DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010
April 23, 1999, Proceedings

Agenda Item: Focus Areas and Objectives

DR. SATCHER: Now we continue to look at public comments and our response to them as we turn our attention to the focus areas and objectives. This session, I think, is an opportunity to assess the extent to which the focus areas and draft objectives have been revised to be responsive to public comments, to be based on sound science, to be reflective of important public health priorities, and the extent to which they are understandable and useful in the communities and the constituencies that we serve. I think that is the key. So we want to make sure that they are consistent with policies and initiatives-in some cases, we may have to even change policies as we move forward-sufficiently motivating to propel action toward national health improvement, and futuristic-you know, that discussion we had about the future that was so helpful.

Deborah Maiese, the Senior Prevention Policy Advisor in ODPHP, will begin our discussion with a review of crosscutting issues that have emerged, and I certainly encourage all of the presenters to feel free to add any other crosscutting issues that you think would benefit from discussion by the Council. After Debbie has given her overview, the lead agencies will begin to review key issues within their focus areas.

Debbie?

MS. MAIESE: Thank you, Dr. Satcher, and I certainly want to recognize all of the public comments that we received. As Secretary Shalala referred to in her opening remarks, we heard from people from every State, the District of Columbia, and Puerto Rico. Under Tab III of your briefing book is this map to really show the sort of outpouring of comments. We heard from school nurses and firefighters and people who suffer from chronic kidney disease. We heard from individuals and health professionals. We heard from academicians. We heard from people around the country and, as Dr. Satcher just said, we need to be responsive to those public comments.

Our workgroups have really had a great deal of public comment to deal with. In fact, let me just show you in some respects which are the top five vote getters. There were five focus areas that actually got more than 500 comments each-the Access chapter, the Educational and Community-Based Programs chapter, Nutrition, Maternal, Infant and Child Health, and Injury and Violence Prevention. So to take this advocacy and now translate it and back it up and ground it in good science is, in fact, our first challenge today, and certainly one of those that we turn to is the lead agencies, to ensure that these objectives are based on sound science.

The next part of our-all of us have a little model, and I think I will put up a three-legged stool to support our framework that incorporates science in the base. Add to that, policy and good data.

Let me talk a little bit about the policy implications of this. I think Dr. Richmond alluded to it a few minutes ago, about the challenge of whether or not there are sufficient numbers. Are these of significance and relevant to the public and to the public health community? I think we need to again turn to the lead agencies to help us look at the public health significance of each and every one of these objectives that we are putting forward today. Certainly there is no one size that fits all chapters or all objectives in this framework, but rather we need to evaluate each and every one of them on its merits and on its science, as well as its public health significance.

The other dimension of policy that I would like to put forward to everyone for consideration today is consistency, consistency within and across chapters and among agencies, not just in the Department of Health and Human Services, but across Federal agencies-our partners in Education and Agriculture, in Environmental Protection. We need to make certain that we are coming forward with a consistent set of messages and measures for the American people.

It seems to me as we in ODPHP-and there are a few of us who have actually read all of Volume II; I now have reading glasses thanks to this process-and what we found in our evaluation of this volume that you have before you today is some overlap, perhaps even some redundancy. So we challenge each of the lead agencies to go back and look at the extent to which the objectives within a particular chapter really tell a cohesive story. To the extent that we use more than one measure, are we in fact diluting the attention of the American people? Is there a way, as we have just discussed with the Leading Health Indicators, to pick one sentinel measure rather than two or three or a constellation of measures? So the consistency internally of factors is one challenge today.

The second challenge is consistency across chapters. Let me just give you three examples of things that we found in many different chapters. School health education objectives-I think there are about 10 of them in 10 different chapters, as well as a comprehensive one in the Educational and Community-Based Programs chapter. We also saw that there are about 20 provider counseling objectives, again throughout the document and, of course, looking at the quality and measurability of provider counseling is a huge challenge to this initiative.

The third crosscutting issue that we put on the table to you today is provider training, not just physicians, but nurses, physicians' assistants, nurse practitioners, public health professionals, that are going to help us move this agenda forward in the 21st century. We have about 20 provider training and education objectives. Is there a way to synthesize these subjects into one cohesive objective that really will help us put forward the prevention curriculum, the provider counseling message, or the school health education message?

In part, I propose this test and this screen of consistency to get us to our third leg of this diagram, and that is data. Ed Sondik and I appeared before the Data Council last week to talk about the challenges we have in measuring this initiative, and I think we need to be very careful and cautious about the promises we bring forward to the American people about what is going to be maintained as measures in the next decade, as well as developed as new measures or developmental objectives. We need to be particularly cautious about the data development agenda we have put forward to make sure that we can fulfill those commitments.

So our lead agencies really are in the lead. We in the Office of Disease Prevention and Health Promotion really are just the coordinators and orchestrators of this big initiative for Healthy People, and we really rely on your expertise to bring forward the sound science, the good data that will help us drive the policies for health improvement in the 21st century. So let me leave those challenges to our lead agencies.

DR. SATCHER: Thank you very much. Any questions? Any burning questions?

[No response.]

Okay, we are going to move on. I will just remind you now, you know, our objectives are organized into focus areas or categories of objectives, and the agencies will be discussing these areas.

We are going to change the lineup a little bit and go to family planning first, because Dr. Shervington has to leave. Let me just say that Dr. Denese Shervington is our newest appointment in the Office of Public Health and Science. She heads the Office of Population Affairs and comes to us with a strong background in public health and family planning.

DR. SHERVINGTON: I want to thank you very much for allowing me to go first in presenting our data. I am representing the Office of Population Affairs, and we are responsible in Healthy People 2010 for the Family Planning section. At first, when I saw who got the most comments from the public, I was kind of looking for Family Planning, and then I stepped back and said, No, I am really glad we did not get a lot of comments, because usually things are so controversial for us.

In terms of the 2010 objectives, I think that, just giving a quick outline, we have 16 objectives. Six are developmental, and one new objective has been added, which is access to contraceptive supplies and services, and two are for compound objectives or split.

Basically, we have three basic, broad themes. One, the first, is to increase the intendedness of pregnancies, to reduce unintended pregnancies. The second is to reduce adolescent pregnancy. The third is to improve access to family planning services and supplies by increasing insurance coverage for contraceptives.

Summarizing our public comments, most of the comments were very supportive of the chapter, offering suggested language changes or identifying areas that required further clarification. Several comments recommended an additional objective to increase the number or percent of private health insurance plans that cover all forms of FDA-approved contraceptives. We have included a new objective in this area.

Others recommended an objective focused on monitoring abortion use among women, particularly an objective on reducing the number or rate of elective abortions. We have chosen not to adopt this recommendation, and we will leave that to get some feedback from you as to your recommendations there.

In terms of the changes in the family planning chapter, for the goal statement, in response to ODPHP's recommendations that goal statements reflect terms of action contributing to progress rather than an idealized outcome, our goal statement was changed from, every pregnancy to be intended, to improved pregnancy planning and spacing and prevention of unintended pregnancies. In terms of our terminology, the definition of contraception is modified to list each of the specific permanent and temporary methods rather than referring to temporary methods generically as barrier, behavioral, or hormonal.

Further, emergency contraception has been added to the list of terms. Sexual intercourse has been added to the list of terms to clarify that, since the chapter focus is on pregnancy prevention, sexual intercourse refers to heterosexual, vaginal intercourse.

Then I am just going to quickly go through each of the 16 objectives and tell you what the changes are. In terms of unintended pregnancy, many comments pointed out that, while the objective was stated in the positive-that is, to increase intended pregnancy-the data was reported on unintended pregnancies, and this has been corrected.

On objective number 2, birth space emphasis, one, that is developmental. The objective was revised to reduce the proportion of births to all women 15 to 44 occurring within 24 months of a previous birth, rather than repeat unintended births. This was in response to comments that such an objective ought to address all women in order to provide for healthier pregnancy spacing and is not just focused on adolescence.

Objective number 3, contraceptive use. This objective has been modified from the previous draft with proposed goals of increasing use of effective contraception, which was defined as not including withdrawal, to a simpler statement in which we seek to have 100 percent of all women 15 to 40 who are at risk of unintended pregnancy use some or any method of contraception. The 1995 baseline is 92.5 percent.

Objective number 4, contraceptive failure. The objective is no longer considered developmental since we now have the data to establish a baseline.

Objective number 5, emergency contraception. This is developmental. Again, in response to public comments, the statement of this objective was modified so that we are seeking to increase the proportion of all health care providers and not just family planning clinics that provide emergency contraception.

Number 6, male involvement is developmental. The objective has been modified in response to some of the public comments, which found the statement to be too broad.

DR. SATCHER: Denese, if you want to focus on your major issues-and then we will find out if other people have other things that they want to add. You are giving us a lot of information, but we probably are going to have to settle for less.

DR. SHERVINGTON: Okay, well, I will go back really to overall themes. The major one is to increase the intended pregnancies, reducing unintended pregnancies, and how the objectives reflect basically trying to increase the proportion of women at risk of unintended pregnancy who use a method of family planning to decrease the proportion of unintended pregnancies that occur despite contraceptive method use-that is, contraceptive use failure-to improve birth spacing, to increase male involvement in family planning, and to increase access to emergency contraception. That is kind of our basic objectives, what the objectives feed into.

In terms of adolescent pregnancy, the objectives support promoting delays in adolescent sexual intercourse, promoting pregnancy prevention and STD protection among sexually active youth-that is, using dual methods-and increasing instruction on a full range of age-appropriate reproductive health topics. That perhaps is the focus of our objectives. As everyone probably knows, this is a very controversial area.

We chose not to include any objectives on abortion because we think that is so politically charged, and when we get lumped with the abortion issue, we are in a lot of trouble. So we chose to avoid that, and we really leave that up for some feedback.

DR. SATCHER: Okay, comments, questions?

The male involvement in family planning is an important area. Do you want to just say a little bit more on how you implement?

DR. SHERVINGTON: Yes, it is important, and it is also very controversial. What we have done over the past 3 years is attempt to understand a little bit better how to involve males in supporting reproductive health rights, in particular reproductive health and health rights as related to women, who primarily are the ones who have to deal with the issues of reproductive health and fertility.

There are a couple of things we have done. We have worked with community-based organizations in partnerships with our clinics to look at effective ways. We are trying to collect the data to understand how we really reach males and, in particular, the very hard-to-reach males, males from ethnic minorities, males who may be substance abusers, and even we are thinking about males who are incarcerated.

We have also for the first time had questions about males and males' sexual and reproductive behaviors included in the National Survey of Family Growth. We are in our office particularly trying to look at some very sound signs to evaluate those programs that are working primarily with males. I say this is controversial, because for so long family planning has been very female dominated, and it is sometimes hard to let go and shift and let the guys in.

DR. SATCHER: But it is critical, though.

