KOSTELECKY: Yes, the ones that suggest that local public health jurisdictions reimburse managed care providers for the treatment of partners.

MS. WILSON: Yes, okay, I got you.

MS. KOSTELECKY: My local county commissioners will not appreciate this.

DR. SLOAN: Thank you for that insight. We appreciate that.

Next person's comment, please?

Are there further comments on the focus area of sexually transmitted diseases?

Hearing no further comment, I will close the focus area to any further comment, and we will open the area to No. 26, on substance abuse. Winnie Mitchell from SAMHSA will be the federal representative hearing your comments.

May I have the first person's comments, please, on substance abuse?

The focus area is substance abuse. Ross, did you have any comment? Ross Perot?

DR. RAMEN: I was disheartened to see nobody rose up because that is one of the biggest problems facing the country and you will find that substance abuse can be dealt from a variety of areas, macro to micro. I am not going to go into the philosophy of it, but I am concerned about one area, disability and secondary conditions. I work with school districts in order to prevent pathologies so people don't go into special ed, and I find that if I am right the World Health Organization published an article in the New York Times saying that 8.3 tons of Ritalin are dispensed annually and 92 percent are for the American kids from ages 6 to 14. I can give you the reference if you want from the New York Times.

So, substance is a part of what we take as cultural norm. When somebody doesn't learn properly you give him Ritalin, and then he will be all right because they become zombies but as an educator I want them to be interactive with me so that they can learn.

So, I would like the school system to have a completely different thinking about how to reach those children who are labeled ADHD, ADD, a non-drug approach.

In fact, there are 17 other methods by which we can prevent them from taking Ritalin. If anyone is interested in that I am willing to send the reprints for that.

Thank you.

DR. SLOAN: Good. Thank you, again, for a provocative comment, and we appreciate your presence here.

Further comments, ma'am?

MS. AZCAPOTZALCO: To respond to the good doctor's comments about that, he was surprised no one came up to say anything about the substance abuse problem as it is so prevalent. As a community nurse I just feel that I am just overwhelmed. I have a lot of disabled clients in the community and a lot of them are secondary to substance abuse, especially when I see those who have chronic hepatitis, you know, the IV drug injections and all this other business, and you think well, what can you do, and now they have got the portacavs(?) that we have to flush every month, and some of them are putting stuff through that and then they end up in the hospital, and so it is a huge problem, and I just feel pretty overwhelmed. What can you do, you know, unless you have good enforcement of laws that you maybe can mandate if some of these abusers do get into treatment that you do not have an option if you are still practicing it, especially when you go to the doctor's appointment or when the nurses come into your home to draw your blood once a month, and it shows up. I think it needs to be enforced. Otherwise, what can you do?

DR. SLOAN: Yes, a very complex area, and I appreciate your comment.

Winnie, did you have any additional comments?

MS. MITCHELL: I guess I would just say that many of the objectives in this chapter really address youth and the prevention of these problems from the very beginning, and I wanted to, also, share with you, I think many of you were in the work session on healthy behaviors yesterday, but I would bring to you the emphasis from our recent progress review on substance, in that really part of prevention for youth is addressing the alcohol, the access to alcohol and the need for community enforcement of the age 21 drinking age.

So, I just bring that as a general theme throughout this chapter.

DR. SLOAN: Thank you for that comment.

The gentleman from Utah had a comment?

MR. BAILEY: John Bailey, again, from Utah, representing the local health departments there. Almost all, if not all of the goals and comments in the substance abuse section seem to me to be directed towards illicit or illegal substances, and I would suggest that if we are looking at the population in general and the number of people affected that we should make at least some comment about the inappropriate use of legal or prescription or even over-the-counter medications, that again the sum total of the ill effects suffered from the inappropriate use of these substances and medications, also, takes a toll, and I think it is a great oversight to not direct at least some goals to that area of substances, also.

DR. SLOAN: Thank you for that thoughtful comment. I appreciate that.

Next comment, please?

Ma'am?

