Healthy People 2010 Washington, D.C. National Meeting

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Also, as an emergency provider, we see the most critical manifestations of disease and injury. We have a tremendous appreciation for the importance of preventative services, as well as primary care. And as a sexual assault nurse examiner, I have provided care for victims of sexual assault, both male and female. And one of the things we were asked to comment on as emergency nurses has to do with violence and abusive behaviors. We do support the combination of injury and violence prevention. I do have a concern, though, that most people don't see violence in the same context as they see motor vehicle crashes and we are going to have to really do well on a philosophical change for people, even though I totally agree with that.

Also, another thing in general to the whole framework, we have some concern that you don't look at the whole spectrum of health. A part of health and wellness is death. And we just sort of wonder why death got left out. Maybe we don't like to think about it, but it is there.

The other thing the Emergency Nurses Association would like to propose is an additional objective in injury and violence prevention. That objective would be to increase the number of victims of abuse, either sexual assault or intimate partner abuse that receive forensic evidence collection by trained professionals. We feel that particular goal would help in several ways. One, that these people would get good care, they would get good assessment, and also would help to contribute to healthy communities by, hopefully, recognizing some of the perpetrators and taking them off the street. Thank you.

DR. FOX: Great. Thank you very much. Number 54. Number 54, Kimberly Collins. Fifty-five, Andrea Stephenson.

MS. STEPHENSON: Hi, my name is Andrea Stephenson, for the Washington Consumer Advocacy Coalition.

I would like you guys to stop and think about what you would do if you had a mental illness. Many people in this nation with mental illness--adults and children with mental illness--face numerous obstacles in everyday life that range from access to care, education, getting a job or occupation that provides fulfillment, housing, public perception of persons with mental illness, which is known as stigma, and related social barriers, and numerous other barriers that people with mental illness face.

I, myself, deal with a mental illness known as bipolar disorder, and have a (PTSD) disorder. I deal with it on a daily basis and have faced every one of these above issues in my lifetime. I lost my job because I could not get access to care when needed. I have felt stigma and discrimination at the level of getting an education and employment. All have been painful experiences that no group of people should have to face. And everyday in this nation, people with mental illness face these issues.

The ability to get up everyday and face these challenges that a person faces with mental illness is difficult. But it can be overcome with the following: proper treatment; access to treatment; supportive family and friends; access to good education; the changing of the public perception of persons with mental illness; advance directives that can be considered legally binding and honored; treated fairly with 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 can be respected; medical providers who communicate effectively; involve persons with mental illness on an equal basis at all levels of decisionmaking at Federal, state, local, insurance, or any other level that may effect them.

Respect and dignity go a long way. I would like you to think that the head is connected to the body.

MS. THORNGREN: Good afternoon. Buenas tardes. Thank you for the opportunity to testify today. My name is Mary Thorngren, and I am testifying on behalf of the National Coalition of Hispanic Health and Human Services Organizations, COSSMHO, and our 1500 members. Our membership includes community-based organizations, health and human service providers, researchers, and other professionals who work to improve the health and well being of the Hispanic community.

It is interesting for me to be here today, because I am about to make the same points that I made on behalf of COSSMHO during the development of the objectives for the year 2000. In some ways, we have made great progress; in other ways, we have a long way to go. COSSMHO is pleased to see that there is an overall goal and emphasis in Healthy People 2010 to eliminate racial and ethnic disparities in health, and we have three suggestions for accomplishing this ambitious and challenging target.

First, COSSMHO supports the use of the better than best method for setting the measures under all objectives. Setting the target using the better than best method allows for optimal progress for all the groups. For example, if we look at the area of infant mortality, we see that Hispanics in general, and particularly first-generation Mexican Americans, have a lower infant mortality rate than non-Hispanic whites. Therefore, the standard should be set using the Mexican American rates. In the past, the standard was set using non-Hispanic white rates, which does not recognize those groups with the best health. In many health areas, the majority culture has much to learn from racial and ethnic groups who, despite having less access to health services and other risk factors, may have the best health practices.

Secondly, COSSMHO supports reporting of data by racial and ethnic group under all objectives, as called for in the OMB directive 5, which mandates the reporting of all data by racial and ethnic groups. For racial and ethnic categories where data are not available, we support the current proposal under Healthy People 2010 to specifically state "data not available." This gives the most complete picture of the status of health information in the nation.

Finally, I urge the committee to carefully consider the comments that will be received from community-based organizations, specifically those from racial and ethnic communities. Their perspectives are critical to ensuring that we will indeed eliminate the gap in disparities in health. However, they are hampered in their ability to comment because they often do not have the adequate resources to travel long distances to testify at the public hearings and do not have the infrastructure within their community-based organizations to use the latest technology to provide comments on the Internet. Therefore, you may not get the quantity of comments from them, but their comments will be quality ones and need to be factored heavily in the final analysis.

DR. FOX: Number 57, Neal Baker. Neal Baker. Number 58. Number 58. Number 59, Robert Collins?

DR. COLLINS: Yes, I am Robert Collins, and I am from Maryland. I am representing the American Association for Dental Research, of which I am the Deputy Executive Director, and also Past President of the American Association of Public Health Dentistry.

Both AADR and AAPHD believe that Healthy People 2010 has been a very valuable process, and we appreciate the opportunity for oral health to be part of the overall health focus as we move forward into the next decade. Both of our organizations promote a focus on effective prevention, on increased access to care for those who are in need, and also on the collection of data, and the analysis of those data that would help us to better elucidate problems and lead to better identification of effective strategies.

I want to make four quick comments, in general, related to the oral health objectives, and then I want to say one thing about leading health indicators, and then we have a number of specific comments that we will submit to the Web site before December 15th.

The opening line in the goal statement of the oral health chapter talks about quality of life, and how that is an important part of this process, and it seems that it might be appropriate to include a target that focuses specifically on quality of life from the consumer's point of view, for example, those individuals who are experiencing dental pain and have been unable to chew effectively for a portion of the year or missed school or work during the past year.

Tobacco, we all agree is a major risk factor for a number of conditions, including those that affect the oral cavity. The tobacco section does have an objective that relates to the involvement of health care providers and does include a notation that dentists are part of those health care providers, and we think that is certainly appropriate. However, again, we may want to consider an objective that is related to consumers who may have been advised during the past year by their dentist or dental hygienist to quit.

We note that the Surgeon General's report on oral health will be released only one month prior to the final release of these objectives, and we certainly hope that there will be sharing of information so that those two activities are coordinated.

We would like to see the lumping of text--which I think, affects many of the sections, not just oral health-- better integrated with the objectives themselves. That seems more efficient.

And lastly, I would like to comment on leading health indicators, and ask that maybe you consider water fluoridation, a measure which attacks a very ubiquitous disease, does so effectively, has a great science base, has for many years, benefits all ages, is very inexpensive and, I would argue, reflects a prevention-oriented community, and certainly fits the larger sense of the word immunization. So why not fluoridation as a leading health indicator?

MR. ASTUDILLO: Hi, my name is Rene Astudillo, and I represent the Asian and Pacific Islander American Health Forum, which is a national policy and health advocacy based in San Francisco.

At the outset, let me say that I do not represent a model minority. Just like the rest of the population, we do have some serious health problems and gaps that need to be addressed.

First, some comments on the objectives in the draft. Throughout the draft, there are pages and pages of objectives dealing with select populations where data for Asian Americans and Pacific Islanders is quote and unquote "not available." And I think it is the same with Native American and Alaska Natives. We urge the HHS to clarify what this means exactly. It could mean that data has not been collected at all, or that data has been collected, but not yet analyzed, or that data that has been collected involves just a small sample size, too small to be representative of the entire population. In cases of small sample size, we can certainly propose to combine multiyear data, but in any case, it would be very useful not only for health officials and providers, but also for our own communities to know why data is not available.

On specific objectives, as discussed in the race/ethnicity breakout session yesterday, we would like to propose the inclusion of an objective, perhaps under the public infrastructure section, that would focus on linguistically and culturally competent health services. Also, we would like to propose under the section on injury and violence prevention as mentioned earlier by the gentleman from New York, an objective focusing on hate crimes, since many in our communities are victims of hate crime and that certainly affects their health and well-being.

And just a few comments on the leading health indicators: On audience interpretability, we strongly feel that literacy levels, as well as language capacities of limited English speaking populations, be taken into consideration when selecting and disseminating these indicators in order to benefit the diverse national population in the most equitable way possible. On population applicability, it is important that we do not neglect to consider the impact of leading health indicators on emerging populations, or subpopulations, given the reality that the changing demographics of the American population now reflect groups that have not been traditionally considered in health planning and policy.

We are pleased with the acknowledgment of the diversity of the national population and the need for a leading health indicator to reflect an issue that applies in important ways to this diverse population.

DR. BERNSTEIN: Good afternoon. Ed Bernstein. I am an emergency physician. I represent the Society for Academic Emergency Medicine.

Thirty years ago, I was practicing in the mountains of northern New Mexico. You had a sense of being alone and isolated, and yet, the regional medical program part of our government came up and addressed some very serious needs. They provided us with training for EMPs, ambulance services, and ultimately, years later, several years later, a Health Service Corps physician. But it required the community. They had to build this clinic, they had to recruit physicians, and they had to rebuild it once it was burned down, which is a painful process. So, I came away 30 years ago with this idea that with the community and the public health sector, in the practice of medicine, that partnership was essential.

So, I think that this meeting is really inspiring, and the whole process that our organization has been part of has inspired us that we are not alone. And I think everybody here today--when we are trying to listen to other people's presentations, while you are thinking about your own--realize how important it is that we have all of us together to address these problems.

In emergency medicine, we have our fingers not only on emergency care, not only on the pulse of our patients, but on the community, and on the health care system. We really have a sense of what is going on, and I think out of that comes our concern about both access into the emergency department and access from the emergency department.

A lot has been said about this access into the emergency department, so I won't dwell on it. But in terms of access out of the emergency department, we feel that access should be a leading health indicator. Lack of insurance remains a major determinant of access to necessary health services, including preventative care, primary care, specialty care, and mental health and substance abuse services. There are also serious access issues for the insured and underinsured to the same array of issues. Assuring access is an essential public health function and central to eliminating health disparities, especially for racial and ethnic minorities, is a critical mission, and cultural and linguistic barriers need to be addressed. An access indicator meets all the criteria for leading health indicators.

Audience interpretability-- does everybody understand access? I think it is easy to understand the problem that people throughout this whole country are actually coming to the polls and voting with their feet. This is an issue for them.

Problem impact. It is a deeply felt issue, especially when in a rural area, when you don't have timely access to care, when your loved ones aren't given appropriate and quality care, and they are not linked up with a whole system of services to prevent further disabilities. It is linked to other objectives, A.1, B.1. I am not going to go into them. C.2 speaks of increase to X percent the proportion of patients who have access to emergency services when and where they need them. We say, let's increase it to 100 percent that this access is unimpeded. B.6, reduce preventable hospitalization rates by 25 percent for chronic illness, for three ambulatory care center diagnoses.

Throughout the whole document, there are access-related objectives. It is representative, and it is not narrow. It is measurable, and it has multilevel tracking ability. There are databases for the Medical Expenditure Panel Survey, for the National Household Interview Survey, et cetera.

DR. FOX: Thank you very much. Number 62, Mary Rose Tully. Number 62, Mary Rose Tully. Number 63, Joann--

MS. PETRINI: I am Joann Petrini. I am with the national office of the March of Dimes Birth Defects Foundation in White Plains, New York.

And the March of Dimes Birth Defects Foundation, with its mission to prevent birth defects and infant mortality, has been involved in the formation of the Healthy People 2010 objectives and is pleased to be able to continue to participate in this public comment process. The March of Dimes strongly supports the aim of Healthy People 2010. The March of Dimes applauds the expansion of the year 2010 objectives to focus on additional areas not previously addressed, including additional objectives in maternal and infant health, and strongly supports the expanded focus on birth defects objectives.

The March of Dimes will integrate the year 2010 framework at the Federal, state, and local level in its health promotion and advocacy activities at the national and chapter levels, and within the various perinatal data projects it undertakes, as it has done for the year 2000 objectives. Toward this end, we put forth a few suggestions. To promote appropriate use and interpretation of perinatal data, add two sections in the background chapter. The first on data issues carefully describes the changes and their expected impact, including the use of the tenth revision of ICD, the use of year 2000 population for all age adjustments, and the new proposed racial/ethnic classification algorithms.

The second section--create a second section on small numbers and small area analysis which would provide guidance on how to apply the objectives in communities where population and number of outcome events preclude the traditional statistical comparisons. The perinatal data center at the March of Dimes will be pleased to work with appropriate agencies in developing and disseminating these needed resources.

Secondly, to enhance clinical perinatal data systems, develop, refine and expand clinical care tracking systems to enhance the utilization of electronic primary data collection for the proposed health objectives to minimize missing data and errors of transposition. Specifically, add one objective supporting the development of uniform computerized clinical care systems in hospitals, ambulatory settings, across the country. These systems should be based on standard definitions, whereby the provider of care documents the factor or outcome, and the resultant database is the source for subsequent reporting. We have additional comments that we will provide in writing, but we thank you for this opportunity.

DR. FOX: Right. Thanks a lot. Number 64. Sixty-four. Laura Lee Hall. Number 65, Rose Ann Soloway.

MS. SOLOWAY: Hello. I am Rose Ann Soloway, and I am Administrator of the American Association of Poison Control Centers.

Poison centers in the United States answer more than two million emergency calls annually. About 80 percent of the callers are nonmedical; that is, moms, dads, day care providers, and the victims themselves. Seventy-five percent of these calls are managed entirely over the telephone with the guidance of the poison center experts. Just over half of the calls are about children under the age of six, a smaller percentage than many people think, actually. But more than 90 percent of fatalities are in teenagers and adults, usually as a result of intentional actions.

In addition to providing emergency and follow-up treatment advice, poison centers gather and publish data about these poison exposures. Found within the American Association of Poison Control Center's toxic exposure surveillance system are cases of all of the poisons listed in several sections of the draft objectives lead, arsenic, mercury, cadmium, carbon monoxide, many kinds of pesticides, household chemicals, and drugs. Poison centers provide expert treatment advice about these and other poison exposures ranging from inhalation of occupational chemicals to swallowing batteries, being bitten by pet cobras.

The information provided by poison centers is lifesaving and cost-effective. But researchers, government agencies, and public health officials use the data generated by poison centers. Maximum effectiveness in both the information and data arenas depends on unimpeded access to poison centers, and this would be promoted by objective C.3 of the access to data quality services section. This objective calls for establishment of a single, toll-free telephone number for poison center access, an objective that the American Association of Poison Control Centers wholeheartedly supports. Poison center utilization would increase because it would be much easier to publicize a single, nationwide telephone number than it is now to publicize dozens of regional phone numbers.

A single toll-free number for poison center access is an important means of meeting objectives related to decreasing exposures and decreasing deaths due to poisoning by household chemicals, drugs, pesticides, heavy metals, and other substances included in the draft objectives. It would also increase the data available to track such exposures.

We will be submitting additional comments that will deal with data collection issues. Thank you.

DR. FOX: Great. Thank you very much. Number 66, James Crall. Sixty-six. Number 67, Robert Bolan.

DR. FOX: If I call your name and you are here, jump up. I don't want to miss you if you are here, but we are not going to pause very long.

DR. BOLAN: My name is Robert Bolan, Interim Executive Director of the Health Care Quality Alliance. I am a resident of Virginia, testifying on behalf of the Alliance.