DR. SHERVINGTON: I know that in terms of work with adolescents, that is also a very politically charged area for us. We very much tried to be respectful and very much support the issue of abstinence for young people, but we recognized that there are some young people who are going to be sexually active, and so we are trying to look not only at their contraceptive needs but also at the need for disease protection, protection from HIV. So there may be some feedback on the STD section about dual methods.

DR. SATCHER: Okay, any other questions or comments?

[No response.]

Okay, we will move on. I know we have quite a bit to cover. I think I am going to go to Martha Katz next, who has the most to cover, in a sense, and Martha also has to leave after lunch. I appreciate those who have allowed us to skip them for a minute anyway.

Martha?

MS. KATZ: David, thank you, and you know, since I have the most to cover, I will do it at the fastest pace.

I agree with Roger Bulger. It is quite fun to come and see old friends, and it is better than an ice cream social. For some of us, we were talking at the break about what we were doing 20 years ago, and some of us were working for Dr. Richmond on Healthy People, the first Surgeon General's report, and the 1990 objectives, and boy, we have come a long way, haven't we, Dr. Richmond? A lot has changed over 20 years.

I feel like I need to start with a little bit of perspective that we have been talking about at CDC that cuts across all of the chapters. I may be more sensitive than others to this, because I had to figure out how to carry all three volumes on the plane, and I have to admit, I could not do it. So it has really made me think about sort of where we are going, and at this point, now that we have received all of the public comments, and as I go through my chapters, you will see that, mostly, we added. We did not really delete based on public comment.

So, David, we have a request of you, because we talked about doing this ourselves at CDC, and we decided we could not do it unless all 28 chapters were asked to do it at the same time by you, and that is to ask you to help us restore the balance between inclusiveness and priorities. We are fearful that having over 500 objectives will make our percentage of those achieved continue to decline. It is striking that, of the 226 in 1990, we achieved or exceeded a third of them. As we grew-the year 2000 objectives-our percentage of achievement declined, and I am fearful that, with 500 objectives, many of them not having baseline data, that it would shrink even more.

But when you ask us to be more rigorous, give us some criteria. Like, are the objectives really going to help us go where we need to go as a country? Are they science based? Are they driving us toward outcomes? In everything that he says at CDC, Jeff Koplan is really pressuring our programs to make sure that what we are doing truly has measurable outcomes attached to it.

Are the process objectives-how do we limit them? Do we limit them by requiring some measure of effectiveness to have been demonstrated? With the work that has been done for the Guide to Clinical Preventive Services and what has been done with the Guide to Community Preventive Services, so much work is being done on what is known about effectiveness. Make us go back and bring that back to looking at these objectives for part of the narrowing process.

Then we have had extensive discussions with Ed Sondik about the data systems and our great concerns that we have so many developmental objectives, those for which we have no way to measure them. Quite frankly, I think a good criterion for that is, are we the agencies willing to spend our own program dollars to build the data systems to measure those objectives? Because, if we do not think they are important enough to do that, they may not be the most essential objectives in our set.

So it is time for you to be tough with us and say go back, set priorities, and trim them down and make them really something that we can all be proud of and we can actually focus on. So we really are pleading for that, and we need some help.

DR. SATCHER: So you are going to demonstrate to us how that is done, since you-

MS. KATZ: Well, no, I am going to demonstrate that we have not done it. I kept reading all that we have done, and all we are doing is expanding. We are not focusing as much as we need to.

Well, as we all know, the world has changed in the last 10 years, and much of it for the good. We do have a more aging population, and that is reflected in our objectives. We have a more diverse population, and I think we are all quite supportive of that health goal of eliminating disparities. That is great progress for the 2010 objectives. I think, when we look at our own point of view from it, we see much more globalization, and I think it is quite delightful when we see that other countries have emulated what we have done in setting objectives.

So let me turn to our specific program areas and tell you quickly what we have incorporated as a consequence of the public review period.

First, the chapter for HIV. Two major changes have been added. The first one is to add an objective on knowledge of serostatus, which will be important. The second is to focus on what has become a very serious problem, which is HIV/AIDS, STD, and TB among inmates in penal institutions. It has become an important program area for us, and increasing the education among the inmates is an objective that has been added.

The second chapter is Immunization and Infectious Diseases. Two objectives are being added there. The first one is to include vaccine coverage targeting men who have sex with men. The second one is really anticipating the continued success of the development of new vaccines and recognizing that, once we finish these objectives, what we hope is that many new vaccines come on line. So we are proposing to add an objective for immunization coverage for any vaccine that has been added and recommended by the year 2005 so that there will be a target for vaccine coverage for new vaccines.

Third chapter, Injury and Violence Prevention. We have actually deleted some objectives dealing with the enactment or extension of State laws and have added three new objectives-one in the area of injury prevention counseling, one in the area of data collection and surveillance, and a third one for the reduction of nonfatal firearm-related injuries.

Fourth topic, Occupational Safety and Health. Objectives concerning workers have been revised to look at, I believe, lead exposure in work settings, and the second one adds an objective addressing needle stick exposures in the workplace.

Fifth chapter, Sexually Transmitted Diseases. Abstinence has been added as the first option for modifying personal and sexual behavior to reduce the risk of acquiring STDs.

Last is the chapter on Tobacco Use. We have included persons with disabilities as a tracked population on the objective that addresses adult tobacco use.

I can comment briefly, if you like, on the areas for which CDC is a co-lead.

The first one is Diabetes and Chronic Disabling Conditions. A number of objectives have been added to look at the nonglucose-related risk factors, including high blood pressure and lipid control, and then greater emphasis has been placed on the value of diabetes education.

For Disability and Secondary Conditions, an objective has been added to assess mental health of children with disabilities, and a second one has been added to reflect public health policies moving from institutional care of persons with disability towards home and community- based care.

I promise, only two more chapters.

Education and Community-Based Programs. The definition of health education has been replaced and, I would say, updated to reflect the practice and the profession as it has evolved and it reflects the definition proposed by the national health education organizations.

In the chapter on Public Health Infrastructure, we have added a section, or revised one, on data and information systems to reflect concerns about the loss of emphasis and the need for a focus on data and surveillance.

I believe that is it.

DR. SATCHER: Okay, thank you very much. Your comments at the outset were very important, too, and I just do not want to ignore them, because I think we do need to focus more. One of the things that we hope will happen, as we select leading indicators, is that it will at least help us in our thinking about what is really important, what is critical, and what can be left out, because we do need to reduce, and that is one of our overall goals.

Comments, questions, on Martha's presentation? Yes?

DR. DUVAL: Well, I would like to agree with you about Martha's opening comments. I think the issue of guaranteeing failure by having too many objectives is very real. Now, when I say guaranteeing failure, what I am saying is if you try to spread your resources so very, very broadly as to touch on all of these topics, I am worried that your failure rate per topic will start to increase. It bothers me. It bothered me to look through them.

Now, of course, as you go through-and I am sure that on an interagency basis, this is very difficult to do-there are an awful lot of objectives that are very close to one another if not, in fact, even in some cases identical. Even taking the two presentations we have just had and just completed, I noticed that two, specifically with respect to pregnancies, sexually transmitted diseases, and hepatitis, are virtually identical objectives in two or even three different chapters of the book. Now that kind of thing will-you know, with a little additional work, meetings, you can probably pare those down, but I worry terribly that we are touching on too many, and under the circumstances you have lost sight of what is important. We are down to trees, in other words, instead of forests.

DR. SATCHER: Yes, and as Martha implied, these objectives come out of the agencies as they expand their programs, as they try to do more, but the challenge is to focus better on what is really critical, and I think we can do that.

DR. LEE: David, this is Phil. I agree with Monte and your comments. Unfortunately, I have to go off to the Chancellor's inauguration. Also, I did not get the IOM report that Roger discussed, and if that could be sent to me, I would appreciate it.

DR. SATCHER: We will get that to you, Phil, and we really appreciate your joining us.

DR. LEE: I would like to give you more comments after I get that material.

DR. SATCHER: Great, okay. We look forward to it.

DR. LEE: Thank you.

DR. SATCHER: Other comments?

MR. HARRELL: Following along with the notion of paring down, it seems to me that this is an overall comment-it would probably fit CDC, but everybody-that there is not a whole lot of pattern or structure to the order of objectives, the way they fall out, anymore. There was in Healthy People 2000, I think, a pretty clear effort at that. Now that we have this, I think, quite elegant conceptual framework for the overall picture, it seems to me that that could be applied to the chapters, perhaps, to give some order to things, and in doing so, it would lead to some paring, because I think some things are going to kind of fall off the edges, if you apply the conceptual framework.

DR. SATCHER: Yes, that gets back to the point, I think, that Monte raised, but I do think you are right, in the sense that I think that leading indicators should help us in terms of interagency communication and coordination of objectives. So I envision that that will happen with the leading indicators once we settle on them, and it will help that kind of coordination and communication. That could result in better targeting the objectives.

DR. DUVAL: Let me ask a question. We have a guest here from Florida, Bob Brooks, who is in a great position to respond to this specific issue. If within your jurisdiction you were able to say, here are the ones among these 520-some objectives that I think we ought to focus on, how would you go through the book? What procedure would you go through the book to identify them?

DR. BROOKS: Well, I think I would be keeping in line with many of the statements made today if I said that, from a State level, we look upon this from a different angle, and that is implementation. How are we going to use State resources to implement what it is that is being decided on through the good work of so many people having national input? I think in that regard, clearly, I would be in line with what has been said in regards to simplicity, the KISS system, and keep it simple.

We will become unfocused if there are lots and lots-we can measure certain parameters, and we should measure certain parameters of health statistics to help us along in getting to our goals, but I think when it gets down to the State and local level, there needs to be a few issues that can be highlighted where we can have a much better chance of assuring success. That, I think, goes along with some of the comments that have been made today. We would certainly have a problem explaining this magnitude of good work, even though it is a good framework. It has to be distilled down to something that we can explain to legislators, administrators, and the public, at some point at a local level.

DR. FOX: David, I was going to save my comments on this issue for when I do my presentation, but I am going to go ahead and make them now, because I think they are more appropriate. When we started this process about 31/2 years ago, it was my hope that we could put Healthy People on a diet and end up with a small document. As we have gone through this public process, everybody has said no, that is not what they want.

I think there are several things that have become apparent. One, Healthy People is a document that obviously addresses a lot of issues and a lot of constituencies and is used as a reference document. I will tell you in Alabama, when we did Alabama Healthy People 2000, we didn't take all of the objectives. We took a subset of objectives, and what we found when we started initial hearings 3 years ago was that almost every group did the same thing. They took the objectives that were pertinent to them and shaped them in a way that the-the lab directors, the document called LIFT that they took and used for State lab directors. So this is just to tell you that I think one of the dilemmas is trying to constrict the document when all of the input we have gotten from most of the people who have been involved in this have pushed it the other way.

So I think one of the things we talked about to address this-and I do think we ought to look at objectives that are redundant. I think there are some, objectives that initially were kind of compound objectives that we split out and made-and one example of such I am going to talk about when I give my report. I think that those kinds of things we ought to try to address.