MS. JACKSON: Emma Jackson from Colorado, again. I just wanted to make mention of the Ritalin, and the schools prior to 1991, I retired full-time employment with the Denver schools in 1992, and I may have had three kids on Ritalin coming in daily. When I went back to orient new nurses in a new position I find that the cupboards were totally filled with Ritalin. This is in 1992 up until the present time, and I am concerned. I am concerned because like the gentleman said, prescribed abuse, prescribed medication abuse as well as, I don't know, health disparities because most of these children are of African-American descent. So, that is a concern that I have. I do have a concern about the high levels of Ritalin in our schools.

DR. SLOAN: Thank you for your comment, ma'am.

Next person, please?

Ma'am?

MS. SANCHEZ MARTIN: I am Barbara from Denver. I just looked at the book real quickly, and there isn't anything in there on food addictions, and I know it is kind of controversial in terms of whether or not compulsive eating could be considered a food addiction.

One of the other observations that I made with the many groups that I conducted, the women who have problems with, and again, this was a heart disease weight reduction program, the women who had problems with eating, compulsive eating, their husbands tended to be heavy drinkers, not that they were alcoholics, but they were heavy drinkers, and I don't know what kind of relationship exists there, but I am thinking maybe we need some kind of an objective that deals with food addictions or worded something to that effect, and I think, also, in terms of substance abuse in general there is a community aspect to it because there are so many events, cultural events that are underwritten by alcohol, beer companies. So, maybe we need an objective in there that deals with what communities can do in local events to try to stop modeling these kinds of behaviors.

DR. SLOAN: Thank you for your comment.

Ma'am?

MS. WELLS: I appreciate that 2010 is focused primarily on this issue on children. I would like to suggest that for 2020 you perhaps look at people 60 and over. As you know, the Baby Boomers are aging. There are some that have had chronic substance abuse and alcohol issues and I recently visited our needle exchange program here in Seattle and was surprised to find the number of 60-plus who visit that, who do have an IV drug use. So, it is just a suggestion for the next go-round.

DR. SLOAN: Thank you.

Yes, go ahead.

MS. MITCHELL: I have to say that there are some objectives explicitly aimed towards 60 and over, I think No. 19.

DR. SLOAN: Sir, do you have an addendum to your initial comment?

DR. RAMEN: You have been extremely kind again to recognize me. Look at this room. Those who are remaining, 90 percent are women. Women's role is healing. So, in the next century we had better listen to women more than anybody else because they have a perspective that we have lost in Western medicine for a long time.

Coming back to the --

(Applause.)

DR. RAMEN: Coming back to the issue of Ritalin many have wondered what can we do. We have got 8.3 tons of Ritalin being dispensed. What can we do about it? Because I am a biochemist, I am giving you a particular answer. All of us recognize attention deficit disorder has something to do with a neurotransmitter abnormality, and if Ritalin is going to be the one to rehabilitate it, we are in the wrong direction because nutrition is extremely important for rehab of the neurotransmitters.

That is a very broad paradigm that can even take care of mental health problems because the micro-environment of the brain cell neuron is extremely critical. So, what we can probably do is nutrition is going to assume a tremendous importance in the next 25 years whether we believe it or not, not because we had forced it but by virtue of the knowledge we have accumulated in this country we have a moral, scientific, professional obligation to bring this knowledge to the community.

So, we have to look at the nutrition of children in terms of ameliorating some of the attention deficit disorder problems.

Thank you.

DR. SLOAN: Thank you, sir.

I might say that maybe we should invite the doctor in to help us rewrite the preamble. Thank you, sir, very thoughtful.

DR. RAMEN: Yes, sir, even a person like Ross Perot.

DR. SLOAN: Thank you.

DR. RAMEN: You are very spiritual people because you allowed me to come here and you invited me three times when nobody else was here.

DR. SLOAN: Thank you, sir.

Next person's comments, please?

Those of you who might have just come in, we are focusing on the last area, 26, on substance abuse.

Ma'am?

MS. HANES: I am Paula Hanes. I am a dietetic intern and from the Pasteur(?) University. I just want to express my hope that ONDCP will recognize nutrition therapy as an important part of substance abuse treatment and that they regard nutrition deficiencies under the umbrella of medical problems. I am referring to the paragraph on 26-23, and their establishment of the national treatment outcomes monitoring system, and, also, I would like to make a comment about if they could include in some section on education for children the importance of food security and nutrition education among children of substance abuse parents.