Health Care Quality Alliance is the coalition of approximately 100 national voluntary health organizations, medical societies, consumer groups, nursing associations, accrediting organizations, and related national groups. HCQA was founded in 1987, and it was incorporated as a 501©(3) organization in 1993. Our purpose is to serve as a forum for examining national issues that influence quality health care.

First, HCQA would like to join as a member of the Healthy People Consortium and participate in the process in the future. Sorry we haven't been on board up until now.

DR. BOLAN: We observe that some of the focus areas have excellent objectives for initial disease prevention, but are less forceful with objectives for restoring available quality and years of life after disease onset. As one example, in Chapter 20, regarding "Heart Disease and Stroke", there could be an objective concerning the use of beta blocker therapy after heart attack, a topic of vigorous current attention which seeks to overcome barriers that stand in the way of this inexpensive, easy to provide, and proven therapy. Numerous HCQA member organizations, and HCQA itself, currently are bringing attention to this topic both to improve health outcomes and also to measure the change in health status for this topic. The objective could state, "Increase to 90 percent the proportion of eligible adults who receive beta blocker prophylaxis after myocardial infarction."

Third, the same principle probably could be applied throughout the focus areas. We recommend that the final Healthy People 2010 report provide a stated process for the Consortium to develop and add other objectives to improve the quality of health care when the evidence of a particular intervention has been widely confirmed and communicated.

Fourth, we would like to make a general comment on the joint influence of two major trends in promotion of quality health care. One trend is the increasing role of the patient or consumer to participate more actively in personal health decisions. The other trend is the rapidly increasing role of the Internet as a source of information. The serious concern is that patients may have difficulty assessing the validity and applicability of information they obtain. To improve this, we believe the following developmental objectives should be added in health communication: "Increase to at least X percent the proportion of persons who report that they have accessed a Healthy People Consortium member organization's information during their search for health information."

DR. FOX: Thank you. Number 68. Number 68, Sandra McElhaney. Number 69. Sixty-nine. Number 70.

DR. BARTLETT: Dr. Fox, I am going to nominate you as the new Speaker of the House of Representatives. You are keeping us very nicely on track.

For years we have been hearing about the gap in life expectancy between men and women, the so-called "life-span gender gap." In 1920, women lived one year longer than men did. In 1940, the gap had widened to four and a half years, and by 1990, the life span gender gap had reached seven full years. A review of mortality figures reveals that men have a higher death rate than women do for every single one of the top ten leading causes of death in the United States. Clearly, men are at high risk.

So, it was with surprise that my reading of the Healthy People 2010 draft revealed that men's health is consistently downplayed, or even ignored. The Men's Health Network, a national coalition of men and women who are concerned with men's health, has three recommendations to share.

The first recommendation is--nowhere does Healthy People even state that men are a high-risk group. Nowhere is the life span gender gap even mentioned. Why aren't we highlighting the fact that men are dying of heart disease at almost twice the rate of women? That 50 percent more men are dying of cancer than women are? That the suicide rate for men is four times the rate of women?

Number two. If we truly believe that we can eliminate health disparities, Healthy People needs to include gender-specific objectives for men in the sections on heart disease, cancer, HIV, and injury/violence prevention. Yes, there is one objective on prostate cancer, and that is commendable. But prostate cancer accounts for only two percent of all deaths among men.

Number three, we ask that Healthy People be fair in presenting gender-specific statistics. For example, the section on violence/injury prevention highlights women's risk of sexual assault but, sadly, glosses over the fact that the victims of seventy-five percent of homicides are men.

I want to close by saying that men's health is also a woman's issue. Every time a young Afro-American boy is killed by a stray bullet in the inner city, you will see his mother at the funeral, weeping. Every time a young man commits suicide, you will see his sisters wondering if they will be next. Every time a father dies of an early heart attack, his children are wondering how can they possibly go on without a daddy. And when an older man dies, he leaves behind a widow grieving over the loss of the dream of spending their golden years together. The life span gender gap is an issue that affects all of us.

DR. FOX: Thank you. We are scheduled to finish at 5:30. If we finish beforehand, what I am going to do is go back and start down the list, and give people that might have missed their opportunity to speak a chance. So whether we will do that or not will depend on our timing.

MR. HILL: I am Gil Hill, and I am the Director of the Office of Rural Health of the American Psychological Association.

The Association really applauds vigorously and appreciates the overall objectives that have been adopted by 2010. The recognition of the role of behavior in health represents real progress as far as the Association is concerned, and we really appreciate that. We also would point out that at the same time as this is going on, Dr. Satcher has commissioned a report on mental health, a Surgeon General's report on mental health, and I would hope that somehow that report might be coordinated with the 2010 effort, because it is an important effort.

We really look forward to working with the Public Health Service in implementing 2010. We will be submitting detailed comments on all of the aspects of 2010, and I just can't resist getting a few words in on rural and frontier areas, areas that are terribly underserved from both a physical and mental health standpoint, and I hope that that recognition is reflected in the report.

In addition, I salute you for including, in the communication portion of the report, attention to telehealth and informatics. These two modalities present a real opportunity for getting good health care out to rural and frontier areas, and I am very pleased you included them.

MS. CALVANO: Good afternoon. I am Margaret Calvano. I am Senior Director of the Epilepsy Foundation's National Information Center on Epilepsy. I am here on behalf of the Epilepsy Foundation to seek inclusion of objectives for the prevention and treatment of epilepsy and seizure disorders.

An often devastating disorder, epilepsy should be addressed independently of the other conditions listed in the Healthy People 2010 objectives. Even as a secondary issue, seizure disorders were not mentioned in the draft publication. This is a serious oversight that requires correction in the final version.

There are more than two million people with epilepsy in the U.S., and one in ten in the general population will experience a seizure in their lifetime. For the more than one million cases of epilepsy for which the etiology is known, more than 100,000 cases are the result of traumatic brain injury. More than 290,000 stroke survivors have epilepsy as a result of their brain attack. Three hundred and fifty thousand cases of epilepsy are the result of alcohol abuse.

Health professionals, patients, and families are struggling to cope with many serious issues related to epilepsy. Among these are the high prevalence of depression in epilepsy, leading to a risk for suicide that is five times greater than that of the general population, the critical need for universally available, high-quality prenatal care for women with epilepsy, to influence pregnancy outcomes in a positive manner, underemployment and psychosocial issues that reflect public attitudes to seizure disorders, the prevention of seizure-related injuries that affect thousands of people each year, and episodes of status epilepticus from uncontrolled seizures, lack of antiepileptic drug compliance, alcoholism, and stroke that result in 22 to 42,000 deaths in the U.S. annually.

There is a pressing need to improve the quality of life for those with seizure disorders. The public, patients and their families, and the health care team all require excellent information, education, and access to quality health care.

As we commence the 21st century, we should also build upon the foundations of the closing years of the 20th century. It should be noted that the National Institute of Neurological Disorders and Stroke is conspicuous by its absence from this initiative. Do not allow the gains we have seen during this decade, the years that have been observed as the decade of the brain, to be diminished through lack of awareness.

The Epilepsy Foundation urges the inclusion of epilepsy and seizure disorders in the Healthy People 2010 objectives.

MS. PEROT: Good afternoon. My name is Ruth Perot. I am the Executive Director of the Summit Health Institute for Research and Education, Inc. Summit Health Institute, also known as SHIRE, was established to serve as a resource for the achievement of Healthy People 2010 goals.

We think of the Healthy People 2010 not so much as an initiative, but as a movement, or a campaign that must engage every individual and every institution in the nation. This perspective helps us look at Healthy People 2010 in a very special way. First, we are absolutely convinced that no matter how well intentioned we all are, we will not eliminate the health gaps between racial and ethnic groups in this country by the year 2010 until and unless we make profound changes. We can't continue to do what we have always done and wipe out these gaps. One critical key to success, we believe, is to promote the engagement, empowerment, and leadership of each racial/ethnic group experiencing disparities in a campaign on their own behalf.

A second key is to provide universal health coverage and access to replace the patchwork of systems and nonsystems that leave 43 million people uninsured.

Further, in order to reach our goals, we must agree to hold ourselves accountable for producing results. Eliminating health disparities is a measurable goal. To achieve it, we must know that everything we do is moving toward that goal. Doing our best is not enough. Improved health outcomes must be the yardstick we agree to use to determine if our best is good enough.

It follows, therefore, that everybody should be committed to understanding the importance of data. Every government agency, health insurer, hospital, managed care organization, and health professional must be committed to collect health data by race and ethnicity. We need these data with respect to encounters, treatment, and health outcomes, and we must collect it regularly. How else are we going to determine whether we are moving toward the elimination of disparities if we don't have the data?

Third, we must commit to sustained effort until the victory is won. Adequate government resources are essential, and so are resources from foundations in the private sector. We need multiyear funding and investments in building capacity and infrastructure within racial and ethnic groups. It is also important to invest in building multicultural cooperation and networking among people of color. We are not just talking about new funding here. We are also talking about re-prioritizing existing funding, and in particular, we would like to see that more money is put into behavioral health research at NIH.

We are going to submit written comments, but we certainly are grateful for this opportunity to pledge our support to a campaign to eliminate health disparities and achieve more optimum health for all of our people.

MS. GERMAN: Good afternoon. My name is Jacquilyn German, and I am Director of the Community Health Risk Reduction Program for the Association of Black Cardiologists, or ABC, headquartered in Atlanta, Georgia. I bring you greetings on behalf of our Chief Executive Director, Dr. B. Wayne Kong, and our President, Dr. Frank James. The ABC is a national nonprofit member organization whose goal is to make health care more accessible and affordable to all in need and to reduce the incidence and prevalence of cardiovascular disease within the African American community.

The ABC applauds Healthy People 2010's efforts to address heart disease, given its epidemic proportion in the American community. While I certainly respect and recognize the need to address heart disease and stroke in the selected communities presented in the objectives, I believe the objectives should also specifically state, reducing these occurrences within the African American community, since these occurrences overall disproportionately affect this community. Also, the goal of making health care accessible and affordable to all in need should also be specifically stated in the goal statement of Healthy People 2010 heart disease and stroke objective.

And finally, looking specifically at objective eight of the educational and community-based programs objectives, the definition of health care organization needs to be expanded to include nonprofits like the ABC that can also provide patient and family education. This will increase the number of organizations that provide these services in addition to the traditional organizations that provide health care services as defined in objective eight.

The ABC certainly thanks you for this opportunity, and we look forward to working with Healthy People 2010 in the future.

DR. DEAL: I am Dr. Brad Deal, National President of the American Medical Student Association. On behalf of AMSA's 30,000 members, I am pleased to be here to advocate for the future of healthy communities in America.

AMSA fully supports the goals and objectives of Healthy People 2010. We believe that communities across this country should utilize all available resources including, but not limited to, physicians, nurses, public health officials, educators, health professional students, and physicians-in-training in addressing the mission of Healthy People 2010.

To increase the quantity and quality of healthy life, and to eliminate disparities in health, medical students must first be taught public health objectives, via innovative curricula during the basic and clinical science years. The physician-in-training has a unique role as a patient advocate, less experience than physician colleagues, but more time for clear, direct patient education. This special role must not be overlooked when strategizing the plans and implementing the goals and objectives for Healthy People 2010. Numerous opportunities for student involvement must be made readily available. Medical students want to play a role. They simply need an invitation to sit at the table.

Last year at our national convention, AMSA devoted a full day to medical education reform. We discussed ways to improve medical education, to promote healthy behaviors and safe communities, to improve systems for personal and public health, and to prevent and reduce disease.

We look forward to working with you, our medical schools and our communities, to bring Healthy People 2010 to the classroom and on the wards. Once medical students have a sufficient background in public health, we will be ready to be part of the team Healthy People 2010. But we will need to know how to get in the game. Students can help, but we need to be informed about opportunities and resources like clinical electives, summer opportunities, curriculum committees, or other ways to become involved.

If we are going to accomplish what we set out to achieve, we all need to work together as colleagues. I encourage the panel and Consortium to empower physicians-in-training and other students to reach the goals of Healthy People 2010.

Again, I am happy to have the opportunity to address you today. AMSA will be submitting written testimony in the next few weeks.

MS. RATHBUN: Good afternoon. I am Jill Rathbun, and I am here on behalf of the American Society of Nephrology.

The American Society of Nephrology was founded in 1967 as a nonprofit organization to enhance and assist the study of kidney disease, to provide a forum for the promulgation of research, and to meet the professional and educational needs of its 6500 members.

I would like to thank the Department of Health and Human Services for taking on the Healthy People 2010 initiative, continuing to identify opportunities to truly improve the health of our nation. However, the ASN is very disappointed that at present, kidney disease is not mentioned within the Healthy People 2010 initiative.

Currently, the number of patients in this country with end-stage renal disease, or what is truly total kidney failure, exceeds 335,000. End-stage renal disease is showing an alarming increase in incidence, with the number of new patients approximately doubling in the last decade. Per the United States Renal Data System (USRDS), kidney disease impacts disproportionately on minorities, especially African Americans and Native Americans. In 1996, the prevalence rates per million population were 3,404 in African Americans, 2,761 in Native Americans, compared to 754 whites per million. Total ESRD spending by all payers in 1996 was estimated to be 14.6 billion, with approximately 12 billion of that amount coming out of the Medicare system.

To compound this problem, while kidney disease patient populations will more than double by 2010, the supply of nephrologists in this country is declining. For that reason, nephrology is a subspecialty that is actually facing a shortage, not a surplus of physicians.

Recently, the National Institutes of Health, the Health Care Financing Administration, and your agency, the Health Resources and Services Administration (HRSA), authored a plan of objectives to reduce chronic renal failure in our nation. While this document is still in draft form, we would very much like it to be included in Healthy People 2010, this ten point outline with a goal of reducing the incidence, morbidity, mortality, and health care costs of chronic kidney failure.

While I do not have the time to truly provide you with the whole plan today, and we will include it with our written comments, the plan touches on the following areas: end-stage renal disease incidence, cardiovascular mortality in end-stage renal disease, preparation for end-stage renal disease, racial disparities in transplantation, micro- albuminuria screening in people with diabetes, which is the number one cause of kidney disease, treatment of diabetics with proteinuria, screening for hypertension, blood pressure control, counseling for renal risk factors, and management of CVD risk.

The American Society of Nephrology supports this plan that these three agencies have put together and hopes that it will be included within the Healthy People 2010 initiative.

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

Last summer I took one bite of a salad at a restaurant and I started to have an anaphylactic reaction. My throat started to close, and I could not breathe well. We discovered the salad had been made using latex gloves. Almost every ambulance and emergency room in America uses powdered latex gloves, which could kill me if I am touched by latex or breathe latex protein that is carried on glove powder. Even if emergency services have non-latex gloves available, if their glove of first choice is a latex glove, they may injure me, because they may not know I have latex allergies until it is too late.

Many people do not know that they have latex allergies. That is why emergency services nationally should be completely latex safe. All medical providers should only use low-allergen powder-free latex gloves or powder-free non-latex gloves throughout their facilities. Food service and housekeeping should never use latex gloves.

I need your help receiving access to safe medical care. When my parents have asked hospitals to switch gloves, we have been told the cost is too much, and doctors like the feel of their gloves. This doesn't seem fair to me. What are my rights as a patient?

Please help those of us with this disease and help stop others from getting this disease, by making medical care providers switch to safe gloves.

Number 79, Karen Sealander. Seventy-nine. Number 80, Michelle Farmer. Michelle Farmer. Number 81, Michael Fraser.