One of the things that we talked about is the idea that agencies can issue-and we are going to do it with children with special needs-we are going to issue what is called a companion document for 2000 and 2010 that is going to take all the objectives for children with special needs, and we are going to patch that and work with March of Dimes and put that document out with just those objectives. That will be kind of a companion document to the big Healthy People document, which will give a focus to that area and will allow those objectives to be marketed in a way that will give them some increased visibility. I think we have encouraged agencies and constituents to think about this whole thing as a way to take this reference document and make it more user-friendly and get some visibility in particular areas.

The second thing that I want to say is on the issue of the developmental objectives, and Debbie Maiese has cautioned me and, I think, been quite instructive. I have been from the start saying, you know, we should look with NCHS at the objectives where we did not have data. We went through a process of those objectives, where we said there was hope, those where we said there was no hope, and really tried to kind of tease them apart as far as the ones where we felt we could get data.

But David pointed out that, if you go back to 1990 and go to 2000, there were a significant number of objectives where, during that period of time, data systems did develop. So I think that, on one hand, we really ought to try to be judicious in developmental objectives. For those where there is absolutely no possibility or reasonable possibility that we are going to have a data system in the next decade, we probably ought to consider putting them aside.

But there are some that, by having them in this document, will push Federal agencies and others to develop data systems. So it is not an issue of not having any developmental objectives there with data 10 years from now; some will. So I think we ought to try to scale back the developmental objectives, but I think we have to be judicious about how we do that.

DR. SATCHER: Yes, I think the issue of balance is a key here. There are a lot of very important objectives that can be useful to people in one area but maybe not in another area, and you have to be careful. At the same time, I think moving toward more focus is something we can do together, and I believe the discussion we had earlier today will help us with that. That was very helpful, because I think you are absolutely right. That is what we found as we went around the country talking to the regional community groups. We want to get people engaged. We want to involve as many people as possible in this process.

Yes?

DR. RICHMOND: Just a brief comment, Martha. I first want to say, too, I appreciate seeing Martha after a number of years, because she was there at the beginning and through the first iteration. But I cannot help but be a little bit amused, because you appealed to the Surgeon General to sort of help produce more focus, and yet you came in from CDC with more suggestions for add-ons.

DR. KATZ: No, we had this discussion at home, and I kept saying, I am troubled that we just keep adding, and they said, but we can't be the ones to do it without overall guidance that it is going to be done to every chapter.

DR. SATCHER: Sort of make us do this is what I hear.

[Laughter.]

MS. KATZ: You were listening, thank you.

DR. IRVIN: From a researcher's standpoint, I appreciate the comments made that, if there are objectives in there, they may be utilized as a resource for trying to get funding to achieve those objectives. It may even come down to a matter of, these are the objectives we would like to achieve, and then, focusing on the Leading Health Indicators, these are the objectives we must achieve. Then maybe you can use some of those criteria to help you narrow down your focus to really focus on the important criteria while trying to achieve that objective.

DR. SATCHER: That is a great point.

Charlene made another point at the break that I want to just say something about, and that is-it will only take me a minute-and that is, she pointed out that it would be good as we look back at Healthy People 2000 to be able to identify really successful efforts and strategies, best practices if you will, that could really help us as we pursue Healthy People 2010. We are going to give that some effort, to try to look back and identify best practices in our efforts to achieve Healthy People 2000 that can better inform us as we move toward 2010. So I appreciate that input, Charlene.

DR. DUVAL: One other comment about what Claude said a moment ago is, I was very impressed-maybe should not have been quite so impressed-but I was very impressed with that first sheet behind the blue thing in Tab VI. It is a variant of what I guess I would call the 80-20 rule that everybody knows about, that 80 percent of the interest is focused on 20 percent of the problems, which is the way these things tend to work out.

You may end up stacking yourself for a situation in which you will have to totally redo your approach because of failure. Look at the back side of that first sheet after the blue thing where you talk about tracking progress. It was mailed to us, and I got it in mine. It is called tracking progress, and it is the back page of the evolution of Healthy People. That is the label of it.

Let me read you just two things that are in your sheet of paper here. This is a 1990 effort. You had 226 objectives, okay? You attained 32 percent, and 11 percent regressed. You go to the year 2000 and you jump from 226 to 300 objectives, and the number attained went from 32 percent down to 15, and the number regressing went from 11 up to 18. Now you are coming in with 531 objectives. I am saying that you have loaded yourself with the possibility of substantial failure.

DR. SMOLINSKI: For those of you who are looking for that, that was inserted into Volume II.

DR. DUVAL: I regret that. In mine, that was behind Tab VI in the briefing book. I am sorry. But in any case, I think that makes the point.

DR. SATCHER: It is a little misleading. I just want to make this point, because I do not know what is going to happen between now and the year 2000, but we are really moving in the direction of achieving 75 percent. Now, obviously, we will not get all of them, but assuming you will need more than 15 percent when it is over, and we have been-

DR. DUVAL: If you combine attained and progressed, that is true. On the other hand, the combination of attained and progressed is greater in 1990 than it was in 2000.

DR. SATCHER: I am just reminding you that we are at the end of the year 1999. We are not in the year 2000 yet.

DR. DUVAL: I only throw it out as a caution, David. It is one of those things that I guess I was worried about, because if people say-and I think what Bob said about Florida's situation and to some extent what Martha has said illustrate these points. As a matter of fact, if time permitted, we could talk to some of the folks who are representing obesity organizations and so forth and ask them how they would go through these objectives and which ones would they pick. I am worried that the size, the volume of the numbers that are not picked, will grow, and that is my point. If they grow, it increases your failure.

DR. SATCHER: At 3 o'clock, we will probably get back to this subject again with Ed. We will be talking about data and such.

DR. RICHMOND: David, one quick comment, because Earl brought this up, in terms of the document and its utility in libraries by students and all. I think the fact that we are going through the exercise with the multiplicity of the health goals is an important thing to keep on the record. How we operationalize this becomes another matter, and I would like to add to his comments that we need to pay attention to the fact that all around the world people look at these documents. I am amazed; during the first iteration, we heard from virtually all of the ministries of health around the world about how useful they felt this document was for them. So I think it is extremely important that we not lose the value of the exercise, but as we operationalize this, and that is what we are focusing on more this morning, we need to have a sense of priority.

DR. FOX: I think one of the reasons the document has evolved like this is, one, this has been a public process. I think this process has been required, because there have been a lot of people that have had their say and they have had a voice in it, and I think that that tends to drive it to be bigger and to include more objectives. I think we need to see if the workgroups can skim it back some. But I think, in part, it is because it is a reference document that has been put together because a lot of people have had a voice in it.

Now, David, I just want to go back to what you said. One of the things we talked about-and I think I will put this on the agenda for certainly every...down the road - is the issue of how to blend or bring together the CDC Guide to Community Preventive Services and the Healthy People 2010, because the type of things that are being done to develop the Guide to Community Preventive Services could be the kind of things that would go into the objectives of what works, what ought to be done. That is part of what I understand is being looked at as a part of CDC preventive services.

So I think those documents and the ability to marry them-I am not saying to have a single document, but maybe a third document or some way of referencing for those issues that are addressed in the community guide, what is looked at in the literature, what is felt to work from the standpoint of community interventions, and how that could be put together with the objectives in a way that communities could say, yes, I want to try this objective, and here is what the literature says about what works around community interventions. I just think that that is a joint activity that I think could support and feed into whatever we are trying to do to go with implementation of 2010.

DR. SATCHER: Okay, thank you very much. We are going to move forward, and the next presentation-and I appreciate you all allowing us to make these changes in order, and I appreciate Martha moving so rapidly through a large volume of material. It has helped tremendously. The next topic is Physical Activity, and Dr. Sandy Perlmutter.

MS. PERLMUTTER: Thank you for making me a doctor, Dr. Satcher. I appreciate that.

[Laughter.]

I will be brief. I first would just like to acknowledge that the President's Council on Physical Fitness and Sports has been working on this project for a long time, and we are delighted that the CDC will now become our co-lead for Healthy People 2010. They have been acting as our scientific advisors.

Physical inactivity is estimated to account for approximately 250,000 deaths annually and is associated with many health conditions that lead to functional disability and poor quality of life. That is why we have chosen our goal statement to read improve the health, fitness, and quality of life through the adoption and maintenance of regular, daily physical activity. Based on comments of the five regional hearings, the second comment period that ended in December of 1998, our progress review with Dr. Satcher, and numerous workgroup deliberations, we are recommending that we add one additional section to our five themes, which will include community access to walking and bicycling. Our objectives have now gone from 13 to 19.

Some of the highlights and considerations of issues-because of the importance of physical activity and its decline in prevalence among young people, a separate section has been added to focus on physical activity issues for youth. Public comment has strongly recommended that we do this, and our objectives reflect all young people and not just those in grades 9 through 12, even though our data only reflect 9 through 12. We reinserted an objective on reducing television viewing among young people to raise awareness about growing problems of sedentary behavior, and there is now a data source to track that. We also have added four new objectives that are included to increase community access to safe walking and bicycling with an established data source.

Our ongoing concerns are, one, a consistent depiction of persons with disabilities, and the second is, references to elementary, middle and junior high school, and high school should all be changed to reflect public and private schools. That concludes my report.

DR. SATCHER: You know, notwithstanding our previous discussion, I think you have added some very important objectives.

MS. PERLMUTTER: Thank you.

[Laughter.]

DR. SATCHER: By the way, in case you are not aware of it, this is turn-off-television week. Did you know that? It started yesterday. We have been meeting with school-kids throughout the community, and in fact, we have even been giving them a prescription for turning off television. The prescription is for other things to do when you are not watching television, like biking and walking or hiking, things like that. So I just wanted to let you know. If you want to turn off your television and join what we are trying to do with the children, we encourage you to do so.

MS. PERLMUTTER: Dr. Satcher, there was a piece on ABC News the other night where they called us a resource, and they did not actually give us a full understanding of what it was. They used our public service announcement, and it was about a gimmick someone developed to put a TV on a bicycle. So somebody could have a bicycle and ride around the block watching TV.

[Laughter.]

DR. SATCHER: Okay, comments?

DR. HARRELL: The only comment-I take every opportunity to say this-we still have this big gaping hole in terms of data about children younger than high school, and it is a crucial age. It is a difficult task perhaps, but I am wondering if, with CDC now as the co-lead, not depending on the budget of the President's Council to accomplish these kinds of things, and the possibility of looking at whether there is any kind of piggybacking we could do with the Department of Education surveys that go on, we could find out more about what the physical activity levels of pre-K through 8th grade is.

DR. SATCHER: I think that is a very good point, and I think that is really doable with this partnership.

Other comments or questions on physical activity?

MS. HAYNES: Do you include surfing the net for noneducational purposes? When you said eliminating television-I am concerned that kids are actually going to their computers and playing games in addition to watching television in their free time, and that could become more and more popular.