Thank you.

DR. SLOAN: Thank you.

Any comments, Winnie?

MS. MITCHELL: I think that is interesting. I would like to talk to the lady after this period though to get her specific comment on that one provision.

DR. SLOAN: Thank you.

Next person's comments, please, substance abuse, focus area 26.

My understanding is that the other session is closing down, is that correct? They may join us, and we will keep open for some general closing comments.

Before we leave substance abuse are there any further comments anyone would like to make?

Hearing none, we will close that focus area then. I want to thank each of the panel members for the specific contributions and charge you with the responsibility of incorporating the comments here. We appreciate all of you who have commented.

We will spend a few more minutes, if you would like, taking general comments on anything that might be on your mind about the general framework.

We spent some time here and there on infrastructure, on some of the objectives of size. We have got a couple of general comments.

Ma'am, could you come to the microphone?

MS. SULLIVAN: Thank you. My name is Patricia Sullivan, and I am a pediatric psychologist in the Director of the Center for Abused Children with Disabilities at the Boy's Town National Research Hospital. I am sorry I was late for the disabilities and secondary conditions comments because I was giving a talk at another conference here in town on people with disabilities. I will be very brief because I am, also, submitting some written comments, but I would just like to strongly encourage you to include people with disabilities as a select population in all the chapters of HP 2010. We need to reinforce the significance of people with disabilities as a population really with great disparities in health care.

I have done research at the Boy's Town National Research Hospital on children with disabilities as victims of maltreatment, two population-based studies. Children and youth with disabilities are three and one-half times more likely to be victims of child maltreatment than children without disabilities. They are 3.7 times more likely to be neglected, 3.79 times more likely to be physically abused, 3.87 times more likely to be emotionally abused and three times more likely to be sexually abused than children without disabilities, and the chapter on injury and violence prevention is silent on children with disabilities.

I attended a special conference in Washington with Michael Marge(?) on Healthy People 2010 making suggestions and was told that, well, if you don't have a population-based study we cannot include it, and I have population-based studies, and children and youth with disabilities cannot wait until 2020, and so I would just strongly encourage you to include them in all chapters but particularly in the injury and violence prevention.

Thanks. I was brief.

DR. SLOAN: Ma'am, were you able to get to the other session or is this your first comment about this being included in focus area No. 7?

MS. SULLIVAN: Yes, sir, it is. I am just on disabilities and secondary conditions. I didn't go to the other session.

DR. SLOAN: Okay, but you would like to have this addressed in focus area No. 7, injury and violence prevention?

MS. SULLIVAN: Yes, I would.

DR. SLOAN: Okay, thank you, ma'am.

MS. SULLIVAN: Thank you.

DR. SLOAN: Ma'am?

DR. THORBURN: My name is Kim Thorburn. I am from Spokane Regional Health District here in Washington, but I am speaking as myself, a former prison physician, and I would, also, like to comment on the absence of another population that I think faces tremendous disparities, and that is the incarcerated population in the United States.

One might argue that if we are able to achieve these objectives that we could empty out our prisons. However, it seems that public health really stops when we get to the doors of the prison.

I count four places that there is reference to incarcerated populations in this document but they need to be recognized in many, many more places; for example, in immunizations and infectious diseases there should be reference to incarcerated populations. Many times when we introduce new vaccinations we introduce them for targeted populations, and very often these targeted populations are well represented in our prisons, and yet we don't start vaccination programs in the prisons.

One example, hepatitis C, tuberculosis, very common infectious diseases in our incarcerated populations, and that should be acknowledged, I think in this document. Tobacco use, another area, tobacco control, we see a lot of degenerative diseases in our incarcerated populations because of tobacco use and certainly cessation programs should be targeted in correctional facilities, and I can go on and will submit written comments on this, but I do recommend that incarcerated populations show up a lot more in this document.

DR. SLOAN: Thank you, ma'am, for taking the time to share that.

Sir, in the back? I am sorry, we have one up front here. Go ahead, ma'am?