MR. FRASER: Good afternoon. I am Michael Fraser with the National Association of County and City Health Officials, or NACCHO, here in Washington, D.C.

NACCHO views the Healthy People 2010 document as a vital tool for improving the health of people in the United States. All of the chapters in the Healthy People 2010 document are necessary and important. We feel they speak to the many different functions and capacities of local health departments and the diverse components of local public health systems.

NACCHO particularly supports the infrastructure and capacity-building objectives included in the draft infrastructure chapter. Building and improving the local public health infrastructure is an area of crucial importance to local health officials. NACCHO, therefore, urges strongly that the objectives include increased emphasis on the assurance that public health services are delivered at the local level.

NACCHO also believes that the objectives set forth in the Healthy People 2010 document must be comprehensive and measurable. The full spectrum of local health activities must be included in the Healthy People 2010 draft objectives.

NACCHO is also aware of the difficulties often experienced in measuring public health capacity at the local level. In order to improve the nation's health, we must accurately measure current conditions and turn the data we gather into information that can be used by local, state, and Federal officials to increase public health capacity and strengthen local public health infrastructure. In recommending that the Healthy People 2010 objectives include local level infrastructure measures that are comprehensive, NACCHO also believes that we must engage in discussions and decisions about how to finance the collection of data on the Healthy People 2010 indicators.

NACCHO represents the local health officials who direct the almost 3,000 local public health departments in the United States. These officials are charged with promoting and protecting the health of people in their communities. In addition, local health departments partner and collaborate with state and Federal public health agencies, other public and private health organizations, and community members to improve the way public health services are carried out. Only with a strong local public health infrastructure can these services effectively meet the needs of each community, and improve the health of the public in the decades to come.

DR. BOWYER: Good afternoon. I am Dr. Norma Bowyer, chair of the Public Health Disease Prevention Committee of the American Optometric Association. Thank you. The American Optometric Association appreciates the opportunity to comment on the plans for Healthy People 2010. Visual disabilities potentially threaten the quality of life for all Americans. Vision is the second greatest unmet health need in the nation today. Vision and eye health are a strong health indicator for quality of life. The American Optometric Association has recommended and continues to support that the nation's health objectives for the year 2010 include vision and eye health as a priority area with a major separate heading. This is a significant opportunity to work toward the goal of health for all, to improve quality of life for all Americans.

Vision and eye health needs are irrespective of age, gender, racial and ethnic, socioeconomic characteristics. No select population is exempt. Vision and eye health needs cut across all populations. Vision is as critical to the quality of life for a young athlete that is trying to increase his batting average as it is to a Native American or African American grandmother who has diabetes and is caring for three of her grandchildren. Whether the issue is the nurturance of our preschool young to prevent illiteracy and impact juvenile delinquency rates through early detection of developmental visual problems, or the lessening of the personal and financial burden to the individual, families, and the nation of ocular complications of disabling chronic diseases, specific, quantifiable, measurable goals and objectives and strategies to eliminate these disparities are essential. Americans fear blindness more than any other disability. And as our nation ages, so also will increase the number of Americans who suffer blindness and age-related eye diseases. This number is anticipated to double in the next century.

So, in conclusion, it is necessary to emphasize the significance of vision in the multiple areas as a significant risk factor in disease prevention and health promotion. By creating a separate section on vision and eye health, the objectives for the year 2010 can reflect the importance vision has for all age groups. The relationships between vision and prevention, and the importance of poor vision as a significant risk factor for impaired functioning, morbidity, and other factors that impact the quality of life. The American Opt--

DR. FOX: Thank you. Number 83, Linda Holmes. Eighty-three. Number 80--84? Theresa Rogers? Eighty-four. Number 85. I feel like an auctioneer.

My name is John Evans, and I am the Deputy Commissioner for Community Health and Prevention in the State of Texas. We realize that every group here represented a different perspective of health, but our main objective here is to eliminate the disparities of health status, especially among racial and ethnic groups.

But it sounds like a competition, and in order to discontinue the competition, the Texas Department of Health--we have created this division for the community, community not as a locality, but as a state of mind, a community where people feel like they belong, that people care, that they are accepted, they can contribute, and that they can become all they are capable of becoming.

When we look at what the data tells us, we know that as a nation, we have the highest amount of social pathology of any industrialized nation in the world. The data tells us where our efforts should be, but we don't go there. The data also tells us where those resources should be, but they are not directed there. There is only one solution to this. We must appeal to a sense of human spiritualism that goes beyond all the isms we don't want to talk about, ageism, racism, sexism, and chauvinism. We believe that we can address the impacts of power and privilege, whether it is earned or unearned, social injustice, oppression, stereotypes, cultural myths, misconceptions, how we can go beyond the concepts and concreteness of cultural competency, political correctness, and diversity. We must begin with ourselves. We must create community in our own departments. We must create community in public health. And we must act with an ethical purpose to eliminate the barriers, to eliminate the inequities, to eliminate the disparities. We are going to create a 27th objective, and that is community, the elimination of alienation, and we will write those to you.

That was really marvelous, my colleague from Texas, because what I was going to say was, we are talking about the American people in all their diversity. And when I say diversity, I don't necessarily mean ethnic diversity. I am talking about diversity root and branch. And with that, you know, sometimes we get caught up in our own way of seeing the world, in our own way of engaging the world, and so, we say we are going to load these goals and objectives on the Internet, and get access to people, when five, maybe ten, million people don't have telephones and are wondering how they will feed their children tonight.

So this business of community, and framing this initiative, not in the hands of the health providers, and I am one, and not in the hands of the voluntary agencies. But I suggest that this document be reality-tested by a set of focus groups of individuals who don't get any revenue from the health care system, but who bring their pain to it, and let those folks audit the vehicles through which we communicate the mobilization of health. That is my first thought.

My second thought has to do with the document itself, and I reviewed the draft, and I am going to speak to the implementation section. You know, the one that is not there yet. The last time I spoke to a group of Federal officials about the implementation section, where were we? We were in the Indian Treaty Room with Ira Magaziner, and we asked him, we said, "Ira. Where is the implementation section for this thing?" We ourselves had come together with the Summit Health Coalition. We had designed a model. We said if health isn't right for the American people, much like education, then perhaps what we ought to do is design a public health system like the public education system. And we did. And we presented it to the White House. People thought we were smoking something. And so, at least I went back to San Diego, and we wrote some legislation, and put it in place. It will come up in 1998 later this year, where the health department reviews the data and does the assessment.

I say this to say simply that in this business of implementation plans, the thing has to fly. And if you look at the IOM report, the data systems have been dismantled. Managed care is generating less data now than fee-for-service. HCFA is still struggling with trying to figure out how to get the plans to say yes, as it relates to accounting data. So, our recommendation would be that there needs to be an implementation section.

Finally, Dr. Fox, thank you for your comments last week at the assessment meeting of Healthy People 2000 as it relates to African Americans.

Number 89. Number 89. You will have to pardon me. If I don't see you out of my bifocals, just shout.

DR. SLOBODKIN: My name is David Slobodkin. I am an emergency physician, and I am on the faculty of the School of Public Health at the University of Illinois at Chicago. I want to address several issues regarding adult immunization. I am very appreciative of the amount of effort that has gone into that section, but I think there are some things that need to be improved there.

As several people have mentioned here today, emergency departments care for people who have no other access to health care. That also means that we have access to populations that nobody else has access to, and that programs that are sited in the emergency department will disproportionately affect the poor, and the uninsured, and ethnic minorities, and programs that neglect the emergency department will disproportionately neglect those same populations.

The American College of Emergency Physicians submitted to the Consortium two suggestions for objectives. One, that 100 percent of emergency departments be screening and immunizing against influenza during influenza season by 2010, and one that 100 percent of emergency departments be screening and immunizing against pneumococcal disease by 2010. And those objectives were not included in the present draft, and I would urge that that decision be reconsidered.

I also think that, in general, adult immunization has been a little shortchanged in this document. Without diminishing from the tremendous importance of childhood immunization programs, in general, they have been a success story in this country, whereas adult immunization programs, in general, have been a failure in this country. And the overwhelming number of vaccine-preventable deaths and morbidities in the country are, in fact, in adults, not in children.

Specifically, I am disappointed that the two largest vaccine-preventable killers, influenza and pneumococcal disease, are not included in objective one on page 229 in the list of targets for reduction. I am also disappointed that the objective on immunization registries refers only to children, whereas I think it is fairly clear that a voluntary immunization registry for pneumococcal immunization and hepatitis B immunization certainly would be very useful to those engaged in adult immunization.

I am also disappointed that, despite the fact that there are ambitious goals regarding influenza and pneumococcus, that there is very little process that is being talked about in this document to achieve those goals. There is nothing about immunization of health care providers, which is a major issue in influenza immunization, and preventing influenza. And in general, I think this chapter needs to be looked at again by people specifically interested in adult immunization, and that would strengthen the chapter. Thank you.

DR. GOODMAN: Good afternoon. I am Harry Goodman. I am the Maryland State Dental Director, and I am also representing the Association of State and Territorial Dental Directors.

ASTDD strongly supports the goals and spirit of Healthy People 2010 and is generally supportive of the oral health draft objectives. We are very pleased that oral health is finally earning its due recognition as a serious, systemic health problem. Dental caries is the most prevalent chronic disease in young children. It is not simply about holes that need to get filled. It is about pain, and pathology, and infectious disease that significantly contribute to the lack of learning and productivity in both the school and workplace environments.

Among the many objectives that we do support, we would like to support the existence of a state oral health surveillance system. Many states lack the resources in the oral health chapter. Many states lack the resources to conduct epidemiological surveys to assess oral health. Using existing databases and surveillance systems, such as the BRFFS, the YRBS, the Oral Cancer Registry, and other state surveys is very critical to assuring that oral health data is available at the state and local level.

We also wish to support oral health objective 20 in the oral health chapter which states that all state and local health agencies with jurisdictions of 250,000 and above have an identifiable dental public health program in place, directed by dental health professionals. Currently, only 31 states have a full-time state dental director, and we feel this is a travesty. We are going to provide comments in the future, whether we like this to be in the oral health chapter, or possibly part of the public health infrastructure chapter.

I also wish to recommend support of oral health objective 21, which calls for an increase to 50 percent on the number of adults age 18 and above to receive an oral cancer or oral cavity and pharyngeal exam. Oral cancer is one of the few cancers which has not significantly improved its five-year survival rate, and it really is the responsibility of all health care practitioners, dentists, physicians, hygienists, nurse practitioners, all health care practitioners, to provide timely, inexpensive, easy to perform examinations of the oral cavity and pharynx at an early age, in order to reduce mortality, and eventually reduce morbidity.

And finally, we wish to support objective number 15, which basically says to increase the proportion of oral health components in school-based health centers. We believe that there is no better environment than the school to provide useful, timely, and scientifically proven preventive oral health strategies.

MR. BOHLMAN: Hi. My name is Robert BOHLMAN. I am the Director of Government Relations for the National Alliance for the Mentally Ill, which headquarters here in the Washington, D.C. area. NAMI is very grateful to be a member of the Consortium and for this opportunity to testify.

NAMI was founded 20 years ago by families each of whom had a loved one with a serious mental disorder institutionalized in one of the old state or county institutions, or having committed suicide, and more often than not blamed for that. We have certainly come a long way since Healthy People 2000. Dr. Satcher, as the new Surgeon General and Assistant Secretary for Health, has made the number four objective in his tenure to do something about mental health nationally and, as was already mentioned by the American Psychological Association, he has commissioned a Surgeon General's mental health report. And we are so pleased that focus area 23 is significantly expanded over Healthy People 2000 with respect to mental health. We have objectives in there that we applaud. We have some that we would add. We have some that we believe could be improved by stating them a little more forcefully, and I have an overarching comment to make.

We applaud the objectives on suicide, on the homeless people with severe mental illness, employment of people with severe mental illness, the links to juvenile justice, and the better primary care provider training which Dr. Satcher mentioned as one of the two primary ways of achieving better mental health outcomes. We would add in each state at least three of the best outpatient best research outpatient treatment models for the most severely disabled, the programs for assertive community treatment, and we would add an objective on stable and appropriate housing.

The things that we think could be improved, that are understated; they are the health insurance parity issues. We believe that 14 states have already enacted health insurance parity, and we should expect all of the states to have it by the year 2010. We believe that there should not only be treatment of people with severe mental illness in the various correctional institutions at Federal, state, and local levels, but there should be fewer of them in the jails. We believe that the expectations of the states to set up programs around the elderly, around co-occurring addictive disorders, and around the offices of consumers and family affairs should be stated as, "we expect all states to be there in the year 2010." Because there is no database for it, they show it as something that they are not sure how far they should go.

And then, with respect to the overarching comment. Twenty-five percent of the disabled folks on SSI or SSDI are there by a primary diagnosis of a mental disorder other than retardation. One of the largest bangs for the mental health buck would be to address the most severely disabled. We would like to see that. It brings back some of the largest public health benefit. And we would like to see consumer and family involvement at all levels of this system.

MR. ROLFS: Good afternoon. My name is Robert Rolfs. I am with the Office of Public Health Data in the Utah Department of Health. I appreciate the opportunity to comment.

Data and measurement, although often considered boring and very difficult to fund, are critical for public health and healthy people. We really appreciate and support the inclusion of infrastructure objectives regarding access to public health data and epidemiologic services.

I spent the summer being an interim local health officer, which reminded me just how much public health occurs at the local level. Wherever possible, the measures and data sources chosen should be available and useful at the local level. One specific example is to ensure that, where NHIS or a national source is cited, that BRFSS or something that is available at the state or local level also be usable for measuring objectives.

We strongly support the inclusion of the leading health indicators. We use the indicators developed as part of Healthy People 2000 extensively. Our experience showed us that while they were imperfect, having them was much more important than their being perfect, and so having them is the most important thing.

I have two specific recommendations, though. The first is that unlike the Healthy People itself, they should be few in numbers, certainly less than 20 and, ideally, closer to ten. And secondly, that they should do a better job than the last round did at measuring a broad definition of health, such as that defined by the World Health Organization. One way to do that would be to include a measure such as number of healthy days in the last month that is available from the BRFFS data.

DR. FOX: Thank you. You are talking to the man who wanted to put Healthy People on severe caloric restriction and, obviously, I lost.

DR. HOBBS: I am Dr. Ron Hobbs. I am Dean of the University of Bridgeport College of Naturopathic Medicine. I am a member of the American Association of Naturopathic Physicians, and it appears that I am the token representative of the entire complementary and alternative medicine community.

I am excited to be a part of this very important project early on for this next decade of Healthy People and delighted that you will hear my comments.

With all due respect to Dr. Richmond and his comments yesterday, I don't believe that the fact that many people in this country are seeking alternative medicine care is a sign of failure of the conventional world. Rather, I believe it is, as one article put it, that you have unwitting partners in meeting these goals. For example, naturopathic physicians have been recommending eating fruits and vegetables, staying fit and exercising, avoiding tobacco and other drugs, and breastfeeding their infants for well over 100 years now.

I am here to make this partnership a little bit more witting, I hope. I, for one, am committed to healthy people in healthy communities, on a healthy planet, I would add, and I believe that is true of most, if not all, of the practitioners of complementary and alternative medicine. I would point out that Washington State has done some great things in terms of integrating natural medicine practitioners to meet some of these goals.

While we are new in this process, and I won't have too many comments on the objectives, I do want to pledge myself. My students will be aware of these objectives and, when they get out into practice, they will be using them in their preventive and therapeutic services.