DR. PERLMUTTER: Actually, the way we have decided to address that is in our narrative, because we realize that they are using computers and doing sedentary behavior. However, the data sets are not available at this time; it does not mean that they will not be later. But that is addressed in the narrative below the objective.

DR. SATCHER: Any other comments?

[No response.]

Okay, we are going to move on to our next area then. Sharon Holston, we appreciate your being patient and allowing other people to go ahead of you. Sharon is from the FDA and is going to discuss three areas of objectives.

MS. HOLSTON: Thank you.

In Healthy People 2000, FDA had the lead responsibility for the Food and Drug Safety chapter and co-lead responsibility with NIH for the Nutrition chapter. For Healthy People 2010, it was decided-and this was largely on the basis of public comment as well as a working group recommendation-to create a separate chapter on Food Safety and then to add a new chapter, Medical Product Safety, that will address safety issues in terms of drugs, biologics, and medical devices. On the same basis, it was also decided to enlarge the Nutrition chapter with some elements that deal with the issue of overweight.

On the subject of Food Safety-and incidentally, as Dr. Satcher said, we have invited USDA, the Food Safety Inspection Service at USDA, to share responsibility with us on this particular chapter. The food safety objectives have been expanded from 4 to 12 by including issues such as antimicrobial resistance and food allergy, which were also strongly supported by public comment. We have not been able to include all of the emerging pathogens that we have proposed and that the public comments supported, because we do have difficulty finding meaningful representative data. But we have included surveillance of newly emerging pathogens in planning for the future.

I think all of these objectives are based on sound science. Just a couple of examples-in consumer food safety practices, two of the objectives track scientifically based needed improvements in practices and behaviors involving cleanliness, preparation, cooking, and refrigeration of food. These are food safety practices that we have been working to promote, and they do have a lot of support, both in the public and private sector.

The second example is the expansion of the antimicrobial resistance objectives from the one that was in the public draft of Healthy People 2010 to four, which includes testing of salmonella isolates from humans, cattle, swine, and poultry. All four objectives will track resistance to antimicrobials such as fluoroquinolones that are often used to treat foodborne illnesses.

The third example of changes in the Food Safety area is the objective for retail food practices, which has been adjusted to be more scientific. In Healthy People 2000, we measured how many States adopted FDA's food code, and that was the objective. In 2010, what we are looking at instead are improvements in food employee behaviors as far as food preparation and food storage practices and avoiding risks such as improper holding and cooking temperatures that have been associated with foodborne diseases and outbreaks of foodborne illnesses.

Turning to the expanded chapter on the safety of medical products, we have three main themes in the safety of medical products, that is, drugs, biological agents, and medical devices. We have an emphasis on spontaneous adverse event reporting, looking and depending heavily on our MedWatch system, and then we have sex and gender analysis in medical product testing. These themes, that, again, were included based on public comment and on working group recommendations, really do expand the medical product safety chapter, because the previous chapter primarily focused only on drug issues.

So, a few of the changes in that area. We are asking or looking to enter into a collaboration between FDA and outside researchers to encourage the development and the implementation of databases that will include at least 20 million individuals so that we can, in fact, investigate suspected associations between specific drug exposures and adverse events and then explore the risks that are associated with that.

Another objective in the drug area is to increase recording by health professionals of patients' use of botanicals, dietary supplements, and complementary and alternative medical products in order, again, to try to help identify risks or adverse events that are associated with using these products in combination with conventional drugs and biologics.

In the biological product safety area, we are looking to increase the size of the blood donor pool in order to improve, one, the overall blood supply, but also to broaden the participation of minority donors to help reduce shortages that could affect those populations.

Another important objective in this area is the development and the use of effective methods for inactivating pathogens in plasma, in blood, and in blood products.

In the field of medical device safety, we want to create a national surveillance network that is composed of clinical facilities where the staff have been trained to report patient outcomes related to medical devices. We right now have in our Medwatch program about 140 health professional, consumer, and other health-related organizations that provide us with information, and we would like to increase those partnerships to at least 200.

The final objective of the new ones in the medical product area calls for increasing the proportion of new products that have had, as I mentioned earlier, pre- and postmarketing clinical data that is analyzed for gender differences.

The last chapter, and we share the co-lead with NIH on this chapter, is Nutrition and Overweight. We work together with an interagency group and input from the public, and we have 22 objectives. The 22 objectives address the following issues-health status and risk reduction related to diet and disease; nutrition education and nutrition services in health care settings, worksites, and schools; undernutrition; and food insecurity. As was the case in the year 2000 objectives, many of these objectives have the Dietary Guidelines for Americans as their basis, and they do reflect the latest deliberations of the guidelines committee.

The new chapter-and we changed the title to Nutrition/Overweight. It was chosen obviously to increase the visibility of the overweight objectives, and that was again done largely in response to public comments, some of which actually called for a separate chapter on obesity. Also in response to public comments, we added two new measurable objectives aimed at increasing consumption of dark green and deep yellow vegetables and whole grain products. And we have proposed three new, possibly developmental, objectives for which there is a strong public health rationale, as well as a potential data source. One of them addresses healthy meals and snacks at schools. The second calls for an increase in the proportion of health insurance plans that provide nutrition services as part of their coverage. The third is aimed at reducing iron deficiency among pregnant women.

Finally, there are a lot of crosscutting issues in the chapter that are associated with focus areas in other chapters, and we have noted that in our chapter.

DR. SATCHER: Thank you very much.

Comments, questions? Yes?

MS. MOORE: I just wanted to comment that, in some instances, the packaging is an implicit message, and that packaging the overweight objectives with nutrition objectives is an implicit message that somehow what you eat is intimately connected to the problem of overweight in this country. I think that the data are as strong that overweight is linked as much to physical activity issues-inactivity, sedentary behavior-as it is with what you eat.

So I would again urge you to consider the possibility that overweight deserves to be in its own chapter, particularly if overweight is selected as a Leading Health Indicator. It is very difficult to find overweight objectives in the document, and it would be important, I think, that if it does get selected as a Leading Health Indicator, that it reside in its own separate chapter and that there be no covert messages to hint that overweight is somehow linked with diet when it may turn out that it is-I am not saying that diet is not going to contribute to overweight, but that it is more intimately connected perhaps to physical activity and physical inactivity.

DR. SATCHER: Thank you. Well, it is going to be interesting to see how this all works out, but without question, the leading indicators I think are going to help us in some ways. I am not sure it would result in a separate chapter. It may help us to bring some of these different areas together in terms of physical activity, nutrition, and other things that all impact upon weight and that certainly contribute to the problem of overweight in this country, which has increased dramatically in recent years.

DR. FOX: David, obviously the Secretary's Council is free to recommend, I guess, whatever it wants to recommend, but just for those that may not be aware-I know the agency representatives are aware that the layout and construction of 2010 at this point has been a long and involved process, and in fact even issues like looking at a separate obesity chapter we discussed on several occasions. We actually took an agency vote on it, and there were obviously divided opinions and some advantages and disadvantages to having a separate chapter. When it came down to it and we had a full airing of the issue, we took a vote and the decision was not to break it out as a separate chapter.

DR. SATCHER: So there is a history here, but there is also a future. So we will see how the future discussions are impacted, but I think it is very important to know that we have been looking at this critically.

Any other comments?

DR. DUVAL: Yes, sort of a minor one. I tripped over one of these objectives under nutrition-and I am really not sure that I would be-if I was asked, I would vote against its inclusion, although, again, I am not beyond persuasion-that is, to try to increase the number of insurance companies that cover nutrition as a service. Finding help for people who need this kind of education is a very desirable objective, but the purpose of insurance, of course, is to underwrite, so to speak, or to socialize the actual cost of a morbid situation. This nutrition just does not fit that. I cannot see that, and to me this is an objective in which, to go back to our earlier conversation, you are virtually guaranteeing failure, in my judgment.

DR. SATCHER: And, for instance, how prescriptive do we need to be, also, in some of these areas. I agree, we need to look at critically at these.

Okay, now, we are not going to have a lot more discussion on this. I want some short, concise questions or comments, not long ones.

MR. DOWNEY: I am Morgan Downey with the American Obesity Association. Just to follow up on that, as one of the advocates for a separate obesity chapter, this is why this kind of hiding of obesity under some other labeling becomes problematic. I appreciate the issue of the third party reimbursement for nutrition services and support that, but that is also distinct from the failure of insurance companies to cover obesity surgery, to cover obesity treatments for morbidly obese individuals. The more we try to hide and to not deal with this, the worse these problems become.

DR. SATCHER: We have to deal with the problem of childhood and adult obesity over the next 10 years. Now the question is, how do we best deal with it, but I agree with you that we have to take it on forcefully, aggressively, and clearly, and we will. So it is a real important discussion.

We are going to move on to SAMHSA, Peggy Gilliam, Mental Health and Mental Disorders and Substance Abuse.

MS. GILLIAM: I would like to point out just in starting that Healthy People 2000 was one of the venues where the essential connection of substance abuse and mental health with overall health was recognized explicitly, and we really do appreciate the power of that. The current draft of Healthy People 2010 maintains that connection and, through the proposed set of leading indicators, enhances public understanding of that relationship. So we do appreciate that continuing support.

At SAMHSA, the new decade of Healthy People featured increased collaboration among agencies and departments. We worked closely with CDC, HRSA, and NIH, and with the Departments of Education, Justice, and Transportation. The expansion of the National Household Survey on Drug Abuse that we are now undertaking will yield improved substance abuse data on both racial and ethnic groups and also will enable us to produce State-level data, and we think that that activity will really support Healthy People.

In addition, mental health questions are being developed for the survey, which will support the proposed leading indicator for depression. That is really a step forward for us, because we have had trouble all along having adequate data in the area of mental health.

Our workgroups reviewed about 400 comments on the mental health chapter and about 300 comments on the substance abuse chapter. So even though we did not make the top group with the most comments, we did have a lot of public input and public interest in our chapters. We heard from constituency groups, other HHS agencies, private individuals, and really a full range of commenters. Eighty to ninety percent of the comments resulted in some sort of change in the chapters, either to objectives or to the actual language in the draft.

The Mental Health and Mental Disorders workgroup, which is co-led by NIH, the National Institute of Mental Health, and SAMHSA's Center for Mental Health Services, is placing new emphasis in this iteration on the improvement of mental health for children and young people. We now have 21 objectives in the chapter, seven of them focusing on youth.

There are, unfortunately, a very large number of developmental objectives in the chapter as it now stands. The good side of that is, we do think that we have some data sources coming along for a number of those. Also, we did find that, in Healthy People 2000, putting in some of these objectives for which we did not have data sources helped bring data sources along. For others, we found that even with that impetus, we could not get the resources to develop needed data sources. Healthy People 2000 had 14 objectives. So this has increased substantially.

We were helped in developing youth objectives by a conference of experts on children's mental health as an auxiliary activity. With guidance from Dr. Satcher and others, the mental health workgroup developed new objectives on eating disorders and on risk reduction and foster care. Risk reduction also figures in several services objectives, such as getting help for problems, making needed mental health care available, primary caregiver training for mental health screening of children and adolescents, primary caregiver training to protect children, and screening of juvenile justice facilities.