MS. AHN: My name is Jae Wha Ahn, Deputy Director at the Asian Pacific Center, Denver, Colorado, a community-based organization. One of the services we have is language interpreting and translation services to the medical, legal and other arenas for the last 10 years, and my concern might have to do with health communication or public health infrastructure. The concern is to establish the resources for the language interpreters at the public health facilities and the efficient management. Having an interpreter should not delay the patient's treatment and the second concern is quality control of the interpreters. There aren't recognized training programs and screening measures, and poor interpreting can deter the treatment results, and it is hard to detect what went wrong. So, I would like to see some of the resources put into these issues.

Thank you.

DR. SLOAN: Thank you for your thoughtful comments. We appreciate it.

Sir?

MR. BAILEY: John Bailey, again, from Utah. One of the features of the objectives the way they were presented in the Healthy People 2000 document that I found really useful was separating them into three major categories, service objectives, process objectives and outcome objectives.

If you read those carefully more often than not even though the outcome objectives were presented first and then the process and finally the service objectives, if you read each section backwards, you could more often than not make a connection between the community infrastructure kind of objectives leading to some kind of process that then led to some kind of outcome.

In reading the draft for 2010, I don't see a similar organization of objectives there. I don't know whether the distinction of measurable objectives and what is the other category, developmental objectives are intended to replace that other category, but at least I would like to make for the record the comment that I found that other organization of objectives particularly useful and would recommend that it be considered again for 2010.

As an example of that in Section 22 on infectious diseases and immunizations, if you look at goal 27, talking about decreasing the inappropriate treatment of otitis, I certainly agree and endorse that as an outcome objective. However, that presupposes that the community that diagnoses and treats that condition understands the difference between acute otitis media and otitis media with effusion, and I think if that is the assumption it is an incorrect one, and we will never get to the outcome goal unless we take process and community service objectives to educate the medical community and treating community of that.

Also, a general public education goal, a busy family practitioner or pediatrician in an office dealing with an insistent mother with a child with an ear infection is going to more likely treat unless that mother has the understanding that there is appropriate and inappropriate use of treatment. So, again, attention to the process objectives will help us get to that outcome objective.

DR. SLOAN: Thank you, sir. Before you leave, Pom, do you have any specific comments about the organizational framework that he saw as missing? I know you have been in on much of the --

MR. SINNOCK: I think the way these were certainly, at least the 2010 we had the developmental objectives and I don't think those were meant to replace that process outcome arrangement, but I think it is certainly a suggestion we can carry forward to ODPHP who has the overall structure of 2010.

MR. BAILEY: Thank you.

DR. SLOAN: Sir?

DR. RAMEN: It is very highly commendable that this kind of forum is happening in Seattle. I can see that in this particular document which I had no chance to read entirely there have to be some major recommendations done to institutes of higher learning who prepare health care professionals at all levels.

So, we need to have a comprehensive meeting with the people who are actually delivering this. Because I am a faculty in one of the universities called Walden University, we have got a health care administration division, but they are not concerned about this. They are only concerned about how to make sure that the insurance companies and the AMA and the doctors don't fight. These are the problems that we are looking at a great revision of a cultural transformation towards health attitudes. So, we need to really look at who are these people being trained; what is the paradigm; how can the institutes of higher learning take an active part in this meeting? Do I see anybody from Washington University Medical Health Department here? Maybe they are there, but we should really focus on them. They are the ones who will prepare the crops for the next year.

Thank you.

DR. SLOAN: Thank you, sir.

Additional general comments on any particular portion that either you didn't get a chance to comment earlier or that might have been reflected in the other session or just general comments?

Additional comments?

Hearing none, I wold like to congratulate each of you who has taken the time and specifically spoken today. I think it is important that this process take on a life of its own and without your input it would not be basically a document that reflected on the needs and interests that each of you has expressed.

Again, I would like to thank each of the panel members for being here with us and taking the time and to again assure you that they will be representing us in assuring that your comments, at least are incorporated and thought about as we try to refine the draft.

Again, you have got 12 days, I believe, to make further comments through the Web site, and any written comments that you would like to submit as you are driving or flying home, and you thought why didn't I say that, go ahead and say it.

Is there another housekeeping item that we need to mention? Okay, they are through upstairs.

Okay, hearing no further comments, then this meeting is adjourned. We thank you very much for coming and hope to see you along the way.

(Thereupon, at 11:28 a.m., Session Two was adjourned.)

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