From what I have learned today, I would like to throw my weight behind the idea of making obesity one of the leading indicators. It is clear that this is an area that is becoming an epidemic in this country, and this would give us a chance to possibly improve health in a number of ways. Thank you very much.

MR. LIVINGOOD: I am Bill Livingood. I am representing the Society for Public Health Education, SOPHE, and we thank you for the opportunity to present our comments today.

SOPHE is an independent, international professional association made up of a diverse membership of health education professionals and students with a primary mission of promoting the health of people by advancing health education theory, practice, and research. My comments today will be necessarily limited, and we will provide more detailed comments. I would like to comment on just a few of the chapters that are of primary concern to us.

Chapter 4, Educational and Community-Based Programs, in particular, we are very concerned about the definitions of health education and health promotion. They are very narrowly defined, and they are not the types of definitions that are commonly used and supported by public health education professionals, and so on. So, we strongly recommend that you adopt definitions that are more supported and more widely used by health education professionals, including some such as those offered by Green and Kreuter.

We would also, in regard to that chapter, like to encourage the expansion of the school health section, particularly to recognize the special role of schools. The comments of someone a few persons ago related to oral health are an example of that. And also, to better articulate the relationship, the interrelationship of health and learning.

It would also be very appropriate to add some intermediate outcome objectives related to this, such as the percentage of schoolchildren completing referrals for vision and hearing within 90 days of the time that they receive the referral. That would be one example of an outcome type of thing. All that are there right now are some process measures, and a very distal outcome measure.

We would also like to encourage that the school health instruction and the objective related to the nurse-to-student ratio be included within the context of a coordinated school health program and that attention is given to that. We also, in regard to that chapter, have some concerns about, again, the use of health education and health promotion, and the use of health promotion programs, and health promotion initiatives, and them being used very inconsistently, and we would like to encourage that consistent definitions be used.

In regard to Chapter 14, Public Health Infrastructure, we would particularly like to encourage the summary measures to include broader determinants of community health beyond health status. In addition to promoting and encouraging healthy behaviors, to encourage things such as improving community health, or improving community capacity, getting away from the focus on the individual. Also, in some of those objectives they are related to the research that expands beyond just epidemiology as a research foundation. Include more social and behavioral and other researches in those objectives related to objective 13.

MS. COTTMAN: I am Roberta Cottman, Wayne State University of Detroit, and health consultant. I would like to address my commentary to public policy and health policy, suggesting that the health agenda should drive public policy when appropriate.

I would like to speak, first of all, and to clarify, that there is a difference between health as a human right, and universal health care; that as a human right, I should have the opportunity to live my life at its highest potential, physically, emotionally, mentally, psychologically. And that should be a human right. If by chance my health is interrupted by illness or disease, or by lifestyle, or by social or economic determinants, then I should have a right to health care, or to care of my health. There is a difference. I will remind you that the United States and South Africa were the only two industrialized countries in which health is not a right. And now, with the constitution of new South Africa, the United States is the only country in which health is not a right. And therefore, 2010, as 2000, must address person-centered, not patient-centered, and community-based.

As we gather data, that data must be able to be transformed, translated, into human effectiveness, and therefore, I am suggesting that, concurrently, as we gather data, that we should certainly transform that into empowerment of communities, empowerment to make moral and ethical decisions about our health.

And last of all, the United States Senate has never ratified the universal declaration of the rights of a child, in which a child has a right to a name, and a home, and health; nor has the United States Senate ever ratified the treaty on the elimination of discrimination against women. And therefore, if we do not speak as health professionals, as health representatives, concerned about the health of the public, we will never have the goals and objectives of 2010.

MS. MILLER: Good afternoon. I am a coordinator of a breast and cervical cancer early detection project at a county health department and a health educator at a local hospital in Pennsylvania. But I am not here representing those organizations. And I will send my comments in writing, but I would like to use the group here to participate with me to demonstrate a point that is important to my program, and--

DR. FOX: Just comments for the record. This is not a group process. Any comments you have for the record, feel free to share, but--

DR. FOX: Number 97. Ninety-seven. Ann Mahoney. Ninety-seven. Ninety-eight, Jackie Noyes. Ninety-eight. Ninety-nine. Philip Ziring.

DR. ZIRING: I am Phil Ziring. I am the chairman of the Department of Pediatrics at Cook County Hospital in Chicago, one of the largest safety net institutions remaining in this country. But I am here today to represent the American Academy of Pediatrics, where I am also the chairman on the committee for children with disabilities.

I wanted to remind you, and I am sure Dr. Fox doesn't need reminding as a pediatrician, that children are not small adults, and it is a pleasure to see, for the first time, kids with disabilities finally represented in a significant way in the Healthy People 2010 program. We do applaud the inclusion for the first time of objectives related to the inclusion of prevention and treatment of infants and children with chronic illness and developmental disabilities, and I do think it is important to add adolescents to that group of individuals in the section on maternal and infant care. This is a very good start, but I think we should recognize that it is just a beginning of a very important process.

Two, we support the inclusion of newborn screening, especially treatment of infants with sickle cell disease, and universal newborn hearing screening programs, a very important advance. However, it is important to recognize that these kinds of screening programs must be linked to the provision of a medical home for all of these children. So is the need to not only identify the kids with these impairments through screening programs, but also provide treatment and follow-up. There needs to be adequate care provided through the primary care physician and adequate reimbursement for that physician in order to take on that added burden of taking responsibility for these kids.

Third, we still need objectives for important things that are not mentioned, and I do want to remind this public health group of an old-fashioned program that had tremendous merit and still does, and that is infant visitation following discharge from the newborn nursery. There are tremendous advantages to continuing to promote breastfeeding, to follow-up on kids with disabilities, to prevent child abuse and neglect, through infant visitation programs in our communities, especially some desperate communities such as the ones we serve. We need to remember that there are important things that we have learned in the past that need to be, perhaps, promoted once more.

Finally, there is a need--again, I want to reiterate what has been mentioned before. We need to remember that children need not only access to care, they need to have care paid for by health insurance programs which are universal in their nature, access to pediatric specialists and pediatric surgeons, which are currently denied in many cases by managed care organizations.

MS. DEMPSTER: Good afternoon. I thought we would be the only four here at 100. Thank you to everyone who has stayed. I am the Executive Director of the American Academy of Nurse Practitioners. We are a national organization for nurse practitioners of all specialties. We are the largest nurse practitioner organization in the country, and we also maintain a national database for nurse practitioners.

Thank you to all that have continued to shape the 2010 objectives. They have come a long way from last year about this time. So, all those efforts are much appreciated.

Briefly, the comments today are related to Chapter 10, Access to Quality Health Care. First, we would like to applaud you for including the IOM definition of primary care. This includes nurse practitioners as primary care clinicians and as providers. Next, we encourage consistent incorporation of this definition throughout Healthy People 2010.

Last, barriers are briefly addressed in Chapter 10 in the overview. We encourage incorporation into Healthy People 2010 of language for removal of continued statutory and regulatory barriers that, one, limit nurse practitioner access to full delivery of quality health care, and even more importantly, two, that limit patient access to quality health care by nurse practitioners.

MR. WHITEHEAD: Thank you for your attention, and we certainly applaud your stamina, as you have listened to all of these statements.

My name is Jim Whitehead. I am from Indiana. I am the Executive vice-president of the American College of Sports Medicine and serve in the adjunct capacity of Executive Director of the National Coalition for Promoting Physical Activity, which includes over 100 organizations dedicated to improving American health through increasing levels of physical activity, and reducing sedentary lifestyles.

Both of these organizations will issue subsequent formal written recommendations regarding the physical activity and fitness objectives in other areas, but I do want to offer brief, more global comments now on behalf of both.

The first is this. It has been said that organizational coordination is an unnatural act between non-consenting adults, and certainly this time, this time with these objectives, we need coordinated implementation strategies and plans for all the areas. ACSM and the National Coalition are committed to creating and executing plans of action to achieve the objectives in physical activity and fitness. We recommend efforts be undertaken to find similar collective leadership for each goal area, and that, furthermore, companion documents be issued to help individual organizations work toward the objectives.

Secondly, linkage among the objectives is important, both in regard to the documents and among the objectives themselves. For example, physical activity needs to be linked even more effectively with issues related to relevant disease conditions due to physical inactivity.

Thirdly, public policy, health policy, and political education are important dimensions of health and keys to our success in achieving these objectives. Leadership in this area may well fall to the private sector in advising and guiding this nation's leadership. The National Coalition is committed to advocacy as a key strategy and encourages similar private sector efforts for all the objectives.

Just fourthly, both organizations, the National Coalition and the American College of Sports Medicine, will submit specific recommendations about physical activity. (This is an important recognition in the document,) and we appreciate that. We certainly do feel that physical activity should be a leading health indicator.

We thank you very much for assisting the process whereby we all can work together even more effectively to improve the health and well-being of all. Thank you.

DR. FOX: Great. Thank you. We don't have a 102, I believe. One hundred and three.

DR. PLETCHER: For all you hardy souls who remain, my name is Beth PLETCHER. I am a pediatrician and geneticist from New Jersey, and I am here today on behalf of the American College of Medical Genetics, and also on behalf of my patients that I care for each day.

I am concerned about the needs of millions of Americans whose lives are impacted by genetic disorders. As you probably know, between three and four percent of all children born today have birth defects diagnosed in the first year of life. Further follow-up of older children and teens has shown that one in six will eventually be identified as having a birth defect or congenital disorder, one third of which pose major health concerns requiring treatment. Therefore, there are large numbers of children and adults with genetic disorders whose needs must be addressed. They are the leading cause of infant mortality in the nation and have shown less reduction in prevalence than any other cause of infant mortality in the past three decades! They are a major cause of disability and morbidity throughout childhood, adolescence, and adulthood as well. Studies of the economic consequences of birth defects have shown that the lifetime excess costs of providing care for individuals with birth defects is in the tens of billions of dollars annually.

Current research has identified major contributions of genetic factors with adult onset diseases such as breast, ovarian, and colon cancer, as well as heritable risk factors as they apply to cardiovascular disease, such as hemochromatosis.

As was stated before, the current objectives are really just a beginning, and the document focuses on the needs of infants and children, largely to the exclusion of adults with genetic health care needs. And I know this sounds funny coming from a pediatrician, but I think we need to consider the entire life span. Only the chapter on cancer truly expresses the explicit objectives as they relate to adult genetic diseases, and we feel that the inclusion of genetic health service objectives could and really should have been seen in many sections throughout the draft document.

It is extremely important for health maintenance organizations to develop a plan to educate both providers and the public regarding the availability of preventative measures for, and treatment of, genetic disorders. We need to bestow our primary care providers with tools to address the health care needs of people with genetic conditions. This will ensure that our public health interest is maintained and strengthened to meet the ever-growing challenge of providing optimal health care.

We concur with the inclusion of objectives on both defect prevention, management, and provider training in genetics, as well as population-based screening, and care of individuals with chronic conditions. We feel that these should be highlighted throughout the entire document as they relate to adults in general as well as mothers and children.

The chapter on heart disease and stroke has no objectives addressing modifiable risk factors such as hemochromatosis and hyperhomocystinemia, which affects men more than women, I might add. Genetic issues are now and will be in the future a major force in patient care and I thank you for your time and consideration.

DR. CORDICE: I appreciate the fact that a number of us have had the stamina to persist. As the song says, "They dwindle down to a precious few." These are probably the true believers. And I want to make just one comment that I don't think has been covered on the previous comments.

I am a physician, and I am a member of the Board of Health, as a matter of fact, in the City of New York, and I have practiced in the metropolitan area for over 50 years. But I am here on the basis of my membership in an organization called the United Black Men of Queens, Inc., which has been in existence for over 20 years. We have a number of programs, including a mentoring program, and over the last six or eight years, we have had what we call health education forums monthly aimed at our membership, which are about 88 or 90 black men. I am one of three physicians in this group.

The men are--perhaps they designate themselves as middle-class. They own small businesses, they are on the police force, they teach, they do various things. And when the announcement was made last year about the possible funding through the CDC for programs aimed at target populations such as ours, we applied. We gave a letter of intent, which has not to this day been responded to. We did call in January of this year, and they allowed as how they had received it, but that was it. There was no commentary; there was no critique; there was no encouragement. So, we did submit a second, in April, which was the second date given, to which we just got a curt dismissal. We followed the rules very carefully, and I think our submission would conform, or did conform, to the stipulations required.

I say that because as a member of the Board of Health of the City, I am familiar with the way large organizations and large bureaucracies work, and they have good reason to be. But I think the smaller organizations such as ours, which can relate in a fraternal way to members of a community in the way that we do are very effective, particularly in habit modification, which are going to be critical in success.

And I think that is where I will end my comment. You will get a further statement of our responses to your--

DR. FOX: I want to run quickly back through, and give people who did not have a chance. We are going to do it quickly. I am going to do it one through ten, in tens, and if we have more than one person in that group, we will take the lower number first. So, was there anybody in one through ten that did not get a chance to speak? I am going to go through this quickly, so raise your hand or jump up if--ten through 20. Ten through 20. Twenty through 30. Twenty through 30. Thirty through 40. Thirty to 40. Forty to 50.

MS. SNOW: Well, it is kind of like Delta Airlines. If you are not there when the gate closes, you wait on standby for the next flight. I am Laverne Snow. I am the Senior Director for Public Health Information and Infrastructure Policy for the Association of State and Territorial Health Officials.

On behalf of Dr. Ed Thompson, our president, and other members of ASTHO and its staff, I would like to express congratulations and thanks to the Office of Disease Promotion and Health Prevent--I did it wrong--Office of Disease Prevention and Health Promotion.

MS. SNOW: For the hundreds of hours that have gone into this, and also to the many people in other public health agencies who have helped contribute to get the document this far along. I had a chance to sit in on one of the early infrastructure meetings and I know it is an incredible amount of work.

I believe Healthy People 2000 was the single, and is the single, most used planning document available to communities and local and state health departments right now, and has a great legacy, possibly greater than anyone expected when it was first developed. To that end, the information systems that are used to collect and track the data for it become a critical piece of our successes. When I say information systems, I mean not just the computers, I also mean the people who are trained to collect, to protect, to analyze, and to turn that data into useful information for the public, who is ultimately responsible for their health status, and for the public elected officials.

The new goals and objectives are challenging, and this will require us to continuously improve how we do our business, and how we partner with businesses, health care providers, and citizens in our community. And I think that is a great challenge for all of us. The goal to eliminate health disparities is bold and timely. We are very excited to see and to participate in the commitment and the activities that will be required to fulfill this vision. We have heard a lot about that objective, that goal, today, and it is very important.

It is quite significant that a chapter on public health infrastructure has been added to enhance the Healthy People framework. This will prove to be a very positive and critical tool for public health. A sound infrastructure must be in place for us to be successful in providing efficient and effective public health services. I suggest that this chapter should be placed strategically as an overarching part of the programmatic chapters, not in the middle of them.

The objectives in the infrastructure chapter are, of course, only indicators of the many pieces that constitute an effective public health system. CDC and HRSA, as you know, have sponsored activities to develop performance measures, system capacity indicators, and community health status indicators, which will supplement the breadth of these objectives. Those are very important projects.

Finally, I would offer for consideration the addition, or perhaps the changing, taking some out and putting these in, of three objectives. The first one is in the area of integrated information systems section. Objectives for state and local health officials to have electronic access to a notification system.

I am going to move on through the rest of the numbers, and we had two other--we do have 105 and 106. They will have the last two comments, but was there anybody between 50 and 60? Yes.