As I mentioned, there are still a large number of developmental objectives. We are working within the agency to try to come up with proposals that will increase support for data. I think that is still the area of most difficulty.

The Substance Abuse chapter is now co-led with NIH's National Institute on Drug Abuse and also the National Institute on Alcohol Abuse and Alcoholism. It continues its focus on where we can most effectively prevent substance abuse. There are now 25 objectives. Nine of them focus on youth. Seven of them are developmental, and also parts of two additional ones. Healthy People 2000 had 19 objectives. Fifteen of the objectives in this chapter are continued from Healthy People 2000 and still enjoy a great deal of support. In mental health, there are a lot more new objectives.

The 2010 draft differs from the 2000 chapter in that it gives much more attention to adults and also to substance abuse treatment issues. The substance abuse workgroup added new objectives on alcohol-related emergency department visits-before, we had just drug-related, illegal drug-related visits-low-risk drinking, substance abuse treatment for low-risk drinking, but drinking that in certain settings will cause problems such as fatal accidents; substance abuse treatment for illicit drug and alcohol problems and for injecting drug users; binge drinking among women of childbearing age; and substance abuse screening for the elderly.

The Substance Abuse chapter links substance abuse targets with those of the Office of National Drug Control Policy, the National Drug Strategy, and also the associated performance measures of effectiveness, and then also with the Secretary's Youth Substance Abuse Prevention Initiative. So there is a crosswalk that is quite evident between the substance abuse objectives, the major objectives of the National Drug Control Strategy, and then the existing Youth Substance Abuse Prevention Initiative.

I would be interested in any questions or comments.

DR. SATCHER: Questions? Comments?

[No response.]

This is a very important area, without question. Just looking at what has happened in this past week in this country and the great needs that we have to deal with in mental health in a more community-based way, it is really critical. So we appreciate the time and effort that you have given to this.

Let me just say that, even though it is late in our process, I do not think it is too late for us to look critically at our objectives and see where there are opportunities for reducing, and especially look for areas where there is redundancy and to find out how we can make a decision about what area we need to keep this objective in and what area can we eliminate without doing harm. So I am going to ask Dr. Lurie, who did such a great job of getting the Leading Health Indicators down-because I remember when I first started talking about reducing them, nobody was really taking it seriously, but in her work with IOM and others, she did a great job, and we are going to ask-she now chairs the Steering Committee-and we are going to ask the Steering Committee to take another critical look at this issue of the number of objectives and the relevance and how we can reduce redundancy in objectives.

DR. LURIE: Well, you better watch out. I have used up my ten fingers, and I only have ten toes left.

[Laughter.]

DR. SATCHER: But I think, again, having the group come back together and take a look at the Leading Health Indicators, for one thing, and seeing how all that relates to objectives, and yet respecting-we have to respect the input that we have received from people throughout the country, and I think we can do that. We have to respect the needs of local communities, the needs of States, and yet, at the same time, be critical about what objectives are most important, where can we in fact reduce a redundancy, where can we assign objectives to this agency, but not that one, because it fits better here. So we have to look at that again.

We would appreciate any input that we can receive, especially from the former Assistant Secretaries for Health. I wanted to let Debbie know, in addition to your reading every page, so did Dr. DuVal.

[Laughter.]

And this is not the first time. So we appreciate it. But also we are going to be calling on you for help, and the other former Assistant Secretaries for Health, in doing this.

Other comments and questions before we break for lunch?

[No response.]

We are due back here at 1:30. Have a great lunch. Continue your discussion, and we will see you back here at 1:30.

[Whereupon, at 12:37 p.m., a recess was taken until 1:30 p.m. that same day.]

DR. SATCHER: How many members of the Steering Committee are here right now? Let's see your hands.

[Show of hands.]

Let's give them a hand. They have done such a great job.

[Applause.]

And our chair here, Dr. Lurie. We appreciate the hard work that you guys are doing and will be doing in the future.

We are going to continue our discussion of focus areas and categories of objectives and objectives with Dr. Harlan, Bill Harlan, from the National Institutes of Health.

Bill?

DR. HARLAN: Thank you, David.

You should have two pieces of handout that are three-hole punched that will help you identify them. One of them starts out Healthy People 2000 co-lead agency, and the second is the chapter on Vision and Hearing, and I will be referring to both of those. I am going to go through the chapters in the sequence in which they are in the handout. They are three-hole punched so that you can put them in your book and study them on the flight back.

What I have put together, and really Martina Vogel and the focus group people did this analysis and summarization, is the objectives within each of these areas. Just to show you the format, the areas that I will be dealing with are the review of the public comments, the number that we received, the number into which they were broken down by editorial or content areas, and also the numbers of comments that were acted upon. Then down below that you will see the objectives that were added or changed in some way.

I will quickly go through Heart Disease and Stroke and point out that there were a fair number of comments received. There is an extra column here that shows there were 43 kudos that were handed out to the group for work that they had done. Five new objectives were suggested. Three of them were shown at the top, and they had to do with heart failure, and I just make the point that heart failure, a leading cause of hospitalization now, was not an important cause of hospitalization 10 years ago-an example of the changing spectrum of disease. Not only that, but the ability to prevent and to treat heart failure and keep people out of the hospital is clearly demonstrated by randomized controlled trials in various areas.

The objective here has been decompounded, which was one of the guidelines that we received early on. It obviously breaks it down by age group. There is a little bit better targeting of the objectives in coronary heart disease, with a little bit greater focus on the preventive aspects of coronary heart disease. Then the second thing that is a generalization from this is trying to make the objectives realistic rather than unreachable, and the targets that have been taken and the objectives that have been taken are an attempt to make them truly reachable, attainable, but make it a simpler component.

There are not a lot of other things that I would focus on about this particular chapter, except that it does have new developmental objectives. The listing of all of the objectives is shown on the last page for heart disease and stroke, if you want a summarization of the number of objectives and where they stand.

I will move on to Oral Health, and here actually a large number of comments were received, 525, and they were able to act on 290. There is another point that is to be made here, and I think it is true of almost all of the comments that came in-there were a lot of duplicates. So in fact, the duplications in some were not focused very well.

The revised count of objectives now is 18, with 13 measurable and 5 developmental. This group also moved five objectives to other focus areas, and that is one of the things that have been happening with a lot of the developmental objectives, the movement of some of the objectives to other areas, particularly where there was a chapter that might contain objectives referable to each cancer, as a good example, because when you are in an oral system, it may also be seen in the cancer chapter or the organ system chapter.

There are some additional comments about why the public comments were not included, and some of this relates, I think, to the issues that they brought up before about the difficulty in having data sources for some of the objectives that had been proposed. The referrals are shown. They do focus around cancer and tobacco and some of the other areas.

DR. SATCHER: Now, Bill, this is an area where we have a group working on a Surgeon General's report, right?

DR. HARLAN: Yes. I should have mentioned that they were privy to the development of the Surgeon General's report, which may be out in the fall or early winter.

DR. SATCHER: Certainly by the end of the year.

DR. HARLAN: -and as a result of that had the ability to combine in rationale for this particular chapter to what is in the Surgeon General's report, and I think it considerably strengthens the chapter and had them take a closer look. They gave up some of the objectives they might otherwise liked to have had in the chapter that will be in the Surgeon General's report. It was a matter of sorting them out into appropriate places.

The next chapter is Environmental Health. There they received a fair number of comments, 184, a lot of comments about adding objectives. You will notice that the revised count of objectives includes 50, and this may be one of the larger chapters in terms of numbers of objectives. Thirty are measurable, and 20 are developmental.

They have six thematic areas. The majority of the environmental objectives are under the healthy homes and healthy communities section of the report, and that also contains the majority of the new objectives that have been added. The last page shows a breakdown of the objectives with some demarcations that have been set in place for the thematic areas that are shown over on the first page. Once again, if you go halfway down the page, when you get to the bottom of the page you will see the home and healthy communities objectives.

The reasons for not including comments, as before, included inability to measure them or lack of a real focus that would allow a clear objective to be written, and that a large number of objectives already existed in this chapter.

Moving on to Cancer, Cancer received only 275 comments-I guess a bit of a surprise to many of us-and they have also taken a new objective, only one, on melanoma. It may not appear in the current version of the chapter, but will be headed to it. Then there are some modified objectives that you will notice down at the bottom, objectives seven, eight, and elsewhere. There was a discussion of a number of other issues, but it was decided not to include them as objectives for the reasons stated, and that is over on the next page. The objectives as they stand are on the final page of the Cancer section. Melanoma has been added at the bottom in the set of objectives there.

Those were the chapters that existed in Healthy People 2000. The next group of chapters are new chapters and represent input on the new chapters. They also represent, incidentally, I think another theme that again is emerging in 2010, and that is more of a focus on disability and less on prolongation of life. What you will see in these chapters are things that impair quality of life.

The other theme, I think, that you could pick out of this is the interest of the outside community. Each of these chapters had a lot of input, even for a developmental chapter. The final chapter, Vision and Hearing, was actually generated by the outside community. What you have is a copy of the chapter that was developed over the past few weeks in response to public comment that was received, and I will come back to that in a minute.

Going through Arthritis, Osteoporosis, and Chronic Back Conditions-many of these were not included in Healthy People 2000, but have become increasingly important with an increased lifespan and, I think, with the contribution they make to disability, and receive attention. The important background is really the rationale for inclusion of the chapter. You see the 18 objectives listed on the last page.

Chronic Kidney Disease, the next section. Strikingly, there were 563 comments received about the inclusion of a chapter on chronic kidney disease. The decision about including this chapter was made at the time that we were out for public comment on all of this and it was developed during that period of time. I think public comment played a major part in deciding that this chapter should be included, and that probably is reflected in the large number of comments that we received. It has ten objectives, and half are developmental. They, again, are listed on the last part of this particular section.

Respiratory Diseases is, again, a new chapter. It was developed and voted on by the Steering Committee before the public comment period and did go out for public comment, and you see again a breakdown of the kinds of comments that came back. There are 23 objectives here. There is a great deal of focus on asthma and chronic obstructive pulmonary disease. Asthma has been a disease that, once again, has impaired the quality of life and is increasing both as a cause of disability and increasing as a cause of death and was not really well-included in any of the previous work. Chronic obstructive pulmonary disease, interestingly enough, I do not believe was even mentioned in Healthy People 2000, and yet it was the fourth leading cause of death at that time.

DR. WINDOM: Was asthma included at all? Asthma was already included?

DR. HARLAN: Asthma was included but in a very tangential way, I think, not in the details you see here.

There are 23 objectives here. Eight are measurable and 15 developmental, and it brings up again one of the issues that we discussed earlier about developmental objectives. The final tally on Respiratory Diseases is shown on the back page with some changes that were made almost as we went to press, or as we went to press, I guess you could say.