MS. REESER: My name is Cyndi Reeser. I am a lead nutritionist at George Washington University Lipid Research Clinic, here in Washington, D.C. I don't have completely organized comments, but I will take this opportunity and will submit the rest in writing.

Speaking as an individual today, rather than on behalf of my organization, I do really applaud the efforts to include nutrition objectives in the draft statement of objectives, and I would like to emphasize especially the importance of including nutrition instruction at elementary, middle, and high school level. It is time we really worked on prevention of these chronic diseases that are impacted by nutrition, and schools are a good place to reach children. So, I would like to see that part expanded and further defined.

Also, I would like to see expansion in the area of access to nutrition services. This should be emphasized throughout the document, especially within the care components for diabetes, heart disease, cancer, kidney disease, and so forth.

Also, at the level of the school, it is important that we find a way to keep track of calorie and fat intake of children at school, so that we can begin to understand the sources of obesity in childhood. This is not currently being done. And I do favor the inclusion of obesity as a leading health indicator, and the addition of a chapter on obesity in the objectives.

DR. FOX: Great. Thank you. Was there anyone else between 70 and 100 that we missed? Between 100 and 110? We will go now to the last two. One hundred and five?

DR. WOODWARD: That is because I exercise and eat my vegetables. My name is Kelly Woodward, and I am a preventive medicine resident at Johns Hopkins University. However, I would like my comments to be attributed directly to me, please.

I am going to speak just briefly about a single recommendation that I would like to make with the rationale supporting it, and it comes from my experience at another Federal department in allocating health dollars, and I know the complexities that you all face in how you allocate huge amounts of Federal money.

I am very excited about this beautiful document, and the strategy to Healthy People 2010, and I think it ought to be run up the flagpole as a monumental example of the success that can be achieved across the nation in adopting a common set of goals, and it should be an example for other programs in our society.

That being said, when I read the document, I saw it was explicitly described that this document could serve as the framework for state and local governments and private organizations to allocate programs and resources to achieve these objectives. However, I could not find in the document any explicit or implicit description that the Federal Government would allocate health dollars in a similar way--based on this framework.

So, my recommendation is that it be explicitly stated in the document that this will be a framework for a rational allocation of the hundreds of billions of dollars that the Federal government spends on health through such programs as NIH, CDC, and even Medicare, which is a huge driver in the health outcomes for this country. The rationale is that I think that it has been stated repeatedly that this document is a road map. I guess I would argue that it is actually more like describing an end state; it is not the road map. And it is very important that we begin before 2010 to start putting on paper how we are going to get there, and correlate the ways and means to the ends that we have described here. And I think, for me, the best way that I can think about it is through a corollary to the old statement of "if you know not where you are going, it matters not what road you are on." And my corollary is that if you know where you are going, you better build the right road.

I heard a couple of different arguments about why we shouldn't make an explicit statement that Federal money would be allocated by this rational model. One of them was, "But Kelly, that would mean that some of these things will have to be prioritized." I would argue that Federal dollars are already handed out by an allocation system and a prioritization system that may not have had nearly the public scrutiny that this has had to get to this document. So, this may be a more rational argument to go to Congress for more money, or to allocate the, again, hundreds of billions of dollars that the Federal Government spends on health. And I guess we have all been taught in health programs to follow the money, and what I guess I would be concerned about is if the money doesn't correlate with 2010, we may end up someplace else.

MS. SHEEHAN: Hi. Actually, my comments follow well with the gentleman ahead of me. I am Kathleen Sheehan, with the National Association of State Alcohol and Drug Abuse Directors. In our work session this morning, there were several state officials that were talking about how they would really like to use this book, but that they had difficulty in terms of adapting it to their particular system.

I guess the compliment I want to make is, the book certainly represents the inclusiveness that you all have tried to have in terms of bringing together all of the different health interests. But states really have a different role to play, because they are funders. They are also people that decide what kinds of services are going to be provided through health insurance policies and other kinds of things. And they also have a fair amount of sway with the state legislatures.

I would encourage you, for that reason--I am looking at the book. It says, "How can organizations and individuals contribute to Healthy People?" and one of the objectives here says that state, you know, state and local governments can get involved somehow. But I wanted to make a recommendation to ask you guys to consider, and that is to ask each of the Federal agencies, which have already committed significant time, and thought, and effort to this, to also commit the same amount of resources and time to work with national organizations which represent state officials, and to come up with an opportunity for states to adapt this, to do their own self-assessment. I think you have a very powerful tool where you could have a state official sit down and say, "Let's look at our chapter on substance abuse. Let's figure out what are the markers for us, for our state. We may be below the baseline; we may be above the baseline. Where do we want to go? What percentage do we want to really change?"

I think it is going to require, however, some money and commitment. I don't think that just having the book available will make it happen. States are under considerable pressure right now, as you know, to do performance measurement and there was also some confusion expressed the other day about how GPRA and performance measurements tied together. I think you could make really a significant and major step forward by working with state governments, helping them develop assessment tools based on Healthy People 2010, and on the other things you are doing and, really, just make a tremendous commitment along the lines of what he was talking about, dollars as well as changes in policies and programs, and how we all work together.

DR. FOX: Let me make some final comments before we have the drawing for the cruise.

I have been involved in this process for almost three years. Many of you have been involved in it much longer than that. And I just want to say there have been some excellent comments today, and I know the written comments will provide us even more substance. The thing that we don't want to do is keep this in the family. I think we have got to move this out to as many groups and individuals as possible, because the kinds of comments that we have received from each of you today are the kind we need. They are very helpful, and I think we all want this to be the absolute best document and the best process that we can have, and I don't think we can have that happen unless it is widely disseminated.

So, in that vein, I encourage each of you as you leave here, to continue to comment, comment, comment. And also, to try to get other people to look at this. We have the business advisory group. The intent there is to try to get the business community to look at and get engaged in prevention, and think prevention, and give us their thoughts. We need other groups as well as the business community.

The public comment period continues until 5 p.m. on the 15th of December. The comments this afternoon, again, are going to be transcribed and posted on the Web page, on the Healthy People 2010 Web page. And comments can still be submitted via the Web page. You can also look at the comments that other people have provided, via the Web page, which we hope, is helpful.

We are also having two additional regional meetings December 2nd and 3rd in Seattle, and December 9th and 10th in Sacramento.

I also want to say one other thing. That is, there has been a lot of effort and energy that has gone into the comments that each of you has provided, both verbally and in writing, and I just hope that after the launch of Healthy People 2010, that each of you will continue to dedicate as much effort to actually seeing these prevention objectives implemented. This is just the beginning. It is not anywhere--it is the beginning of a beginning, and I think that we have got to make sure that we all stay engaged once the launch of this document happens, and to think through strategies to try to make it work.

Many of you have worked closely with the Healthy People focus area coordinators in putting this together, and I just might mention that one of the things that we are working on within the Federal agencies is to fund and support some, what we are calling, companion documents with Healthy People, and Kathleen and others of you have the big yellow book, and it is quite big. But what we want to do is to take selected areas such as--HRSA is planning on looking at children with special health care needs, and pulling out those objectives that just deal with those, and marketing those in a document that specifically addresses those in a way the community can find useful.

We are looking at other comparison documents. One is for adolescents and young adults. I know CDC is looking at that. The Office of Minority Health is looking at pulling out the objectives for various racial and ethnic groups, and putting those out. Again, it is not changing the objectives, but it is taking them, and giving them specific visibility that we think will make them useful in working with specific groups that have an interest in that area, specifically tailoring them. So, I would challenge each of you to think about the kind of ways that this document can be useful to you. And the main Healthy People 2010 document, I look at as a reference document. It is going to have all the information in it. But I think there are some ways we can kind of package it that really will make it much more useful within the community, and I think that is the bottom line of what we all want.

You should have in your packet a yellow feedback sheet. Please fill it out and return it to the registration desk. You may also fax the form back. There is a fax number on the top of the page. We need your feedback on this meeting. Particularly, look at question #5, because we have to start planning now for the January 2000 Consortium. That sounds like a long way away. But, it is not. And I think to look at kind of how we launched this, what kinds of things we do to, again, get the most visibility we can for prevention, and for this document, we need your input.

I would also encourage each of you as you go back home to think about how your individual organization can use this document. I know the American Association of Retired Persons has used the document. I know that the American Association of Health Plans has done some things with it. I know that the state lab directors have a document called LIFT. There are a lot of ways, and quite frankly, from what I have learned over the last several years, that most people have taken this document and tailored it for their own use. And I think that is fine, because what we want, what we really want, is to have prevention become the name of the game in this country. And in my opinion, any way this document can be useful to any group is okay, because that is what it is all about.

So, I would encourage all of you to go back to think about--those of you that come from states and other organizations--putting together state plans, making it a part of business. I will tell you that, at HRSA, we are trying to look right now at our performance measures and make sure that they are consistent with the Healthy People 2000 objectives, and I know many Federal agencies are going to be trying to do that.

So, let's also not forget that we still have a couple of years left in this decade, and we all want to continue to push forward to try to do as much as we can in making progress for the objectives for Healthy People 2000.

And then, finally, let me say that I think that as Dr. Satcher alluded at lunch, we have tried to think of ways that we can get the hard work that the National Center for Health Statistics and others put together in trying to keep us abreast of what the data says each year around where we are with the objectives, and how can we get that out, and use these objectives in our training programs in schools of public health and in others, and any way that we can get the information out, whether it is through satellite uplink, digital streaming on computer, or whatever.

Our next live broadcast on satellite is the Clinical Preventive Services section. It is going to be January 20th. Mark your calendar. Information will be posted on the Healthy People 2010 Web page.

And again, I just can't say enough for everyone, how much I appreciate all the hard work that each of you has put into this effort. We ain't home yet, but we look forward to going the distance with you.

Thank you very much, and I think the reception is probably going to, hopefully, be moved up a little bit, but the reception is going to be in the Congressional/Senate Rooms where we had lunch.

And Dr. Windom is ready to hit the gavel, and there is nobody on the front row, so we stand adjourned.

Major advances in medical science enhance survival for children with complex medical conditions, and technology enables students with chronic diseases to function and participate actively in school programs. Societal shifts affect family structure and function in ways that put children at greater risk and changes in health care delivery systems make access to care an issue for children and youth. All of these impact the school nursing programs that serve 52.2 million school-aged children and youth across the nation. School nurses assess the student's health and development, help families determine when medical services are needed, and serve as a professional link with physicians and community resources. The Standards of School Nursing Practice (ANA, 1983) promulgated by six national professional organizations—National Association of School Nurses, National Association of State School Nurse Consultants, American School Health Association-School Nurse Section, American Public Health Association-Community Health Nursing Section, National Association of Pediatric Nurse and Associate Practitioners, American Nurse Association—reached consensus on a ratio of 1 registered school nurse to 750 students. When a school site exceeds 750 students, they should be served by at least one registered school nurse.

The following additional comments reflect NAPHSIS concerns regarding various objectives in the Public Health Infrastructure Section:

Goal 5 proposes to increase the proportion of state and local public health agencies that provide onsite access to data via electronic systems and online information systems such as the Internet.

NAPHSIS applauds the development of this goal statement. Vital records and public health statistics offices are exploring more options of making public health information available online and it is important that the public health workforce has the equipment and resources to access this information now and to an even greater extent in the future.

Goal 6 proposes to increase the proportion of the population that has access to public health information and surveillance data This section also proposes that data be made available in a timely manner. While these goals are desirable from many perspectives, we believe that language should be included in this goal reflecting the need to increase funding for information gathering organizations to both improve the timeliness of data gathering and expand access to this information.

Goal 7 proposes to increase to 100 percent the proportion of Healthy People 2010 objectives that can be tracked for select populations. This again is a desirable goal, but one that proposes numerous resource and logistical changes for state vital records and public health statistics offices. NAPHSIS members want to serve the special needs of select populations in all information gathering activities, but these initiatives also present some of the greater challenges in terms of collecting and reporting the desired information. Again, achieving this goal would involve the expenditure of significant additional resources at the state level in order for this goal to be achieved; additional funding at the national level will be required. Also, CDC and NCHS are cited as the data sources for this goal when state and local data centers for health statistics will actually be the primary sources of this information.

Goal 9 proposes to increase the use of geocoding in all major national and state health data systems to promote the development of geographical information system (GIS) capability at national, state, and Heal levels. NAPHSIS encourages and supports the use of this coding to improve the reporting and analysis of public health data. Ding is another example of an enhanced data collection tool that will provide additional benefits to data users, but no mention is made of securing additional funding to provide this enhancement.

Goal 13 proposes to increase the proportion of state and local public health agencies that ensure the provision of comprehensive epidemiology services to support the essential public health services. The thrust of this goal is desirable; however, the specific language describing this goal incorporates the data and statistics function of state health departments as a subset of epidemiology. Statistics and Epidemiology are two complimentary but distinctly different functions in a state health department.

One solution to this problem could include a revision of this goal by moving all of the public health statistics functions to a new goal proposing to increase the capabilities of state and local data centers to provide comprehensive information services to support the essential public health services. The NAPHSIS Committee on Virtual State Centers would be very interested in assisting in this important activity which would contribute toward improved information collection for many of the Healthy People 2010 objectives.

NAPHSIS continues to be concerned about the limited number of references to the role of state vital statistics and data centers in the entire Healthy People 2010 Objectives document. This omission should be of particular concern to all of the stakeholders in this project since a large proportion of the data items used to measure compliance with these objectives come from these organizations. The Vital Statistics Cooperative Program that provides a mechanism for state and federal cooperation on data collection and sharing, is a primary source for many Healthy People 2010 Objectives. Unfortunately, the long term funding of this program is still in jeopardy at a time when national and state data users are clamoring for more and better data in almost every area. NAPHSIS believes that the Healthy People 2010 Objectives should address this critical need in some fashion.]

On behalf of 51 million Americans with disabilities, the American Association on Health and Disability is pleased to present testimony on your draft document, Healthy People 2010 Objectives. In our judgment, this is an historic marker for all concerned about better health for persons with disabilities. For many years, a number of health professionals have recognized the significance of health issues of persons with disabilities. Unfortunately, the previous Healthy People planning documents (1980 and 1990) reflected either unawareness about or insensitivity to the health needs and disparities in health care of people with disabilities. For example, a review of Healthy People 2000 reveals very little concern about these needs and disparities. From 1988-1990, I was a member of the key planning group for a Federal interagency committee on developing disability objectives for Healthy People 2000. After two years of deliberation, vine developed 32 objectives for submission to the Healthy People 2000 Coordinating Council. Almost all of our objectives were rejected on the grounds that they were "developmental" and did not meet the criteria for an objective as delineated by directing council. Although a careful analysis of the draft document for Healthy People 2000 revealed that many other areas that were included in the document had developmental objectives, the health needs of people with disabilities were overlooked.

Since 1990, notable progress has been realized with regard to the importance of meeting the special health needs of people with disabilities. As President of the American Association on Health and Disability, I commend and express our thanks to the Secretary and the Assistant Secretary of Health for their support of a chapter devoted to health objectives for people with disabilities.

Goals 1 and 2 do not identify the significant select population of people with disabilities. We request that "People with Disabilities" are included as one of the select populations to be tracked in the Goals Statement and throughout the entire publication of Healthy People 2010: (1) the population of people with disabilities represents one of the largest and most significant select populations in America, and (2) now that DHHS has recognized the significance of the health needs of this population, vile need to scientifically gather data for planning and implementation of prevention programs. Life expectancy, mortality rates, and years of healthy life for people with disabilities are quite different in many instances from those of other select populations. For example, life expectancy for some children with severe disability is shorter. Also, health needs and disparities are as great but in many instances quite different from those of other select populations. For example, we all recognize that each the select populations have a problem with access to health care. But for persons with disabilities, especially those with serious mobility limitations, the problems are unique. Many women with disabilities are examined inappropriately for health problems by physicians and health care workers who do not understand the meaning of "functional limitations." Women who use wheelchairs have complained for years about the insensitivity of gynecologists in conducting a pelvic examination or in conducting a screening test for breast cancer.

Chapter 19: Disability and Secondary Conditions. On page 19-3, indicate that the National Council on Disability refers to 51 million persons with disabilities. The magnitude of this Select Population is significant because it highlights that the health needs of people with disabilities should no longer represent a foot note in planning documents about the health of the Nation. Although for the first time there is a chapter devoted to disability, it is important that the great health needs and disparities of people with disabilities are reflected appropriately throughout the entire publication of Healthy People 2010.

The Objectives for the chapter need some revisions and many additions SO that it reflects the key issues related to disability. On page 19-6, the Principles of 2010 Objective Development are acceptable.

"(Developmental) Increase to 90% the proportion of persons with disabilities who report satisfaction with ten domains of life: health, work, relationship with significant other, housing, community, standard of living, social relationships, creative expression, education, and future prospects for growth and development."

Data Source: Module for BRFSS is under development and will be piloted in 1998. It will request information about satisfaction with key life activities essential to attaining good physical and mental health.

"(Developmental) Increase to 100 percent the proportion of health, wellness, and treatment programs and facilities that are in compliance with the Americans with Disabilities Act, including:

Potential Data Source: State health department American with Disabilities Act compliance plans; Domestic Violence Statistical Survey; and health and fitness trade organizations." Comment: as an intervention to prevent secondary conditions in persons with disabilities, community health promotion programs must be fully accessible.

"(Developmental) Increase to 100 percent the proportion of persons with disabilities who report that they are not limited by environmental factors, to include:

Data source: Behavioral Risk Factor Surveillance Systems (BRFSS), CDC and NCCDPHP. Persons with disabilities are often disabled as much, if not more, by environmental barriers as by personal activity limitations. Plans are underway to include a request for data about these factors with the Participation and Environment portion of the Disability Module of the BRFSS."

"(Developmental) All persons with disabilities will receive appropriate assistive technology services, equipment, materials and training that are deemed necessary by consultation Ninth certified specialists to realize the greatest degree of independence.

Data Source: Institute of Medicine Report. (1997). Enabling America; Cook, A.M. & Hussey, S.M (1995). Assistive technologies: Principles and practices; Gray, D.B., Quatrano, L.A. & Lieberman, M.L. (1998). Designing and using assistive : technology: The human perspective.

"All infants will be screened, using observational, physical and postural assessments for early identification of developmental disabilities."

Data Source: American Academy of Pediatrics Policy Statement, RE 9414; Public Law 105-17.

"All infants with identified disabling conditions will be referred for care and treatment on a timely basis."

Data Source: American Academy of Pediatrics Policy Statement, RE 9414; Public Law 105-17.

"All students in grades K-12 with learning problems will be screened for language, hearing, and vision processing difficulties."

"(Developmental) Increase to 50% the number of health care providers who receive pre-service and continuing education about disability and health."

"Increase to 100% access to community buildings and facilities by people with disabilities as prescribed by the Americans with Disabilities Act ."

Comment: Environment Health must include the elimination of physical barriers for people with disabilities to allow for independence and community integration.

F. Chapter 7. Injury/Violence Prevention: for Objectives 1, 2, 3, 6, 7, 8, 9, 10,11,12, 20, 21, 22, 23, 24, 29, 33, 34, 35, and 36 include reference to People with Disabilities. Many of these objectives refer to fatal and nonfatal injuries that people with disabilities are at greater risk and would represent secondary conditions for a person with a primary disability. For example, individuals with mobility limitations are at increased risk for falls, resulting in fractures, spinal cord injuries and brain injuries. Furthermore, people with disabilities are at risk for physical abuse and sexual assault and need to be protected from these occurrences.

G. Chapter 8. Occupational Safety and Health: for Objectives 1, 2, 3, 4, 6, 7, 8, 11, 12, and 14 include reference to People with Disabilities. Each of these objectives rear potential health problems that people with disabilities may incur and therefore, they should be tracked to determine their impact on this Select Population. In addition, the environmental barriers that people with disabilities may face in the workplace must be addressed as part of the national effort to reduce stress, social isolation, barriers to employment, and good mental health.

H. Chapter 9. Oral Health: for Objectives 1 through 21, include reference to People with Disabilities. Many individuals with disabilities are at increased risk for dental and soft tissue disease because of the primary disability, poor oral hygiene, and medications. In some types of disability, oral health is essential for overall good health and communication effectiveness. Persons with deft palate need good dentition if they require the use of an obturator in order to develop effective oral communication. Children with neurological disorders that require medications are at risk for periodontal disease and need to be professionally managed.

I. Chapter 10.Access to Quality Health Services: for Objectives A.1, A.2, A.3a, and A.3b include People we, Disabilities as a Select Population. For A.5 derange objective as follows:

"A.5. (Developmental) Increase the proportion of physicians, physician assistants, nurses, and other clinicians who receive appropriate training to address important health disparities: disease prevention and health promotion, minority health, women's health, health of people with disabilities. and geriatrics."

For Objectives B.1, B.1a, B.2, B.3, B.4, B.5, and 8.5a include the Select Population of People with Disabilities. All other objectives are acceptable.

J. Chapter 11. Family Planning: for Objectives 1,2,3, 4, 7, 8, 9, 10 and 13 include the Select Population of People with Disabilities. All other objectives are acceptable.

K. Chapter 12. Maternal, Infant, and Child Health: for Objectives 1, 7, 10, 11, 17, 18, and 29, include the Select Population of People with Disabilities. At other objectives are acceptable.

L. Chapter 14. Public Health Infrastructure: for Objectives 1, 2, and 3, include statements about the need for public health workers and agencies to become aware of and sensitive to the special health care needs of people with disabilities. For Objective 16, include the need for support for research on improved health for persons with disabilities and the prevention of secondary conditions. All other objectives are acceptable.

M. Chapter 15. Health Communication: for Objective 1 include People with Disabilities as an "underserved population." Also, stress that alternate communication formats must be used to communicate effectively with people who have vision disorders, hearing disorders, and language disorders (such as aphasia, reaming disabilities, and cognitive problems secondary to traumatic brain injury).

For Objective 4, include reports of satisfaction from the Select Population of People with Disabilities. All other objectives are acceptable.

N. Chapter16. Arthritis, Osteoporosis, and Chronic Back Conditions: For Objective 12, include the Select Population of People with Disabilities. All other objectives are acceptable.

O. Chapter 17. Cancer: for Objectives 3, 4, 5, 6, 7, 10, and 13, include the Select Population of People with Disabilities. Men and women with disabilities often complain that procedures for screening and testing for cancer are often handled in an inappropriate manner.

P. Chapter 18. Diabetes: for Objectives 1, 2, 3, 4, 5, 6, 10, 14, and 23, include the Select Population of People with Disabilities. All other objectives are acceptable.

R. Chapter 20. Heart Disease and Stroke: for Objectives 1, 6, 7, 8, 9, 10, 11, 12, and 14, include the Select Population of People with Disabilities who are increased risk for these diseases because many are experiencing the "disuse syndrome" and are generally sedentary. In fact, heart disease and stroke are considered secondary conditions in persons with spinal cord injuries and other disabilities that result in loss of ambulating, reduced physical activity and weight gain. All other objectives are acceptable.

S. Chapter 21. HIV: for Objectives 1 a, 3, and 10, include the Select Population of People with Disabilities. All other objectives are acceptable.

T. Chapter 22. Immunization and Infectious Diseases: for Objectives 3, 5, 8, and 18, include the Select Population of People with Disabilities. All other objectives are acceptable.

U. Chapter 23. Mental Health and Mental Disorders: for Objectives 1, 2, 3, 4, and 12, include reference to the Select Population of People with Disabilities. Clinical and research literature reveal that children and

adults with disabilities are at increased risk for depression and other mental disorders. Furthermore, people with mental disorders may be at greater risk for diseases and injuries that result in physical disabilities.

V. Chapter 24. Respiratory Diseases: for Objectives 1, 2, 3, 14, and 15, include the Select Population of People with Disabilities. All other objectives are acceptable.

W. Chapter 25. Sexually Transmitted Diseases: for Objectives 1, 2, 3, 4, 6, and 8, include reference to the Select Population of People with Disabilities.

X. Chapter 26. Substance Abuse: for Objectives 1 a, 2, 3, 5, 6, 7, 8, 10, 11, and 15, include reference to the Select Population of People with Disabilities. All other objectives are acceptable.

In addition, we urge the removal of unsubstantiated assertion that the uninsured face barriers in obtaining care in emergency departments, which currently appear in the 10-C. 2 support statement. In keeping with the stated criteria requiring sound scientific evidence to support objectives, 10-A. 1 should focus on the well documented lack of access to preventive and tertiary care amongst the uninsured and under insured, and 10-C.2 should focus on the well described and increasing barriers to access to emergency care among the insured.

While the physical activity levels in some sub-objective populations or age groups were increased as we suggested, many remain below what we believe is necessary to improve the overall health of the American people. For example, we commend the objective to increase to 85 percent the proportion of work sites offering employer-sponsored physical activity and fitness programs. While an increase over the Healthy People 2000 objective, we are concerned however, that a target of just half of the primary and allied health care providers who routinely assess and counsel their patients regarding their physical activity practices, is much too low.

The American Physical Therapy Association is pleased that prevention has made its way to the overall title of this objective as we had suggested. Objective number 23 in this area, regarding reducing hip fractures for persons aged 65 and older by 20 percent, is very positive. However, we would like to reiterate our suggestion made last year for an added objective that would focus on a demonstrated effective means to attain the objective of reduced hip fractures in the elderly. That added objective would be as follows: Increase community availability and accessibility for preventive screening of, and services to, all people aged 65 and older to decrease the incidence of falls and fractures, improve strength, flexibility, coordination, balance, and preserve independence.

The American Physical Therapy Association is pleased to see the strengthened sub-objective #4 focusing on the reduction "by 50 percent the injury and illness cases involving days away from work due to overexertion or repetitive motion, including injuries due to overexertion in lifting". Among the stated strategies key is the need for early reporting and early intervention to reduce disability which is key to achieving this outcome. Physical therapists across the country have demonstrated the value of early work site intervention for musculoskeletal problems. We are encouraged that this successful strategy is now recognized in the Healthy People 2010 document.

Again, this added objective area focusing on musculoskeletal conditions encourages us. However, we would like to state at this time, that the single, somewhat conservative, sub-objective related to chronic back conditions warrants added attention, given the impact that this prevalent problem area has on this country's resources and productivity.

The increased focus on people with disabilities is much needed. The objective to include a comparable core set of items to identify "people with disabilities n in all data sets used for Healthy People 2010 has been deemed "developmental". We strongly encourage the effort that would move this objective from "developmental" to "measurable". The American Physical Therapy Association supports the efforts of federal agencies such as the Centers for Disease Control and Prevention (CDC) and the National Institute on Disability and Rehabilitation Research (NIDRR) to remedy this data gap.

Again, the American Physical Therapy Association expresses appreciation for the opportunity to comment on this important Objective area and others.

While we understand the intent of not setting separate targets, we are concerned that the target for reducing the asthma death rate is set at 14 per million of population without separate attention being given to children and adolescents. The death rate for children and young adults to age 24 has doubled from 1980-1993 and requires focused attention.

While some of these issues are addressed in the draft document, other such major factors in childhood asthma as common allergen avoidance in schools and urban housing are not included, and yet approximately 80% of the children and 50% of the adults with asthma have an allergic component.

In conclusion, the draft addresses important issues, but some fine-tuning still remains to be accomplished. AAFA acknowledges all the thoughtful deliberation and hard work that has gone into this document and pledges its continued collaboration in its final development.

III. The initiation of comprehensive school health programs in all states, stressing the need for grade-appropriate graduated health education from Kgn through 12 focusing on the target areas identified in the CDC Comprehensive School Health Program Initiative, i.e., the leading causes of morbidity and mortality in the US that are significantly influenced by behavior, and including school heath services, i.e. school nursing services in all schools as a resource for health education, immunization review, identification of a variety of risk factors, i.e., child abuse, emotional illness, teen pregnancy and STD's, administration of medications and supervision of chronic disease, all on the increase, i.e. asthma, epilepsy, hyperactivity, HIV/AIDS, first aid and consultation with school staff, parents and providers on heath related issues.

IV. At highest risk are the incarcerated: adolescents, women who give birth in jail and infants of incarcerated mothers and fathers - these are the "hard to reach population" representing for the most part, groups experiencing the highest degree of morbidity and mortality from practically all the conditions targeted in the Healthy 2010. There should be emphasis on five areas:

V. appropriate preventive screening programs and immunization (not just for Hepatitis B).

The old model of patients (consumers) as mere "beneficiaries" is no longer relevant at all. But there is a serious concern that patients (consumers) may have difficulty assessing the validity and applicability of information they obtain in relation to their own health status. We worry that not all Evidence is based on scientifically valid methods. We believe that activities such as the AHRQ's NGC^TM (National Guidelines Clearinghouse) and authoritative publications of established voluntary health organizations and medical societies should be among the primary sources of health information on which patients (consumers) make their decisions for quality health care.

We applaud the Healthy People 2010 effort, and predecessor Year 1990 and Year 2000 efforts, in outreach to voluntary health organizations as primary sources of information about patient (consumer) needs and desires. Similarly, medical societies and governmental entities have been actively involved in the Healthy People efforts.

Therefore, we believe there should be an objective, presumably in Focus Area 15, Health Communication that would result in greater assurance that evidence based (or quality) health information is being used. For example, an objective could be inserted prior to the current objective 154 (which only relates to ... being satisfied with the health information they received...."):

Again, we applaud the excellent and comprehensive work that has produced the Healthy People 2010 Objectives in current draft form, and we pledge that the Health Care Quality Alliance will work actively through our Spotlight on Quality and other efforts to advance Healthy People 2010 goals and objectives.

The school health objectives are critical and we applaud the attention paid to school health. However, this section should more effectively address the systems that serve children other than nurse to children ratio and school health education. We need to recognize special health roles (history and opportunity) that schools have because of their proximity to children and their responsibility for learning. We need to recognize interrelationship between health and learning. We need to mention child centered coordinated approach that can be provided through schools as opposed to fragmented approach through disparate agencies. We need to recognize recent research and evolving role of schools related to managed care such as school based health centers as managed care providers or working agreements between schools and managed care organizations to insure that preventive services are provided to children.

We also recommend that objective #2, related to school health instruction, and objective #4, related to nurse to student ratio, include reference to these elements as part of a coordinated school health program. To maximize health and learning in schools, eight components of a coordinated school health program need to exist and reinforce each other. These eight components include health instruction, health services, healthy environment, physical education, food service, counseling, school-community collaboration, and staff wellness.