The final chapter that I am presenting to you is vision and hearing, and it has I think had a very interesting history, and it is worth reviewing a bit of that history and where it is going at this particular time. At the time that it went out for public comment, there was not a chapter existent-there was not even a particular interest, I guess, in developing a chapter, and it became apparent during the public comment that there was a great deal of interest in seeing such a chapter. In fact, some of the private organizations offered to work on the development of the chapter.

At that point, the Eye Institute, which had previously had, I think, not a very great level of interest, but at least some interest, became very interested in this, and in the process of doing this an interesting phenomenon occurred. This may be the only part of Healthy People 2000 or 2010 that I know of that was ever discussed at a council meeting at NIH, and this came up for a great deal of discussion, that there should be a vision chapter. The council signed onto that, and not only that, as a followup to that, the Eye Institute became interested in making the measurements that they thought should be measured to follow this up and is prepared to make a commitment to making those measurements. So it is a phenomenon that the public really drove the development of the chapter.

When the Steering Committee talked about a vision chapter, a logical question was asked: should there be a hearing associated with it? The Institute for Deafness and Other Communication Disorders, which handles hearings at NIH, had not thought a lot about it, but when asked the question said absolutely. They turned to and developed their part of the chapter in rather rapid fashion, and once again, I think, have taken a very strong interest in having a chapter and having the objectives measurable and they produced the chapter. You have it as a separate chapter. It is probably the first complete version of the chapter that has been out, incidentally, the one you are seeing today.

Finally, on Vision and Hearing, at the end of the outline that I have, you will see the objectives that are listed there. There is within the chapter itself a fair amount of comment on data sources. They have been trying to glean through the data developed by many of the organizations outside, private advocacy organizations, to see what data might be available there, and then identify what the shortfall is on data development, and I think have appeared to make a commitment to developing the data, because they see it as important to what they want to do in terms of determining the research and the application of the research results. So it is an interesting kind of phenomenon, to me anyway, to see this not only driving the development of the chapter and the development of data, but also likely driving the development of research and objectives and a research program.

I will stop there.

DR. SATCHER: Very good, Bill. Thanks very much. I appreciate the way he organizes.

Under objectives for Vision and Hearing, I am just going to try this one out on you, there is a chapter on childhood amblyopia and there is a chapter on child amblyopia treatment. Not a chapter, but an objective. I am trying to-if we are going to start thinking about cutting back on objectives, I am trying to figure out how we would go about those two. Childhood amblyopia and then child amblyopia treatment. What would be the objective in the one that just says childhood amblyopia?

DR. HARLAN: I think it would be the prevalence of childhood amblyopia and then the frequency with which it is treated. It is one of the areas where they have been interested in seeing a complete visual exam done either as a part of NHIS or to be able to pick up the frequency with which it occurs.

DR. SATCHER: That is good. There is a chapter on vision screening for children.

I think this is very comprehensive, but there are probably some opportunities there, like in a lot of the others, for some reduction.

DR. SONDIK: Do we know how to prevent that condition?

DR. HARLAN: No. Like with a lot of other things, we would screen and treat appropriately before it developed blindness in the nonfixing eye. So it is a little like screening for colon cancer.

DR. FOX: But strabismus is what we do not know how to prevent; amblyopia we can prevent.

DR. SATCHER: Good point. You can prevent.

DR. LURIE: Between now and our next Steering Committee meeting, we are all going to have to be thinking hard on strategies to reduce. I think that is the bottom line.

DR. DUVAL: In Respiratory Diseases-I wonder if we could go back to that for just one second and ask a question. Specifically, it happens to be behind Tab 24. Obstructive sleep apnea, this is objective number 20. I guess I would ask if this a sleeper to see whether or not we read these documents, or do you really want more people who have excessive daytime sleepiness, loud snoring, et cetera?

[Laughter.]

DR. HARLAN: No, I think we want to identify the problem and the frequency and then manage the problem.

DR. DUVAL: Take just a second and read it. Number 20 on page 27. On page 27: Increase the proportion of people with excessive daytime sleepiness-

DR. HARLAN: -who seek medical evaluation.

DR. DUVAL: Okay, so something was left out. Oh, I am awfully sorry. Mine says increase the proportion of people with excessive daytime sleepiness, loud snoring, and other signs associated with obstructive sleep apnea, and I am simply saying we have enough loud snoring.

[Laughter.]

DR. SATCHER: Thanks very much. Any other comments or questions?

[No response.]

Okay, very good. We covered a lot in a very short period of time. Thank you.

I guess next we are going to go to AHCPR and to Lisa Simpson.

DR. SIMPSON: Thank you, and good afternoon.

We share the co-lead for Access to Quality Health Services with HRSA and CDC, and we also participate in a number of other workgroup areas, but I will not touch on those. I am going to restrict my remarks to three areas: first, to sort of just emphasize why at AHCPR we are so interested and excited about the transition between 2000 and 2010 and the focus on quality health services; the second area of my remarks is just going to be to highlight what was changed in response to the public comment and the nature of that comment; and the third is to touch on a couple of crosscutting issues that really will be more echoing, I think, of some of the earlier comments today, but to add my voice to those.

In terms of why we are so excited about the expansion from 2000 to 2010 in this focus area, you will recall that primarily in Healthy People 2000 the focus was on clinical preventive services and the quality of those services and the delivery of those services. The expansion here has been to include a more complete continuum of care, though not complete, and I think that is very important. We see this as a real opportunity to promote one of AHCPR's objectives, which is to increase and promote the use of evidence to improve the quality of care. So that sort of central principle of evidence and science driving how these objectives are constructed and how they will be promoted, disseminated, and applied at all levels in our country is, I think, a very important one and may help us in our issues at the end about burden and the volume of objectives here.

The second reason we are very excited about this is that the nation as a whole is focusing on quality. We had the President's Commission on Consumer Protection and Quality in the Health Care Industry deliberate and lay out before us a very coherent agenda for what needs to happen and a very good statement about some of the very real challenges we face in the delivery of quality health services and just how important improving that quality is to ameliorating the burden of disease in this country, not ignoring the services that are delivered in multiple settings and their importance.

The third reason we are very excited is the disparities focus. I cannot emphasize enough how important I think that second goal of Healthy People 2010 is, and to remind everybody that disparities-and I do not have to, but I am going to state a fact that is known to all of us-that disparities also exist in quality of care, and we cannot lose sight of that. I think we were all reminded of that by a recent article by Dr. Shulman at Georgetown that very graphically told us what we knew but really brought the message home about how differentially people are treated with the same medical condition in the health care system and for no explainable reason in terms of comorbidities.

So those are three of the reasons we think this focus, this expanded focus on quality of health services, is critical, and we are very happy to see it in 2010 and to be part of this movement.

The second point I want to make, the second area, is on what has changed and what the response to the public comment has been.

First of all, a quick orientation. We have 22 objectives in this area, and they span the clinical, preventive, primary care, emergency services, and then jump to long-term care and rehab services. Of those 22 objectives, I think nine are developmental. So we share some of the same challenges that I think the rest of the document does in both trying to lay out where we think the future data will be but maybe also needing to be very tough on ourselves in being sure that these are achievable data in the next decade and that they are the most important.

In terms of comments, we received, I think, over 1,200 comments. So folks were really interested in this. So I think it was an appropriate expansion of the focus within 2010. We also got a lot of comments from the emergency services community, and I think that reflects the very real concern that Americans have about their access to appropriate emergency services that has been in the public debate for the last couple of years.

What did we do in response to that public comment? I know Dr. Fox is going to give you some specific examples, because, as I said, we share co-lead, but let me summarize. The good news was that we dropped two, and we moved one. The bad news is, we added three.

[Laughter.]

So we ended up kind of at a wash in terms of the number of objectives that we have, and we will give you some specific examples. Also, within the objectives there was a lot of comment on the issue of subpopulations and either including children in certain objectives, the under-18 age group, or specifying, for example, where possible the disabled and how that measure would apply to disabled populations. So we have included that where possible where the data exists. I think that was really the main sort of consistent comment about the measures. There were some objectives that were suggested that were not incorporated due to lack of data and the difficulty in believing that we could do that.

The third set of comments I want to make is about what the steps are ahead of us and what the remaining issues are, and here I want to make three points, the first one about the size of the overall document. Somebody talked-I think it was Mary Jo-about the BMI of the document.

[Laughter.]

Which is, I think, a tough challenge, and as a former State MCH director, I am torn. I think it needs to be less, but as we use them at the State level, we did use it as a reference document to help us figure out what we needed to focus on based on our State's needs and our population needs, and so it was helpful to have reference points, a menu of things that we needed to focus on.

But I would say that one way we could be tough on ourselves and respond to your call about being tough and reducing numbers is really focus on the evidence and, where we are trying to measure a process that is not well-linked to outcome, that we be tough and we say it is not time yet. The evidence is not there yet for that process being really critically linked to the outcome. So that is my first comment.

The second one on issues as we go ahead is not only Debbie's point about consistency within chapters and across chapters but to the extent possible consistency with other measuring efforts this country is undertaking. We want to reach out to other constituents. We are going beyond the public health community and getting folks like Dr. George Isham, other managed care organizations, other constituencies-primary care, clinical providers-engaged. That is the beauty of the expansion of this document.

But we have to balance with that the reality that we cannot ask them to do everything or else they are not going to come to the table. To give you a specific example, there are over 150 objectives that pertain to the quality of personal and public health services, and I think about 80 of those are intended to stimulate action largely by primary care providers. Now, in case you have not been to a doctor recently, you are probably only going to be in the office for 15 minutes, whether that is a doctor or nurse practitioner or other clinical provider-

DR. DUVAL: Exclusive of waiting time.

[Laughter.]

MS. SIMPSON: This is true, and a lot could be done in that waiting time. That is a very good point.

But as we talk about trying to reach out to that constituency, the clinicians, the primary care providers, and get them engaged in achieving these objectives, I think we have to have a set that makes sense, that is based on evidence, and that is realistic, as well. It is worth stretching, but I think we have to be tough on ourselves with that.

With that, I will conclude my remarks and answer any questions and ask Earl if he wants to comment as well now or save them.

DR. SATCHER: Two comments. This is a very important section, as you point out, and in so many ways. One of the things I think we are continuing to struggle with is the role of the physician versus the role of the health care team, and especially when you consider the whole issue of having in place systems that will ensure that certain things happen.

I was trying to remember the group of physicians I was meeting with-it may have been a component of the AMA in Hawaii. We were talking about adult immunization, and it turned out that the way they achieved it was when the nurses took responsibility for checking to see. You know, they did not achieve it by relying on the physician. So they changed the system, and I think there are so many ways in which the system can be made to work for patients that do not rely upon the physician. You know, I think that is really a critical point.

I appreciated your comments about the elimination of disparities goal. Dr. Richmond and I were talking about that at lunchtime, and we did not say much about it, but as we went around the country we received very interesting feedback on that. A lot of excitement, as you have heard, of people throughout the country, and everywhere I go to speak about it, there is a lot of excitement. Governors are speaking out.

But there were also people who were cynical about it, who question the feasibility, and so it is an area where we really have to continue to make very clear to people the importance of this commitment and this vision, but also the fact that we understand that it is not something that is going to be easy, that there are going to be research questions that we have not yet answered. There are some things we know we can do right now. There are some things that will take a little longer. Some of them will take even 5 to 10 years, but we know they can be done to make a change.

The point you made about the Kevin Shulman study-we have had a big meeting since that time at the White House about this whole issue and what can be done in the country, beginning with how we develop health professionals and how we can improve the sensitivity all along the line of development, and in those who are in practice, how we can make sure that included in continuing education are sensitivity and things. You know, you might not change the way people feel in terms of subjective bias, but we can change the way people behave in terms of dealing with patients. That is going to be very important. When it makes a 40 percent difference in whether somebody gets referred for cardiac catheterization, it is significant, and that is what that study showed, a 40 percent difference.

So there are a lot of things we can do in the area of disparities, and it is critical for us to make sure that we move forward and begin to do them, while acknowledging that there are also some things that we do not fully understand in this area. We have to be realistic and honest about that, but it is an important commitment and it certainly has galvanized a lot of people throughout the country.

One of the strongest statements I have heard on this, and I was surprised, was by the Governor of South Carolina. I was there to speak to some summit, and he came-I just thought it was going to be one of these welcome things-and he talked for 15 minutes about how excited he was and how important this was to the State of South Carolina to be able to have this as a goal and what he was committed to do to make it happen.

I did not mean to talk that long. Other comments?

DR. IRVIN: Yes, as one of the people who spoke out, I know that this has been significant in my effort to try to combine everybody's wishes and desires into one document. I just wanted to commend you, because I know it took a lot of work.

DR. SATCHER: Other comments or questions?

[No response.]

Okay, let's go to Dr. Fox. Earl?

DR. FOX: Well, my colleagues-we actually are co-leads on three different chapters-Access to Quality Health Services, focus area 1, MCH, focus area 16, and Educational and Community-Based Programs, focus area 7. My colleagues have previously, I think, done a good job of laying out some of these issues, and I am not-as my great-grandmother would say, Shakespeare never repeated himself, and neither should I.

[Laughter.]

So I am not going to retrace that ground. I do want to make just a few comments, though, beginning with Access to Quality Health Services, and again, we have worked closely with AHCPR and CDC on this chapter, and it does build off of the previous Clinical Preventive Services chapter. In fact, some of the objectives from that chapter have been carried forward into the access chapter, and there are three I was going to mention. One is the proportion of people with health insurance. The second is the proportion of people with an ongoing source of care, and the third is the proportion of health professions and nursing degrees that are awarded to members of racial and ethnic minority groups.

But access here really moves beyond clinical preventive services, and I think you obviously have to have the context of where people get care if they do not get clinical services. So I think it really does, in my opinion, continue to support what I think has been an effort over the last several years in trying to increase this interface between public health and medicine. We were married, maybe, at the beginning of this country and we got a divorce, and now we are trying to reconcile and come back together. But I think this chapter in trying to bring together the public health, preventive, and clinical services does help kind of set that tone. So it includes primary care, EMS services, long-term care, as well as clinical preventive services.

The chapter has also been adjusted to, again, reflect comments received from the public. For example, in the primary care area an objective has been added to increase the proportion of the population with a usual primary care provider. This objective is designed really to move beyond simply just having a source of care but to focus on having a primary care provider as a usual source of care. Again, hopefully, it will provide some emphasis to some of the attributes of primary care that are beneficial.

In the EMS area, we tried to respond to comments that we needed to focus on specific problems and, again with some of our objectives, not to inadvertently impede access to emergency services. So we have included an objective that States, to increase the proportion of patients whose access to emergency services when and where they need them is unimpeded by the health plan's coverage. At the same time, we have included a more broadly directed objective to reduce the proportion of people who delay or encounter difficulty getting emergency medical care in an emergency department.

The second chapter is Maternal, Infant and Child Health, and I guess the one I am probably most familiar with. We, again, in line with everybody else have not done a good job of constraining ourselves in adding new objectives. We have gone from 17 to 51. About half of those are developmental.

I want to give you some examples of some that I think we can pare down. We have done other things, like we have included proposed reduction in the infant mortality to 5 deaths per 1,000, which is the rate among some of the countries that we ought to be emulating in infant mortality. It also includes a range of indicators of maternal and infant health, child health, primarily affecting pregnant and postpartum women, and infants' health and survival.

I will point out-I guess going back to Jim Harrell's comment about the deficit in information for small children-we actually have a significant deficit in data around college age. I think in trying to think through how to address that-I mean, we have high school data, but for college age we do not, and I think it makes it difficult when we try to talk about where we are and where we should go with that population. So this is something I hope we can correct or improve over the next 10 years.

An example of, I think, a couple of objectives where we could pare down that are not developmental-and Stella, you and others at MCH are going to kill me for saying this-but in looking through them, I think it is something we ought to think about, and one is the objective on breastfeeding. I honestly am a strong advocate for breastfeeding, but we have three objectives on breastfeeding that really address the length of breastfeeding, the duration of breastfeeding, at three points in the first year of life. Do we really need three objectives to do that?

We have two objectives around folate supplementation. Folate supplementation is very important, but there are two objectives around this, and I am not sure we need two.

We have examples in the developmental area of objectives where we have no data now, but where I think we probably ought to retain the objectives. One, the objective on newborn hearing screening. AAP just came out with a recommendation for universal newborn hearing screening. NIH has had a consensus conference recommending that. We do not have data in that area, but I think that is an objective where we have to get information. So that is one that is developmental that I think we really need to push forward.

A second is fetal alcohol syndrome. There is appropriation language in last year's appropriation act to this department to develop a task force around fetal alcohol. I think there is a continued push to try to look at the issue, and we have a developmental objective in that area.

We have an example of an objective that has been subdivided that I think-I guess I complained a little bit earlier about the fact that some of these objectives we have taken and broken apart, and that has contributed to our proliferation-but I think, again, I ought to give an example of an objective where we have done that where I think it is very appropriate, and that is in looking at the cesarean section rate. You know the furor that erupted back several months ago when there was an announcement of the proposed Healthy People target for cesarean sections. There was something, I think, in the New England Journal of Medicine. It received a great deal of comment.

So as a result of that, we convened a group of experts led by Charlie Mahan. We spent a day looking at this one objective with national experts and, as a result, actually recommended elimination of the Healthy People 2000 objective and instead having two objectives that are in this document that looked at the primary and repeat cesarean section rate only among low-risk pregnancies. So we actually-the previous one looked at all pregnancies-and I think we actually just said it is probably not appropriate to look at high-risk pregnancies, but we ought to look at low-risk and look at repeat and initial, primary ones. Again, a great deal of thought went behind that, and that is an example of where we have taken one objective and made two, which I think was appropriate. So again, we cannot make absolute statements.

We are very pleased we are co-leads on three additional focus areas. The first is Oral Health with CDC and NIH and also working closely with HCFA. The second is in the HIV area because of our Ryan White activities, again working closely with CDC. Then the final one is the Public Health Infrastructure chapter because of the activities we have around health professionals' training and some of the other things we fund.

So we are very pleased, again. We feel that the decision you made, David-it add interested agencies as co-leads-I think really continues to broaden the involvement and the activities of all of the agencies in 2010 and, I think, really in many ways helps bring together the service delivery systems and the prevention and surveillance types of things that we need to be trying to marry every way we can.

I would be glad to answer any questions.

DR. SATCHER: Very good. Comments? Questions?

I could not help but think that, when you were talking about breastfeeding, it is another good example of-and we do not think about it this way-of how dependent that it is upon the community. I was with a group of women yesterday from Georgia, and one of them was a State senator who has introduced legislation, because apparently there are States in this country that do not permit breastfeeding in public, not to speak of the fact that there are a lot of employers who do not provide opportunities for women to either breastfeed or store milk to continue breastfeeding. So, again, on the one hand it is the behavior of women, but on the other hand it is a more societal issue and the extent to which the communities support them.

MS. HAYNES: That was one of the objectives that we did not get in in the women's health working group. We wanted an objective to increase percentage of worksites that actually provide facilities for women to breastfeed. So if you are going to dump one of the three, we have another one to substitute.

[Laughter.]

We are also working on a breastfeeding policy for the department. We are the only country, I think, in WHO that does not have a national breastfeeding policy. So we can help promote whatever you all end up with in that policy.

DR. SATCHER: Very good, Suzanne. Thank you.

Other comments or questions about this area?

[No response.]

Okay, moving right along. It sounds like you all want to move right along.

Okay, Health Communications. Linda?

MS. MEYERS: Thank you. I am going to facilitate the moving right along.

Health Communication, as you know, is a new and very short focus area. It is one that represents an area that has grown tremendously in the last decade and will continue to grow tremendously in the next decade as the new knowledge has emerged about the role of communication in prevention and about potential new communication technologies. I think some of the recent articles in JAMA and the American Journal of Preventive Medicine and the British Medical Journal, among others, have emphasized the potential for innovative health communication.

We in ODPHP are pleased to have been a part of developing this focus area, and I would like to commend Mary Jo Deering for her initiative in this regard. This focus area was put together by a very active working group that probably had as many private, nonprofit, and public experts as it had Federal staff. I think it is somewhat unique in this regard. Craig Lefebvre and Tom Eng, who is the study director on the Science Panel for Interactive Communication and Health, were both very active on this, as well as many other persons, a number of you in this room.

The key disparities issue in this focus area relate to cultural, linguistic, and literacy barriers, and also to inequities in access to health information and support. So there are objectives targeting health literacy and public access to health information. There are objectives promoting quality through evaluation or the development of curricula or centers of excellence.

In view of the explosion of health information on the Web, there is one objective about household Internet access and another about the quality of information found on the Internet.

The key problem for this chapter is data. Only one of the eight objectives-I said it was short-only one of the eight objectives has a confirmed data source at this point. However, some of the external workgroup participants from stakeholder groups are exploring measurement tools with several of the objectives, and this is a very positive thing. For example, the Society for Social Marketing executive board is going to consider sponsoring a survey for objective number 3, which has to do with centers of excellence in health communication. Then there are also several others that are also looking into sponsoring objectives. We think that this has been a very robust collaboration by a number of partners and hope that it will continue to develop in this way throughout the next year.

I wanted to mention and did not, there are other areas that have some crosscut with this one. They are Access to Care, Educational and Community-Based Programs, and Public Health Infrastructure, and there has been collaboration with the workgroups developing these. I think I can say with confidence that the developments reflect those collaborations and concerns.

DR. SATCHER: Okay, very good.

I must say, this is an area where a lot is happening in the department in terms of improving health communication. Healthfinder is apparently very popular. We just added a Spanish-speaking component, and so we are going to continue to move forward in that area.

MS. MEYERS: And your Web site.

DR. SATCHER: Oh, and the Surgeon General's Web site, www.surgeongeneral.gov.

Okay, comments? Questions?

DR. DUVAL: On the very first objective, I wondered-I have to believe you decided it was feasible, but when you are going to suddenly jump-I say suddenly; obviously you are talking 10 years, but even so-suddenly reach the point that 80 percent of homes have access to the Internet. That is extraordinarily high. You apparently are convinced that that is a reasonable objective.

MS. MEYERS: I am going to do what I do in Health Communications or ODPHP; I would like to defer to Mary Jo.

MS. DEERING: We actually struggled with that. The proponent of that objective wanted to set it at 95 percent, and we had to arm-wrestle him down to 80 percent.

DR. DUVAL: Was that Compaq or Hewlett-Packard?

[Laughter.]

MS. DEERING: The point is actually that the Internet is not a PC anymore. The Internet is what is behind everything, and it is increasingly delivered over television and telephone. Since there is about 98 percent penetration of those other communication devices in homes these days, it is almost that, by definition, you may indeed reach 80 percent by the end of the decade. You may not, but it is not-it may be a stretch, but I think we are all astonished at the rapidity, at the vertical growth of Internet access in the country. So we hope it is a challenge but that it can be realized.

DR. SATCHER: Other comments, questions?

MS. GORDON: A point of information. We at Medicare have launched this evidence-based center on healthy aging, and the draft report has just come out on how to improve the delivery of clinical preventive services. One of the interesting findings from that draft report was that, if you really want to reach minority populations, one of the most effective ways to do that is through the mass media, and that is not true for the general population according to this report.

DR. SATCHER: Okay. Any other comments on Health Communications? This was actually our last focus area, so any comments on any of the focus areas or objectives?

MR. DOWNEY: It is Morgan Downey again. I do not want to beat a dead horse, but I do have to observe here, from our earlier conversation about the lack of a chapter on obesity or weight, that the explosion of this document from some 25 to 30 chapters now and 300 to 500 recommendations, and all that has been included and discussed today-not dealing with obesity is just inexplicable to me. I do not know how we are doing that, and if someone could explain that to me, I would much appreciation an explication of the rationale for that.

DR. WINDOM: We know that Surgeon General Koop has come out very forcefully on this, and I have heard a lot of people comment about his direction for looking at obesity. I think he has sort of led a charge. Maybe it is not something we should neglect, because it is a significant problem.

DR. SATCHER: I do not think obesity is being neglected. I think this is a different issue. You know, we have major areas on Physical Activity and Nutrition, and we measure obesity as an outcome. So I think debate is about how to frame it, and obviously you have a point, but it is not that it is being neglected.

DR. FOX: We spent a lot of time in the Steering Committee. It was addressed at several different meetings of the Steering Committee. There was a lot of discussion about it. All of the agencies, you know, we all had our say. Again, I did not come prepared to discuss or remember all of the details of the reasons, but I know that we spent-this was not addressed lightly, and it was basically, again-there were several things we just came down to. We had to take a vote because there was a lot of opinion about it and, as I said, the majority of the members of the Steering Committee felt that, for a lot of reasons, we should not have a separate chapter. It was not because of the unimportance of the issue of obesity.

DR. SATCHER: It may well be that it is so important that it needs to be an indicator, because that is the way I am sort of headed.

DR. DUVAL: Well, it is in the preferred IOM -

DR. SATCHER: That is right. Which is much more important than a chapter. It becomes an overriding issue.

DR. FOX: But you know, David, we had several groups, and one was the constituencies that are interested in children with special needs. The problem was we cannot pull out a separate chapter for each area where there-there are a lot of issues that are important. So one of the reasons that we are doing a companion document-we are funding it out of HRSA - a companion document on children with special needs, is because of both the interest of that issue with a variety of groups in this country and the importance, but the fact is that we did not feel we could pull it out as a separate chapter in Healthy People.

So I think there are some other strategies like companion documents to give visibility to some of the areas that we want to target, that we want to get out and market, and we could do that without having a separate chapter within this document.

DR. SATCHER: Morgan, do you want to follow up?

MR. DOWNEY: Well, I realize this is not a debate here, but I would point out or remind members that are probably familiar with this, that there is an article, a very good article, by Phil Lee and Michael McGinnis on the midcourse review of Healthy People 2000. They indicate there that, of the objectives that are going in the wrong direction, of which obesity is a major one and several related goals and objectives, such as Type 2 diabetes, that new thinking has to occur, new directions for the areas where we have had 10 years of one model. It has not worked, and we need to have some fresh approaches to that.

That is not my conclusion. That is their conclusion, but I think it is a point well taken. I think just continuing what we have done for the last 10 years-I do not have much confidence that that is going to change the growth in obesity, particularly among children, women, and minority groups, that we have experienced over these past 10 years.

DR. SATCHER: I can assure you, Morgan, we are not talking about continuing what we have done in the past 10 years. We are going to give much more attention to this issue. I think that is probably separate from how our group decides whether it should be a separate chapter or even more than that, because I think they struggled with how it relates to other chapters, you know, like Physical Activity and Nutrition and some other things. But we will, again, look at it again in terms of how best to bring the appropriate attention to it. It is not a closed issue.

Let me take a hand that I have not seen before.

DR. ATKINS: Dave Atkins. I just want to follow on Earl's comment, because I was also on the Steering Committee and those discussions. I think the concern was that the focus of Healthy People as a prevention-oriented document would be undermined by pulling out obesity from the chapters, like Physical Activity and Nutrition, which are really the essentials to prevention of obesity. I think we can argue about whether it belongs more in Physical Activity or more in Nutrition, but I think it would be a problem to pull it out as its own chapter and, as Earl pointed out, it is not the only issue where this has come up, where you have risk factors and diseases comingling.

DR. JONES: To me, though, as we heard here earlier, I think that is all the more reason that IOM represented it among its seemingly preferred indicator set and why even the indicators working group included it, and it makes the strongest case. Frankly, I would rather see it among the indicators than as a chapter, because if I knew this was one of the top ten, I have this on my fingers here as one of them. That has a lot more primacy to me than having to go find it in a book somewhere and figure out what its substance is. I mean, I remember some of those discussions, too, in the Steering Committee meetings I went to that got quite exercised. But an indicator is in my view the way to go.

DR. SATCHER: It would certainly fit my agenda better that way, because as I go and talk around the country, I always talk about childhood and adult obesity, and, basically, just as Morgan said about it being one of those areas where we are moving in the wrong direction, I use that and asthma and diabetes and low birthweight, among some others. So certainly I do not think the absence of a chapter means the absence of interest.

Julie?

DR. RICHMOND: One of the thoughts that occurs to me is that, as a social strategy, one of the problems that we have is dealing with issues that are so multifactorial in origin. Earl's comment-in some sense, special health needs, special needs of children, represent another example of that. It is not just one single category. So it appears in multiple places. But that does not mean that we should not develop other social strategies for dealing with that. Earl has illustrated interaction with special needs, and one way of doing that is a companion volume.

I guess, David, as Surgeon General, the question I would raise is whether the time has come for a Surgeon General's conference, say, on bringing together what we have by way of dietary guidelines, the Surgeon General's dietary guidelines, the Surgeon General's report on physical activity, and all of the issues that are relevant to obesity, and perhaps giving that national visibility in some other way. So I think there are other social strategies.

DR. SATCHER: When is that due?

DR. MEYERS: We are hoping mid-2000.

DR. SATCHER: But I think your point is well-taken. I think it is time to call that kind of attention to this.

Yes, Monte?

DR. DUVAL: Yes, I want at some point to bring up a suggestion-may or may not have merit, obviously, but Julie has touched on it, so I will bring it up now. It does strike me that, as a pragmatic issue, it might be useful to people in the field to have, I suppose in today's technology, a CD-ROM that takes up each of the potential topics that might be here that crosscut some 28 chapters and to say, here is where I would find all of the objectives on the subject of obesity. You know, I could pick up any one of several different topics-but find some way to say you will find that in chapter 27, item number 16. You see what I mean?

I just think that people who are in the field-which is why, incidentally, I asked Bob before lunch, here from Florida, as a practical matter, what do you do when you find a document on your desk with 521 objectives, to find out what are the ones that are relevant to my area of concern and interest? I just throw that out as a possible way of addressing it.

DR. MEYERS: We can do that. You can actually do that right now on the Internet, with the Internet, not in CD-ROM, with the existing comment draft.

DR. DUVAL: Yes, but I have to wait 10 years to get 80 percent of the people-

DR. MEYERS: Right, so the CD-ROM is an interesting idea.

DR. SATCHER: Very good point. Other comments? Yes?

MS. FOX: Tracy Fox with the American Dietetic Association. We fully support a Surgeon General's conference on nutrition, just for the record.

[Laughter.]

But I had another comment about the draft title of the chapter Nutrition/Overweight, which I do not think is in the actual draft document that everybody got, and I think, in that light, that does raise some concerns about minimizing the importance of both nutrition and overweight/obesity by lumping them together. So we clearly support a separate chapter, but I think, also importantly, take a look at Nutrition/Overweight. Does that really reflect what we wanted to reflect in that chapter? I am not sure it does.

DR. SATCHER: I am going to move toward conclusion of this. So I am going to take the hands that are up and ask you to be brief.

Suzanne?

MS. HAYNES: As one of the advocates for the chapter who got overruled, I think the idea of having a companion document on obesity would help highlight the issue and could include objectives that are throughout Healthy People that really-obesity is the major killer of American men and women, and it is the one objective that has been going in the wrong direction that is so remarkable as compared to others. I mean, I would be happy to work with them to develop a companion document, because I think that would certainly be-

DR. SATCHER: Great, thank you. Morgan?

MR. DOWNEY: Not to be argumentative, just a piece of information. This really is just information. The joint HHS/Agriculture Dietary Guidelines Advisory Committee met a month or so ago, the end of February, I believe. In the current Dietary Guidelines, physical activity and weight, obesity, are linked in their recommendation. That panel decided to uncouple those, that there would be a separate recommendation on physical activity and a separate recommendation on weight. We do have this kind of linkage problem where there is, over here, physical activity or nutrition. I just wanted to let you know the direction that committee is going is separate.

DR. SATCHER: Let me sort of clarify: I am going to make a commitment that we are going to take another look at it.

DR. MEYERS: I just wanted to-the separation of physical activity into its own guidelines is something that the committee is actively discussing. They will make their recommendation about that to the Secretaries of Agriculture and Health and Human Services toward the end of the year. So it is something that is still under active and very serious discussion.

DR. SATCHER: Okay. So in summary, we have had a great discussion, and it is obvious that we have made some progress. We continue to strive, I think, toward more balance between and within focus areas; the challenge to address the scope of developmental objectives and measurability of all of the objectives, obviously the challenge with the number of objectives; crafting take-home messages for this initiative that would reach the American people, and that is really the essence of the Leading Health Indicators. We have to get some take-home messages that can reach the American people.

So it has been a very valuable discussion from that standpoint and one that I think will allow us to move forward.

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