Related to the overview, objective #10 (community health promotion initiatives) and objective #12 (elderly participation), the terms "health promotion program" and "health promotion initiative" need to be clarified so that the most appropriate term is used consistently for an agreed upon meaning. The overview (p. 4-7, lines 33-50) describe the components of a "community health promotion program" as including community participation, community assessment, measurable objectives, monitoring and evaluation, and comprehensive multifaceted interventions. This is similar, though not presented in the same way, as the definition in objective #4.10 of a "community health promotion initiative." In objective 4.12 (elderly participation in community health promotion), the term "health promotion program" is defined as "any health class, presentation on a health-related topic, exercise class, or exercise program." This latter definition is much narrower than the one included in the overview for the same term. While the term, "program" may be appropriate to describe an educational event, a broader term, such as "initiative" may be necessary to reference the more comprehensive activity including community participation, assessment, objectives, multiple strategies (including events or programs), and evaluation. We suggest making terminology and definition consistent for the overview and objective 4.10.

Regarding Chapter 14 - Public Health Infrastructure, we have the following comments:

We recommend that summary measures include broader determinants of community health, beyond health status. Summary measures need to include prevalence of policies, environmental supports/conditions, and availability of resources supportive of good health.

The overview section's first paragraph should add wording such as healthy communities, community capacity, or improve community health; and wording such as effective translation of research to practice.

We recommend to add an objective (placement with objective 15) to reflect the need for increased linkages between health departments and academics/researchers to accelerate translation of research to practice.

In the Overview: Paragraph 1: In addition to "promote and encourage healthy behaviors" which implies a focus on the individual, it is recommended that a statement on "improving community health" or "improving community capacity for health improvement", and "promoting public policies conducive to health promotion and disease prevention" be added.

Overview Paragraph 2:Regarding the statement on research (line 5): Add a statement to

Draft Objective 2, Paragraph 1: Add behavioral sciences, community organization and development, and intervention design and implementation to the skills listed (lines 6 &7 of the paragraph).

Draft Objective 6, Paragraph 1: Add such processes as community-based assessments and assets mapping. In addition community participation in the assessment process itself is critical.

Draft Objective 13, Paragraph 1: This is too limited with just epidemiology; it should also include behavioral research and other evaluation expertise.

Draft Objective 13, Paragraph 2: The team described is not a comprehensive epidemiology team; it is an interdisciplinary data/epi/evaluation/research team of which epi is a part. Epi does NOT subsume the others. It is also critical that newer evaluation models that include community level indicators and policy change indicators be developed and disseminated.

We applaud the inclusion of a chapter on Health Communications. The following comments are provided in relation to that chapter.

We recommend discussion and inclusion of narrative to the important strategy of media advocacy. The following is excerpted from the book Media Advocacy: Power for Prevention by Wallack et al.

"Media advocacy," according to Michael Pertschuk, one of the architects of this approach, "is the strategic use of mass media for advancing a social or public policy initiative. "Media advocacy promotes a range of strategies to stimulate broad-based media coverage in order to reframe public debate to increase public support for more effective policy level approaches to public health problems. It does not directly attempt to change individual risk behavior but focuses attention on changing the way the problem is understood as a public health issue."

Media advocacy is an important approach to promoting health and improving public policies conducive to health.

We also suggest adding a developmental objective that addresses media campaigns for primary prevention to the chapter. There needs to be a strategic approach to creating these campaigns, i.e., appropriate campaigns for greatest risks. As this is a very important type of communication, by approaching it strategically we will get the most bang for our buck.

We thank you for the opportunity to provide these comments and look forward to submitting additional comments electronically. We also look forward to working with you to implement the final objectives over the next decade.

Already we have identified a variety of barriers to the provision of services, not the least of which is the gap between provider knowledge base and advances in medical and genetic technologies. We need to develop standards and systems of care in order to exploit our rapidly growing knowledge about causes of genetic or congenital diseases as well as our growing ability to treat these conditions. We need to insure that our population understands the benefits of folic acid supplementation for the prevention of serious birth defects and reduction of the burden of premature cardiovascular disease. We need to take heed not to lose ground in the battle to prevent birth defects through uncontrolled release of dangerous teratogenic agents. Furthermore, we need to insure the viability of our public health screening programs to address not only the needs of children but of adults as well. Addressing the genetic health of our citizens is a major challenge to our health care system and must be a priority within our nation's public health objectives.

Past iterations of our nation's Healthy People objectives have by in large overlooked this set of conditions. Before now there has been no comprehensive framework developed to speak to this very important set of public health concerns. The American College of Medical Genetics and I, as a practicing geneticist, were pleased to see a number of developmental objectives included in this draft document for public comment. Both the College and I strongly support the retention of and further elaboration upon these objectives as part of our nation's health goals for the year 2010.

Specifically, the chapters on Educational and Community-Based Programs, Access to Quality Health Services, Public Health Infrastructure and Health Communication need to incorporate genetic objectives. The chapter on Heart Disease and Stroke has no objectives that address modifiable risk factors such as hemochromatosis, hyperhomocystinemia or Factor V Leiden deficiency that represent a major genetic health concern for the future. Congenital heart defects as a leading cause of infant mortality have also been omitted.

I believe that the clinical genetic community throughout the US is prepared to partner with the public health service and other organizations with a stake in the health of our nation to insure that these national health objectives are met. The genetic community includes providers with training in pediatrics, obstetrics, internal medicine and family practice that welcome the opportunity to be involved in both the planning and implementation process to help realize these objectives. Genetic issues are now, and will be in the future, a major force in patient care. Genetic medicine embodies all medical specialties and includes patients from conception through adulthood. We appreciate this chance to share our concerns and ideas with you in order to improve health care. We are optimistic about the future and know that through physician and public education genetic issues can be addressed, resulting in improved health of our citizens who no longer fear possible insurance or employment

The Healthy People 2010 Draft Objectives represent a major effort by the U.S. Department of Health and Human Services that is the "nation's prevention agenda and scorecard for monitoring health status."

By the year 2005, the Hispanic population in the United States will become the largest ethnic group in the nation. It is imperative that the Federal government becomes more responsive to this population. A fundamental principle that drives policy and program development to improve the health status of Hispanics is to first develop the databases to include Hispanic identifiers, in this case in the health arena.

The U. S. Department of Health and Human Services (HHS) announced its "Hispanic Agenda for Action" in 1996, a nine-point plan, including data collection, to improve the Department's ability to respond to the growing Hispanic needs. The data collection targeting Hispanics is a Departmental priority that should be included in the Healthy People 2010 program, as one of the premiere national efforts to improve health status.

In 1998, HHS announced the Race and Ethnic Disparities in Health Initiative and convened a successful leadership conference with the Grantmakers in Health. Hispanic leaders from across the nation participated in the discussion that again focused on the strategies that should be a part of this initiative to eliminate disparities in the six identified areas (heart disease, cancer, diabetes, HIV/AIDS, immunizations, and infant mortality). In the summary reports, it was noted that there is a critical need for consistent data across the nation that targets minority populations, including Hispanics.

The following are comments on the leading indicators and the draft objectives as they relate to the health status of Hispanics in the United States.

As noted in the HP20 10 reports, the essential functions of the leading indicators would address the following: promotion of awareness, motivation to action and feedback and assessment.

I believe that one leading indicator or criteria missing has to do with the interrelationships that would promote a better understanding of quality of health care in the nation. Perhaps the data is not yet developed in this area, but, certainly, there is a move toward developing the quality of health care as a major performance criterion for evaluation of the health system in various spheres. For example, HCFA has recently announced proposed regulations for Medicaid Managed Care that includes a focus on quality. The White House and Congress have charged ahead in developing a national agenda for the quality of health for the consumer and HHS has led the challenge to develop quality measures through various avenues¾ internal at AHRQ and external through partnerships such as NCQA and FAACT.

For Hispanics, the area of most importance in the area of quality centers around the concept of cultural competence. Access and health status would be greatly improved if the health system were more relevant to the diverse populations such as Hispanics.

The National Hispanic Medical Association has begun to develop an inventory of cultural competence information for physicians and other providers, of medical education curriculum, and of historical resources for the development of patient materials.

Our discussion will focus on the objectives as they pertain to Hispanic health. The list of draft objectives that relate to Hispanic identifiers are included in the appendix. The following list addresses priority issues that should be included in Healthy People 2010 in order to improve future planning that will positively impact the health status of Hispanics.

It is important to increase the number of Hispanics of all ages who engage in sustained physical activity for 30 minutes per day.

Reducing the number of Hispanic children and adults who have body mass indices at or above 30.0 to less than 15%. Reducing obesity in our population as a whole is an important strategy in preventing a number of chronic disease such as diabetes and heart disease. Iron deficiency anemia in Latino women in particular in the child bearing years is a major problem.

Cultural competence is of critical importance in developing the health system to be more responsive to Hispanics. We need cultural competence standards for medical and other health professions education; the delivery system, including performance standards, medical practice and organizational materials, health education materials; community outreach and enrollment; provider training; and in health promotion, disease prevention, care management, and research policy and program development.

Cultural competency requires awareness of the culture of the population being served. Therefore, in order to ensure services are provided in a culturally competent manner, State agencies should require MCO's to give racial and ethnic minority concerns full attention beginning with their first contact with an enrollee, continuing throughout the care process, and extending afterwards when care is evaluated. MCO's sensitivity to representation of the minority community that they serve to be reflected in the make up of the make-up of the top administration within their organization would serve as one key indicator of cultural competence. Translation services must be made available when language barriers exist, including the use of sign interpreters for persons with hearing impairments and the use of Braille for persons with impaired vision. Further, for each racial or ethnic minority group, the MCO's network should include an adequate number of providers, commensurate with the population enrolled, who are aware of the values, beliefs, traditions, customs, and parenting styles of the community. This awareness includes, but is not limited to, a provider being cognizant, among other things, of the importance of nonverbal communication, the recognition of specific dietary customs unique to certain populations, and the existence of folk medications or healing rituals that may be used by an enrollee. In addition, cultural competence requires network providers to have knowledge of medical risks enhanced in, or peculiar to, the racial, ethnic, and socioeconomic factors of the populations being served. Accordingly, MCO's should have accurate epidemiological data from which to form appropriate education, screening, and treatment programs.

In addition, the infrastructure is needed in the Hispanic community- including public/private partnerships that can serve to enhance the health care efforts to this most vulnerable group without health insurance.

Decreasing the number of tobacco advertisements targeting Hispanic youth in our communities and initiation of tobacco product is key. Reducing the number of adults who continue to smoke will also be a important goal.

Reducing the number of domestic violence incidence in our Hispanic communities and youth to youth violence is key.

Dental caries and gingivitis is more prevalent in Hispanic children than the white population.

The Federal requirements for the application and enrollment process for Medicaid and for separate State CHIP program provide a great deal of flexibility to States to design an application and enrollment process that is streamlined simple and avoids burdensome requirements for families that apply for benefits. For example, under Medicaid, with the exception of obtaining documentation of immigration statue for qualified alien applicants and the applicants’ Social Security numbers, states have the flexibility to determine documentation requirements including self-declaration of income and assets. Legal and Illegal alien applicants would have great reluctance in declaring their alien status for fear of reprisal and therefore is a barrier in enrolling their children into the CHIP program.

Of note, the Hispanic population is the most uninsured group in the nation. It would serve to follow the progress made in the system's attempts to decrease the uninsured. Available and easily accessed transportation and child care services are other important health access issues for Hispanic communities.

Increase the number of all pregnancies among women aged 15-44 that are planned and reducing the number of teen pregnancy are important issues.

Increase the number of infants and children adequately immunized is important. Increasing the Enrollment of Hispanic children into the CHIPS program is pivotal to the general will being of the children as well as the families. Reducing the number of Hispanic children affect by infectious disease epidemics such as measles is also important.

Cancer of the stomach, esophagus, gallbladder and liver is higher among Hispanic than other populations. The prevalence of cervical cancer in Latina women is unclear but some studies show it's prevalence to be higher than that in the White population. Occupational and environmental exposure to carcinogens of Latino communities is worrisome and not well studied.

The Draft 2010 objectives report the tremendous problem with lack of Hispanic data. For Hispanics, diabetes is a yew, critical area affecting many of our population and the lack of data is a serious issue. The following objectives report a lack of Hispanic data:

18-8: Decrease the incidence of Type 2 diabetes to 2.5 per 1000 persons per year.

18-9: Reduce the prevalence of diagnosed diabetes to less than 25 per 1000 population.

18-9: Increase to 80% the proportion of persons with diabetes whose condition has been diagnosed.

18-10: Reduce diabetes-related deaths to no more than 2033 per 100,000 known persons with diabetes.

18-11 : Reduce deaths due to cardiovascular disease in people with diabetes to no more than 850 per 100,000 diabetic population.

18-12: Reduce the frequency of lower extremity amputations to 5 per 1000 persons with diabetes.

18-13: Decrease the prevalence of end-stage disease due to diabetes requiring dialysis or transplantation to no more than 70 per 1,000,000 population.

In addition, we feel it is imperative to follow foot examinations every 6 months/not annual basis.

18-14: Increase to % the proportion of persons with diabetes who have at least every 6 months foot examination.

The San Antonio Heart Study found that conventional cardiovascular risk factors were more strongly associated with angina prevalence among Mexican Americans than Whites. Hypertension and high serum cholesterol levels are a pervasive problem in Hispanic communities.

Increasing the number of Hispanic pregnant HIV positive women who access AZT protocols is key. Increasing the number of HIV at risk Hispanic women who are HIV tested during pregnancy is important.

Reducing tuberculosis in Hispanic of all ages. Hepatitis C is increasing at dramatic rates in Hispanic communities. One preliminary study from a San Antonio HIV outreach program showed that 95% of individuals tested for HIV were already Hepatitis C positive. Some Hispanic communities bordering US Mexico are more susceptible to other infectious diseases such as leprosy, salmonella and shigella.

Depression and anxiety are important mental health problems that plague our Hispanic communities. Specific incidence and prevalence rates of these diseases are not available for the Hispanic population.

Environmental causes for diseases of Hispanic of all ages is not well documented in particular in the US-Mexico border states. Poor compliance with regulations of airborne toxic substances in the border region is gaining increasing concern for Hispanic who live and work in these areas.

Sexually Transmitted Diseases Data on sexually transmitted diseases in the Hispanic populations is not available. Primary and secondary syphilis is 13 times more prevalent than the White population. Chlamydia in Latina women is still high and the leading cause of involuntary infertility.

Substance Abuse Monitoring the prevalence and incidence of drug exposed infants within our Hispanic communities is important and no current data exists. Monitoring and reducing intravenous drug use of Hispanic youth and adults is also key.

Chronic diseases is another area that is not covered. For example, Mexican American have the highest rates of gall bladder disease.

1-9: People 18+ who engage in sustained physical activity for 30 minutes per day.

1-10: People 18+ who engage in cardiorespiratory activity 3 or more days per week for 20 or more minutes.

2-7: Increase to 60% the prevalence of healthy weight among all people aged 20+.

2-8: Reduce to less than 15% the prevalence of BMI at or above 30.0 among people aged 20+.

2-9: Reduce to % or less the prevalence of overweight and obesity in children and adolescents.

2-12: Increase to at least 75% the proportion of people aged 2+ who meet the Dietary Guidelines' average daily goal of no more than 30% of calories from fat.

2-13: Increase to at least 75% the proportion of people aged 2+ who meet Dietary Guidelines' average daily goal of less than 10% of calories from saturated fat.

2-15: Increase to at least 75% the proportion of people aged 2+ who have 5 daily servings of fruit and vegetables.

2-18: Increase to at least 90% the proportion of people aged 2+ who meet dietary recommendations for calcium.

3-9: Reduce cigarette smoking among pregnant women to a prevalence of no more than 2%.

3-10: Reduce the proportion of young people grades 9-12 who have used tobacco products.

3-11: Increase to 40% the proportion of young people in grades 9-12 who have never smoked.

4-14: Increase to at least 50% the proportion of all employees who participate in employer-sponsored health promotion activities.

4-15: Increase to _ percent the proportion of managed care organizations and hospitals that provide community disease prevention and health promotion activities that address the priority heath needs identified by their communities.

4-18: Increase to at least _ percent the proportion of local heath departments that have established culturally appropriate and linguistically competent community health promotion and disease prevention programs for racial and ethnic minority populations.

7-10: Reduce deaths caused by motor vehicle crashes to no more than 11.4 per 100,000 people and 1.1 per 100 million vehicle miles traveled.

7-18: Reduce deaths caused by unintentional poisoning to no more than 2.7 per 100,000 people.

9-10: Reduce untreated cavities in the primary and permanent teeth so that the proportion of children with decayed teeth not filled is no more than 12% among children aged 2-4, 22% among children aged 6-8, and 15% among adolescents aged 15.

9-11: Increase to at least 37% the proportion of dentate people aged 35-44 who have never lost a permanent tooth due to dental caries or periodontal disease.

9-21: Increase to 50% the number of adults aged 18+ who in the last year report having had an oropharyngeal cancer exam.

10-11: Reduce to 0% the proportion of children and adults under 65 without health care coverage.

10-12: Increase the proportion of patients who have coverage for clinical preventive services as part of their health insurance.

10-16: Reduce to no more than 7% the proportion of individuals/families who report that they did not obtain all of the health care that they needed.

10-18: Reduce the proportion of persons who report being in fair or poor health but who have no primary care visits during the previous year to no more than 8%.

10-19: Increase the proportion of all degrees in health professions and allied and associated health professions fields awarded to members of underrepresented racial and ethnic minority groups.

10-19: Increase the proportion of individuals from underrepresented racial and ethnic minority groups enrolled in U.S. schools of nursing.

11-10: Increase to at least 70% the proportion of all pregnancies among women aged 15-44 that are planned.

11-12: Increase to at least 95% the proportion of all females aged 15-44 at risk of unintended pregnancy who use effective contraception.

11-13: Decrease to no more than 7% the proportion of women aged 15-44 experiencing pregnancy despite use of reversible contraceptive method.

11-15: Reduce pregnancies among females aged 15-17 to no more than 45 per 1000 adolescents.

11-16: Reduce to no more than 12% the proportion of individuals aged 15-19 who have engaged in sexual intercourse before age 15.

11-17: Reduce to no more than 25% the proportion of individuals aged 15-17 who have ever had sexual intercourse.

11-18: Increase by at least 10% the proportion of sexually active, unmarried individuals aged 15-19 who use contraception that both effectively prevents pregnancy and provides barrier protection against disease.

11-12: Reduce by 10% the prevalence of impaired fecundity among married couples.

12-16: Increase to at least 90% the proportion of all pregnant women who begin prenatal care in the first trimester.

12-17: Increase to at least 90% the proportion of all live-born infants whose mothers receive prenatal care that is adequate or more than adequate according to the Adequacy of Prenatal Care Utilization Index.

12-22: Reduce low birth weight to an incidence of no more than 5% of live births and very low birth weight to no more than 1% of live births.

12-28: Increase to at least 75% the proportion of mothers who breastfeed their babies in the early postpartum period to at least 50%.

17-9: Reduce deaths from cancer of the uterine cervix to no more than 1 per 100,000 women.

17-12: Reduce deaths due to cancer of the oral cavity and pharynx to no more than 9 per 100,000 men aged 45-74 and 3 per 100,000 women aged 45-74.

17-14: Increase to at least 95% the proportion of women aged 18+ who have ever received a pap test and to at least 85% those who received a pap test within the preceding 3 years.

17-15: Increase to _ % the proportion of women aged 40+ who have received a breast examination and mammogram within the preceding 2 years.

18-8: Decrease the incidence of type 2 diabetes to 2.5% per 1000 persons per year.

18-9: Reduce the prevalence of diagnosed diabetes to less than 25per 1000 population.

18-9: Increase to 80% the proportion of persons with diabetes whose condition has been diagnosed.

18-10: Reduce diabetes-related deaths to no more than 2033 per 100,000 known persons with diabetes.

18-11: Reduce deaths due to cardiovascular disease in people with diabetes to no more than 850 per 100,000 diabetic population.

18-12: Reduce the frequency of lower extremity amputations to 5% per 1000 persons with diabetes.

18-13: Decrease the prevalence of end-stage disease due to diabetes requiring dialysis or transplantation to no more than 70 per 1,000,000 population.

18-15: Increase to 52% the proportion of persons with diabetes who have received formal diabetes education.

20-9: Reduce coronary heart disease deaths to no more than 51 per 100,000 population.

20-10: Increase to at least 50% people with high blood pressure whose blood pressure is under control.

20-11: Increase to at least 95% people with high blood pressure who are taking action to help control their blood pressure.

20-11: Increase to at least 95% of adults who have had their blood pressure measured within the preceding 2 years and can state whether their blood pressure was normal or high.

20-12: Reduce the mean serum cholesterol level among adults to no more than 193 mg/dL.

20-12: Reduce the prevalence of blood cholesterol levels of 240 mg/dL or greater to no more than 13% among adults.

20-13: Increase to at least 75% the proportion of adults who have had their blood cholesterol checked within the preceding 5 years.

21 -10: Confine annual incidence of diagnosed AIDS cases among adolescents and adults to no more than 12 per 100,000.

21-12: Increase to 46% the proportion of sexually active unmarried people who reported that a condom was used at last sexual intercourse.

22-15: Reduce newly acquired hepatitis c cases to an incidence of no more than 1 case per 100,000 people.

22-21: Decrease the incidence of invasive early-onset group B streptococcal disease to 0.5 cases per 1000 live births.

24-9: Reduce the overall asthma morbidity, as measured by a reduction in asthma hospitalization rate to 10 per 10,000 people.

24-9: Reduce asthma morbidity as measured by a reduction in annual rate of emergency department visits to no more than 46 per 10,000 people.

24-12: Reduce to no more than 3% the proportion of adults 45+ with chronic obstructive pulmonary disease.

24-13: Reduce the chronic obstructive pulmonary disease death rate for adults to no more than 18 per 100,000 population.

25-16: Reduce the prevalence of chlamydia trachomatis infections among young persons 15-24 to no more than 3%.

25-17: Reduce the incidence of gonorrhea to no more than 19 cases per 100,000 people.

25-17: Eliminate sustained domestic transmission of primary and secondary syphilis to fewer than 0.25 cases per 100,000.

25-18: Reduce the number of new cases of herpes simplex virus type 2 infection so that the prevalence in persons 20-29 years of age is no greater than 15%.

25-19: Reduce the % of women 15-44 who have ever required treatment for PID to no more than 5%.

25-20: Reduce the incidence of congenital syphilis to no more than 1 per 100,000 live births.

26-11: Increase to 24% the proportion of high school seniors reporting they have never used alcohol.

26-11: Increase to 59% the proportion of high school senior reporting they have never used any illicit drug.

26-12: Reduce to 5.3% the proportion of youth reporting use of marijuana during the past 30 days.

26-13: Reduce to 5.8% the proportion of youth reporting use of any drugs during the past 30 days.

26-14: Reduce to 13% the proportion of high school seniors reporting binge drinking during the past 2 weeks.

26-14: Reduce to 18% the proportion of adults 18-25 years old reporting binge drinking during the past month.

26-15: Reduce to 15% the proportion of adults 26-34 years old reporting binge drinking during the past month.

26-15: Reduce to 3.6% the proportion of 12-17 year-olds reporting binge drinking during the past month.

26-17: Reduce to 30% the number of young people in grades 9-12 who reported they rode, during the previous 30 days, with a driver who had been drinking.

26-18: Reduce to 1% the estimated proportion of high school seniors who report use of steroids during the past year.

26-19: Reduce to 0.7% the proportion f youth 12-17 who used inhalants during the past year.

26-20: Increase to 80% the estimated proportion of youth perceiving great risk from consuming 5 or more drinks at a single occasion once or twice a week.

26-21: Increase to 80% the estimated proportion of youth perceiving great risk from smoking marijuana once per month.

26-21: Increase to 80% the estimated proportion of youth perceiving great risk from using cocaine once per month.

I am Dr. Gary C. Dennis, president of the National Medical Association (NMA). Established in 1895, NMA is the oldest and largest organization representing African-American physicians and other health professionals in the nation. With a membership of 22,000 physicians, NMA's primary mission is to improve the health status of minorities and increase the representation of African-Americans and other underrepresented groups in the health professions.

Key among these goals is the need to eliminate health status disparities between minorities and majority Americans. As you well know, the health status challenges that exist in this country are magnified in underserved minority communities. African-American infants die at nearly double the rate of white infants. Cancer, diabetes, hypertension and stroke rates are also disproportionately high among African-Americans and Hispanics compared to the non-minority population. The injury rate for African-American children ages one through fourteen is higher than for white children. Thirty-five percent of all reported AIDS cases in the U.S. are among African-Americans, even though we only represent approximately twelve percent of the population. And according to the 1993 update of the HHS Secretary's Task Force Report on Black and Minority Health seventy thousand excess deaths occur among African-American when compared to white Americans¾ which means that seventy thousand African-Americans would not die each year if our life expectancy and death rates were the same as white Americans.

We believe that increasing the number of minority physicians and health care providers is a key component in realizing the goal of decreasing health care gaps. As many of you know, African-Americans and other minorities are the most likely group of physicians to serve in medically under-served areas. Yet, African-Americans only make up under four percent of the medical professionals in this country. In the past we have worked closely the Congress and the Health Resources and Service Administration to ensure that funding and resources go into health professions training. We also provide thousands of dollars in scholarships to deserving minority medical students each year and have a history of mentoring minority medical students nationwide.

In addition, NMA works closely with the Centers for Disease Control and Prevention (CDC), and the National Institutes of Health (NIH), to secure funding for community-based public health and prevention activities within minority communities, and the inclusion of minorities in biomedical research to redress health disparities.

Given NMA's concerns regarding this issue, I wish to take this opportunity to commend Healthy People 2010 for setting the health status targets for all Americans at the same level. As you know, in the health status targets set for Healthy People 2000 approximately 300 were set at a lower level for minorities than for the general population. NMA has always supported setting the health status targets for all Americans at the same level. Despite the need to redress health disparities that already exist, we think it is important for minorities to catch up completely with non-minorities and not just make proportionate gains.

Before I close, I would like to raise one more issue regarding the health disparities demonstration program that was included in the omnibus appropriations measure for fiscal year 1999 and is funded through the CDC This demonstration grant was initially proposed by the administration and includes $10 million in funding, but does not set any real parameters on how the money is to be spent. The final conference report merely states that, "it is expected that the Secretary will provide the House and Senate Appropriations Committees with a detailed proposal of how these funds will be coordinated and expended to reduce health disparities in minority populations." To the extent that Healthy People 2010 plays a role in shaping how this program is set up, NMA would urge that this funding be specifically targeted to locales that have demonstrated a high level of "best practices" in the past in terms of outreach to minority communities. These moneys should not just be sent to states to funnel out at their discretion, rather the funding should go directly to cities, municipalities, private not-for-profits as appropriate, and states where there are high levels of the incidence of the six health disparities areas outlined in the President's Initiative on Race. Additionally, the targeted areas should also have a proven ability to provide outreach and education, and to institute prevention measures for public health problems within minority communities in addition to providing treatment. Funding should also be allocated so that programs that are local, statewide, and national in scope are included, and obviously the most successful programs should be used as national models for later programs.

Once again, I appreciate the opportunity to speak at this forum and thank you for leadership with regard to health disparity issues.

Public health practitioners have long understood the effects of occupation, race, and class on health. Many, though, are unaware of the effects of gender.

According to the NCHS, in 1920 the gender gap in life expectancy was only 1.0 year. By 1990, the gap had widened to 7.0 years.

Cause of Death:	Men	Women
Heart Disease	178.8	98.2
Cancer	153.8	108.8
Injuries	43.3	17.9
Stroke	28.5	24.6
COPD	25.9	17.6
Diabetes	14.9	12.5
Pneumonia/flu	16.2	10.4
HIV infection	18.1	4.2
Suicide	18.0	4.0
Homicide	13.3	3.6

Men’s health is also a women’s issue. When a man dies early, it can deal a devastating psychological and financial blow to his mother, his sisters, his wife, and his children.

The Men’s Health Network believes it is time to stop ignoring the life span gender gap. The MHN is making three recommendations for Healthy People 2010:

Across the full spectrum of health problems, men are a high-risk group. We can no longer afford to ignore the gender health gap. Healthy People 2010 needs to consider the special problems of men, too.

Alcohol consumption is a major element of the Healthy People 2010 Draft Objectives, and the draft document makes use of the term "one drink" in a number of places in this regard. "Binge drinking" is defined, for example, as consuming 5 or more "drinks" on one occasion.

The term "one drink", however, is not defined in the Draft Objectives. We believe that not including a definition is a small step forward, because those who have attempted to define "one drink" have done so incorrectly, particularly in the U.S. Dietary Guidelines.

The Dietary Guidelines’ definition, which equates 12 ounces of "regular beer", 5 ounces of wine, and 1.5 ounces of 80 proof distilled spirits, is an attempt to express "alcohol equivalence", not "drink equivalence". This distinction is crucial to the Healthy People Objectives and the drinking behaviors those Objectives are attempting to measure.

Even assuming the chemical accuracy of the Dietary Guideline’s formula, the problem is that it overlooks real world serving sizes and real world behaviors. What is relevant is serving size. The current Dietary Guidelines’ 12-5-1½ oz. formula is incorrect and misleading in that it implies that individuals will consume like amounts of alcohol by ordering an equal number of drinks, regardless of whether the drinks are beer, wine, or hard liquor.

As most people’s experience would confirm, actual servings of mixed drinks often contain significantly more alcohol than do orders of beer or wine. Bartending recipes for traditional mixed drink favorites such as the gin & tonic, the martini, the margarita, the Tom Collins, the screwdriver, the whisky sour, and even scotch and water all call for more than 1½ ounces of distilled spirits. Basic highballs of brandy, gin, rum, and scotch all contain two ounces of hard liquor. Restaurant and club owners also report increasing pressure to purchase and sell higher proof spirits, including over-proof vodkas, small batch bourbons, and other liquors that are well above 80 proof.

In addition, distilled spirits manufacturers are now marketing pre-mixed liquors as so-called "single serve" cocktails. These products, which generally come in 6.8 oz. bottles, often contain up to 21% alcohol by volume (42 proof). Examples include T.G.I. Friday’s "Gin Martini", "Vodka Martini" and "Manhattan".

We therefore need to reexamine the drink equivalence paradigm to account for actual serving sizes. A statistical survey on representative drink servings should be conducted by HHS and SAMHSA, and we have proposed such a study to members of the Dietary Guidelines Advisory Committee. The survey would gather data from a sufficient number of restaurants, bars, nightclubs, and other establishments to determine a scientifically defensible definition of "one drink." This approach would allow our alcohol related health policy to be based on accurate and meaningful data.

After a valid formula is developed -- one based on sound science -- it should be incorporated into the Healthy People 2010 Objectives. For the time being, the Healthy People 2010 Draft Objectives are on the right track by not adopting the "one drink" definition provided in the Dietary Guidelines.

The following are examples of 30 traditional and frequently ordered cocktails containing over 1½ ounces of distilled spirits:

Testimony of: