Agenda Item: Eliminating Health Disparities (Continued)

Soon after I finished my residency in internal medicine, I came down to work in the Office of Disease Prevention and Health Promotion with Michael McGinnis.

That is when I really became convinced that a career in public service is how one could make the most extraordinary and enduring difference.

Let me just elaborate slightly on what I know David has already said, and he has demonstrated this morning his flexibility in terms of juggling scheduling. I thought I was supposed to be here at 9:15 and he, of course, thought that the Secretary was going to be here earlier as well.

So, I think he pretty much covered what I had intended to say with respect to the fact that, building on the President's race initiative and building on the efforts of the Department represented in the Healthy People project, we developed a focused initiative on race and health, setting the goal to eliminate the health disparities in six health status areas by the year 2010. Clearly, this is an ambitious goal, deriving from the work of this Council, I guess, about a year ago when there was a discussion and a commitment that we really had to think in terms of the notion of eliminating disparities, not just accepting that, for different populations, different health statuses could persist.

So, we identified six areas where we felt we had a strong body of data on which to mark where we were and then measure our progress in the future in six health status areas. The work presented an enormous burden of preventable disease in this country, and where there were very striking and disappointing disparities that existed in health status among different ethnic and racial minority groups, and where we felt that these differences were preventable.

In terms of the process, we have both an internal and an external process. We hope that as we move forward those two processes will be intimately intertwined, really building on models developed in the Healthy People process, bringing in outside consultation as you move forward.

There is a steering committee for the race and health initiative that consists of the heads of the operating divisions and some key staff divisions. That steering committee will help set the broad outline, the framework for action, as this initiative moves forward.

Then we have several working groups that will be comprised of representatives from each of the relevant agencies and staff divisions that will be targeting the six health status areas. There is also an additional work group that will be looking at the data questions. As Clay pointed out, there are some critical data issues that we have to address if we are really going to be able to measure health status across the different sub-populations, and health concerns, and really track our progress.

We also recognize that, for many of the health status areas identified, there are cross-cutting issues that represent very real risk factors and real obstacles to progress, and that we have to address those in our work as well. We will be trying to look at some of the behavioral issues, the risk factors that cut across the six health status areas, as well, of course, as issues such as access to care and the fundamental question of the relationship between health status and socioeconomic status and education, as well.

We recognize that the challenges before us are enormous. We also recognize that a great deal of the expertise and opportunity exists outside of the Department. So, we are going to be working through a series of working groups, conferences, and consultants to bring in the best and the brightest from the outside, those people that have been working on these issues and those people who have the most experience working in the community, to develop and implement important interventions in these health status areas.

We also see this as a real opportunity to, sort of, review and catalogue, in a sense, what we know about what works. The work groups are being tasked to really review current knowledge in these areas and develop a blue print for action that will set a number of clear goals and objectives, again, using the model of the Healthy People process, and then identify the action steps that we need to achieve our goals.

We need to identify what the gaps are in knowledge, where more research needs to be done on both a basic and applied level and, again, with a strong focus on the behavioral issues as well. We also need to identify what the barriers and impediments are to translating existing knowledge into action. Then we need to look at communities, what really works and what doesn't, to make sure that we focus our efforts in those ways.

There is money in the President's proposed budget for this effort, $400 million over five years, some of which will go to support existing programs of proven benefits, and some to develop a new community demonstration program, that will help us to test this notion of which interventions will really work and how they can be applied elsewhere to maximize benefit. We recognize that that money is just a drop in the bucket about what needs to be done, and that, really, the success of this effort will be in the ability to mobilize both within our Department, and to mobilize in partnership with so many different kinds of organizations in order to all pull together in the same direction, to all recognize a shared set of goals and a shared commitment to eliminating these disparities that exist.

We really need to work very closely with the Healthy People 2000 and Healthy People 2010 effort as we do this because, really, what we are talking about is not just focusing on these six health status areas -- although that is what has been comprised in this race and health initiative -- we are really talking about improving health status for all Americans, and we hope that through all of our efforts together we are really going to see a measurable difference and a sustained difference, and that we will really do something extraordinary in terms of this commitment that accepting racial disparities can no longer be part of our mission.

I look forward to working with all of you. I am going to be in and out of the room also today, but I know that we will be working a great deal together both on this initiative and so many of the other important initiatives in the Department. Thank you.

DR. FOX: Thank you, Peggy. As you can see, there is a tremendous amount going on in the Department looking at racial disparities.

We want to move now into having some discussion around the issues that Clay raised. Let me remind you that this is discussion time for the Council. There will be a time later on in the day for those who are not part of the Secretary's Council to provide opinions and comments, but this is the time when we want to hear from the Council per se, and especially from our previous Assistant Secretaries.

There are basically three questions that Clay posed. Let me just reiterate those and then we will open it up for comment. The first is, is it the sense of this group that we would have one target for all population groups? I will tell you that, resoundingly, across the Department and with all of the groups that we have consulted with over the last year there has been almost a unanimous feeling that we should eliminate, and not just try to reduce, disparities.

I think that is certainly a strong sense. But I think the question is, within that context, are there some objectives that make no sense or, for whatever reason, we should have a different target, or should we move toward having the same target for all subgroups with the objectives? So, that is the first question.

Second, is that target going to be the national average? Is it going to be the best group or is it going to be better than the best, and what is your sense there?

Finally, the question of, do we use the OMB directive in the way we categorize the groups? Those are the three issues we need some guidance on. Let me just open it up for comment and we will go from there. Any thoughts?

MR. SCHWAB: One opening comment. I think that Dr. Simpson's presentation was very to the point and very important. Actually, there is a subtle distinction that there may not be one between your presentation, Dr. Simpson, and your just summary, Dr. Fox. That is the dichotomy that was in your presentation on the second question -- having a national average or better than the best.

In your characterization just now, you added the best just now as a third option, namely, to do the national average, to do the best, or to do better than the best. I think that is an important point that needs some discussion. If I may defer -- although we have Assistant Secretaries from both Oklahoma and Arizona -- for a moment, I noted in here comments from Texas that were included in terms of this particular question.

They speak to the group with the best indicator as proof of what is possible to achieve and, thus, a realistic target. They make a strong argument here, which is one that I think we should take a clearer look at, and that is to focus on the best and very least, in terms of the targets, possibly in some instances the best of the best.

It would seem to me that, as a national set of objectives here, to settle for less than the best sends the wrong message. I think in most instances achieving the best might be the target to go to, and there are some where better than best might make sense. So, I think that is one that I would just put on the table as an amendment, Clay, to your presentation.

DR. BRANDT: It pains me to have to support a statement from Texas, being from Oklahoma, but nevertheless, I think that is right. Personally, my view is that you ought to set goals that force you to do something, force you to work. They ought to be high enough to really force you to recognize that you are going to fail some of the time.

I would rather see us fail a little bit than to set the goals so unrealistically low that we achieve everything, which strikes me as strange.

I like, by the way, the revised breakdown of OMB. In our state, of course, where we have the highest proportion of Indian people of any state in the country and no reservations, we still have a significant problem with Indian people, which is difficult to deal with, with marked differences among the tribes. I wouldn't break them down, by the way, any further because, when you get down to the Iowas, there are less than 100 people that are Iowa Indian.

Nonetheless, I think we need to set high goals, recognizing that we are not going to achieve some of them. That doesn't mean that we shouldn't try to.

DR. RICHMOND: I think, in terms of long-term strategy, and defining a goal, I think that the more dynamic it can be -- as Dr. Brandt has just indicated in terms of activism, of moving toward achieving those goals -- I guess I still find that the goal we have used in this context since the start of this effort, with the first publication of Healthy People, closing the gap -- seems to me, until we ever get there -- is an enduring goal. It has a certain dynamic quality to it. I am speaking now of eliminating or closing the gap. I think that it is a dynamic term and it doesn't indicate an end point. As we move up, those quantitative goals can be redefined.

I think, until we ever get to the point of having closed that gap, it makes a lot of sense. This goes back to the Secretary's comment, too, something that a person in the street can understand readily, that can be explained readily. That is the concept, it seems to me, that can be grasped readily. My inclination is to retain that term. It has an enduring quality. It is simple; it is direct; I think very clear. I would be inclined to stay with that.

DR. DUVAL: I would make one comment. I strongly encourage you to stick with the term eliminate rather than reduce disparities. The fact that you do, probably statistically at least, increase the likelihood of failure in some areas -- my own feeling is that one can usually do a great deal of good by pointing out the difficult areas that are closed. In other words, you are better off failing and then drawing attention to it. That doesn't bother me one iota. So, I would strongly personally urge that you stick with eliminate rather than reduce disparities.

To make one comment about targets, be sure that in electing any target -- this is true across all objectives -- never use the target for one group to bring up another subgroup. If this forces you toward averages or flattening them out some other way, I would still do it. I wouldn't say, because they can do it, we must use their end point or their result as our target. I am shy of that.

I would say finally -- because you did ask us if we had any difficulty with any of the objectives in this area. I have a difficulty with one, the near-term goal that happens to be on page 18 of your tab that is on the race initiative. I guess I find it awkward to look at a goal that says reduce lower extremity amputation rates. That strikes me as being the kind of thing that involves many variables, including a physician's decision. I think I know what you are getting at, if the issue is bad circulation and so forth, but I would simply throw that out and say that that particular near-term goal bothered me a little bit, as being maybe not as good a way of expressing what you are trying to get at as others might be.

DR. FOX: Let me make sure that I understand your first comment because, again, I think we need some guidance on the national average. Dr. Brandt has expressed his as far as the best, the national average, or the better than the best. Did I hear you say that you would not pick the best of the best and use that?

DR. DUVAL: Not necessarily, but I wouldn't refer to the best as being the best because it is any particular subgroup.

DR. WINDOM: A concern I have -- I am certainly for the elimination as anybody would be. I still like the realistic aspect of people seeking a certain target, to give them a little stimulus of something to reach, that is within the goals that are possible within a decade.

Secondly, as we look at certain diseases, we want changes like, for example, in the amputation rate and also the end-stage renal disease rate. We have got to look at the genetic predispositions that cause diseases, too. No matter what we do externally, we are not going to do anything to correct that, unless we have genetic intervention between now and 2010.

Anyway, if you take the gap and close it, I think the best get worse and the worse get better and come to a common goal, or the best then don't have an incentive, as I see it. I think the goal, even within the states -- I think there is a difference in infant mortality and different goals. Some states are doing better than others. So, in that state that is doing well, it needs to have something to go to. So, we may have to vary our targets. That is a very difficult thing to do, but something to think about.

DR. FOX: I think the one thing I do hear from you -- and correct me if I am wrong -- is that you do want to move beyond the national average.

DR. WINDOM: Yes, in those areas where it is possible.

DR. FOX: The question is, how do you determine, if the target is better than the national average, how do you determine what that target would be? Certainly, the national average -- you think we can go beyond that?

DR. DUVAL: If the national average has been falling -- let's say for the sake of discussion -- 1.8 percent each year for the last 10 years, or whatever the number is, you could reduce that national average and say that is the new one, even though it is an arbitrary number.

The point is to have a number that is understandable, that is applicable to all, and not oppose one subgroup to another. Once you have gone to the concept of eliminating disparities, do away with all the disparities.

DR. FOX: Again, also, the sense is that there is general support for using the definitions under the new OMB directive. Would that be a fair statement?

MR. HARRELL: It occurs to me that we have got two categories of measures here, which can be separated or which can be blurred intentionally. Progress toward a target is one category, and elimination of disparities is something altogether different, or can be something altogether different, that you would put out a separate measurement for, that I picture mainly as kind of a graph that shows that things are getting closer together, but don't have objective or static kinds of targets.

I am wondering whether it is helpful to separate them or whether it is more helpful to kind of blur that distinction as we seem to be doing in the discussion so far.

DR. FOX: Do you mean focus more on the range and show that the range, in fact, is decreasing?

MR. HARRELL: Yes, I think we tried, in fact, in Healthy People 2000 to get at that a little bit, and even had, as I recall, some little graphs out to the side that showed that, even though we didn't have the same target for every group, in every case the target for the minority groups that were in the worst shape were going to move so as to reduce the disparities.

The targets were set at a higher rate. We did not eliminate. That decision was not made for the year 2000, but the decision was made never to sit still for the same level of disparity that existed as those objectives were set.

DR. FOX: Let me ask -- are you suggesting that the rate of decline for the groups that have the disparity would be greater or equal to? For example, if you look at some of the MCH objectives, we are suggesting that we might want to change the objectives of 30 percent from the baseline. Are you suggesting that, for some of the racial groups, we would have a greater rate of change?

MR. HARRELL: That is exactly right, because I think that it does remove the disparity if you could basically have something that doesn't set targets at all, but really measures disparity. They really are separable kinds of measurements.

DR. HARLAN: As a separate entity, when we discussed this under the leading indicators, that is the kind of discussion we had. It averages out to individual numbers, and we described the difference from that average by variance. One way that you get to elimination of disparities is to change the rates of change, particularly for those who are disadvantaged at the beginning.

If you look at it as two separate numbers, the rate of change required to eliminate the disparity, and then have another overall goal as an average, and part of that goal is to decrease the variance around that average number, you begin to think of it as two separate kinds of entities, but also as something that I think is a little bit more manageable, at least mentally.

DR. FOX: I will tell you -- I think that Dr. Satcher, in other discussions I had with him, even this morning before the Council convened, feels strongly that if we focus on eliminating disparities -- which he supports -- that that really does force us to do something extra and beyond what we would do normally for the groups where disparity exists, because you are going to have to push them down at a far greater rate. I think my sense is that he feels that is very appropriate.

You had your hand up.

DR. TAKAMURA: Actually, I have two comments, and one has to do with the discussion pertaining to disparities.

Actually, a specific concern of mine would be in the general overview statement, for example, in paragraph three. One of the groups, Asian Americans, is not mentioned at all. My understanding from the discussion that has been ongoing is that we are really using disparities to talk about differences in general, as opposed to good, better, best, worse. In light of that, I would suggest that we insert Asian within the litany of minority groups, if you will.

More generally, I think that a concern that I have has to do with the overall understatement of aging as a population. I recognize that there isn't an aging cohort breakout. One thing I would point out, in relation to this, is that the year 2010 is very significant. It is only one year away from the year the baby-boomers will come of age.

I would hate to see us arrive at 2010 and discover the baby-boomers and not have had our objectives be somewhat sensitive to the kinds of interventions that I think we can aim ourselves toward, to make sure that that population is not at risk at that point.

DR. FOX: Let me suggest that -- I think we have gotten some guidance -- that we take other guidance in addition to that, from the Council members, either informally as we move through the day or after the meeting, and we move on to the discussion of framework. I am sensitive to the agenda and the fact that we have a lot to cover.

I would like to move the discussion on to the framework. Let me just tell you that there is a proposed framework that is in your book. There actually are two. What we would like to do is have some sense from the Council on the framework that could go out for public comment.

We have already told you we are going to put these objectives out for comment in the fall. There are some groups that we have not gotten very much feedback from and we very much want to pursue that. We have not gotten much from some of the environmental groups and we have not gotten much from some of the senior groups, substance abuse, mental health. We need more from business and other groups such as AIDS. We have groups that we have gotten a small number of comments from.

One of the things we would like to do is have some discussion on the framework realizing that all of this obviously is still subject to some modification, based on what comment we get in the fall from the regional meetings and the public. What we are looking at is a tentative framework that sets the stage for us to get that comment. Then, based on the comment, we may further modify both the objectives and the framework.

We have had, as suggested by this Council at their last meeting, a lot of communication. We did put -- and this Council suggested that we put out both the objectives and the framework for some consultation and discussion. Which we did, which resulted in what you have in your book.

The formal public comment period is going to be, again, this fall.

There are two frameworks under tab 6 under the draft 2010 objectives, if you want to look at them and, again, we want to comment on those in just a minute.

Let me quickly say that we do plan to have five regional meetings that we do hope will involve a lot of the community who have not had a lot of chance to comment on these objectives in the framework to date. I think it will be interesting to see how those go.

We have the two over-arching goals, again, that this council suggested at its last meeting, and they are in five sections. The over-arching goals are to increase the years of quality healthy life and eliminate health disparities.

The five sections are: Promoting Healthy Behavior, Promoting Reproductive and Sexual Health, Promoting Healthy Communities, Preventing and Reducing Disease and Disorders, and Improving Access to Quality Health Services. Then under that there are 26 focus areas. I might also tell you that we have had a tremendous amount of discussion within the Department on how we might construct this, and a lot of, as you might suspect, difference of opinion and thoughts about how we should do it.

I would like to basically ask first for comments from the Council on the five sections and ask you, one, do they look reasonable? Would you construct them differently? Do they adequately describe our strategies, based on the over-arching goals that this Council has already approved, for increasing years of healthy life and eliminating health disparities? Are they broad enough? Do they communicate, as the Secretary said, what we want to communicate when we put this document out?

It is again -- you might not have a tab number, but in my book it is behind the draft 2010 objectives. There is an option A and an option B. Let me also hasten to say these are not the only two options. There are obviously other things we can do based on your comments. These are certainly two.

The first one you see, option A, is the way this book is organized. Option B, really under the focus areas, alphabetizes them. It is as simple as that. But there are other ways we can go at it. So, these are not meant to be the only two.

With that, I would like to open it up and, again, we did not plan to put out for comment the two over-arching goals because that was decided by this Council at the last meeting. I would hope you would not want to reopen, based on the amount of time that we have and the things we need to discuss.

Under that -- the particular areas that we have -- we have these five sections. I would like, first, to ask your comments on the five sections and then we will talk about the 26 focus areas. Let me open it up as far as the five sections and see if you have any thoughts or comments based on what we have here.

DR. DUVAL: Yes, I don't mind opening this discussion. I, first off, don't think it makes a big difference which of the options that you use. I will state that, as I went through, that I probably spent almost as much time on these two sheets as I did on much of the rest of the book.

I like option 2 better for two reasons. One is that option 1, the categories and how you put the 26 items in there, are somewhat arbitrary and the overlap is really quite substantial. As a matter of fact, you could move some around and some people would never question it. The second advantage, to me, of option 2 is that it makes it, from a utilitarian viewpoint somewhat, I suppose, more attractive to relatively narrow interest groups that are abroad in the country, who will be receiving this, and they will want to turn immediately to their own areas of interest and not try to find their interest under somebody else's arbitrary structure.

DR. FOX: As you mentioned, many of these you could make a good argument to place them under several of the five. Other comments?

DR. WINDOM: I like B. I go along with B; same reason.

DR. BRANDT: I hate to be at the center -- actually I don't hate to be at the center -- but I do like A better. I do think that it groups the categories better.

Furthermore, it can help you with overlap if you set the goals properly. I personally like that better than B, but in the end I really don't think it is going to make a whole lot of difference. It is the substance that is really going to make a big difference.

DR. RICHMOND: I would just second Ed's comments. It is what we are dealing with substantively. This gets back to the earlier comment about what is going to be happening demographically in 2010 and the coming of age of baby-boomers and all. I think we need to think not alone of subgroups, and be sure that we try to be as inclusive as we possibly can be.

We also need to think of what the ultimate implications are for the nation's report card on health as a consequence of how we look at this. As the baby-boomers come of age, indeed, are we going to be paying enough attention to those objectives? I think it makes some difference in how we organize the report.

I guess I find it a bit more congenial, too, because, coming back to the Secretary's earlier comments about lucidity and comprehensibility, particularly to citizens on the street, I think that if one can hang these objectives on certain hooks that people can readily grasp -- and I see A as an effort in that direction -- I think it would be helpful. I think this is where a great deal of attention will need to be paid, I think, as we move toward getting a report out. Is this going to be understandable? Can it be communicated readily? If everything looks equal to everything else, I think that is going to be difficult to do.

DR. FOX: The lack of consensus among the previous Assistant Secretaries for Health also reflects the lack of consensus in our talks and some of our differences of opinion as well.

Let me also say that two of the ways we have talked about of displaying this or using it, when we actually get down to issuing the document itself -- one is to put it up on the web and have it indexed so that people can pull it up any way they want. If they want to pull it up and look at a particular area, they can pull all the objectives up and do that.

In the second -- we have had several groups, and one in particular, from which I have gotten a number of letters over the last several days -- from genetics, the people with disabilities and children with special health care needs, interested in a section or chapter that would look at that.

One of the options that we have been exploring -- I think quite frankly that it is a quite good one -- is a series of special reports. One of the things that people have said about the overall Healthy People document is that -- except for some of the business community, who like it short and sweet -- that the number of objectives and the menu really do offer a wide range of things that people can go to and pull out that are of use to them.

One of the things we have thought about is that, for groups like the business community, like areas for children with disabilities, that we might have a document that could be issued at the same time that Healthy People is issued. It could be issued at Public Health Week that same year -- that would be, for instance, a Healthy People special report, say, on work site health promotion issues, that would relate to business concerns. It could be a document that could look at children with special health care needs, and all those objectives that would be applicable there.

You can envision several different reports. What you do is pull those out, put a text with each of them that would market it to a group that could then take and use it in a way that, maybe -- regardless of how we shape the reference document itself -- might be more useful. That is a potential way of addressing this. It is certainly not the only way but, again, I think if we do that, it doesn't make the discussion of the framework unimportant. It just means there are some ways we can get around whatever it is that we decide to do with the document.

MR. SCHWAB: Actually, your comments really reinforce what I was going to focus on, which actually in some ways is an argument for the second option rather than the first. The last time this Council met, one of the points that was raised was having multiple formats for multiple audiences.

The suggestion, I guess, implicit in that is not to have the framework itself get in the way of presenting what is important here. The likelihood is that over the next 10, 12 years, people will have the opportunity, electronically and otherwise to really mix and match and make sense of where it best develops the arguments.

For us, for example, when we look at our substance abuse programs, whether we really talk about that in the context of promoting healthy behaviors or whether we talk about that in a context of promoting healthy communities, or where it is here listed under Prevent and Reduce Diseases and Disorders, it may very well be that, in terms of some of the issues around substance abuse, when you may want to combine it with issues around domestic violence, this kind of a framework in A may get in the way of those kinds of discussions and that kind of a focus.

By having it more flexible, even though it is alphabetic and it sounds somewhat pedestrian, it does allow more of the opportunity of mixing and matching and also, in some respects, that flexibility, and the framework doesn't get in the way of the discussion.

DR. SONDIK: I don't think to me it makes much difference which one is used. The significant part -- as you said about the web -- I think we are going to see more and more documents that really are not linear. You can go and you can pull things off in any number of different ways.

What I do like about A is the fact that there is a categorization of these. I think having that categorization prompts us to think about some summary measures of these objectives. This is, I think, a good set to start off with. I like that fact.

How they are actually arranged, I don't think makes a great deal of difference. I don't think there is any question that there are objectives, for example, in the cancer chapter that relate to what is in the first category here, Promote Healthy Behaviors. So, there is going to be this interrelationship.

What I suggest is that we think about a primary breakout of these, being these five categories, and think about maybe some summary measures. Maybe that is something the public could pick up on and maybe we could find some measures that would be easy to understand.

DR. FOX: How would the summary measures be different from the sentinel objectives?

DR. SONDIK: They could very well be the same. Maybe that is the way we should organize it.

DR. FOX: We are also going to have a discussion later on in the agenda from Dr. McGinnis.

DR. JONES: I just want to weigh in on option A as well, because of its more synthetic approach. For those of us who are interacting a lot with the public, if we can put our stake in the ground that this is what we hope to achieve as HHS, as public health, we can identify these five areas, and talk then more specifically to the community's needs or to the interest group's needs or whatever.

I am just concerned that not having that sort of framework leaves us more in the body part, special interest parsing out, that will occur anyway. To me, it makes it easier to be an advocate of what we hope to achieve, even saying we have objectives for the health of the people of this country.

DR. BROOME: I think the communication objective really is in favor of option A. It relates to the discussion we will also have later of what is our graphic for this. I think, as all of you who have paged through the graphics will realize, developing a graphic for 26 is exceedingly challenging. I think if we draft the right five, or maybe it is four, it is easier, I think, to communicate that. The reason I raise five versus four is something that NIH may also want to speak to.

We have a lot of concerns about whether the reproductive health objective is of the same order and type as the other four, or does it in fact fit really under the promoting healthy behaviors. I think that is a question that is appropriate on its own. It is also a problem because of HIV, which in many ways, we feel, needs to be linked to STD prevention because of the relationship and the ability. At the same time, I think there are a lot of folks who think that doesn't give significant recognition to the role of the IUD as a means of transmission. I know there are a lot of difficulties in finding the right place for things, but I think that is a particularly problematic one which actually could be solved by just having four big objectives.

DR. FOX: Let me also take that -- we want to take discussion to -- we won't segment this. As you have said already, Claire -- the questions like, do you combine HIV and STDs? Do you combine unintentional injury with domestic violence? You know, there are some that you could put together and some that you could make an argument either way. Again, we have had a lot of internal discussion, as some of you know, and we need any additional comments that you want to provide.

DR. KNOUSS: I would favor option A for some of the reasons that were already expressed. I was somewhat impressed by the assessment of the way we currently structure Healthy People. Option B follows along the lines of the way we currently structure Healthy People. And yet, some of the assessment that we have done and that has been done on the current approach to Healthy People, I think, would lead away from that organizational structure and more to one that would facilitate communication, and mobilization of community support.

After all, we are talking to the American people and we are involving them as the key partner in this. They are the ones that are going to have to really increase their understanding and ownership of this process. In order to do that, I think it is going to be far easier to achieve that ownership if we use option A.

MS. COOPER: I guess I have a problem with option A because, when I look at Prevent and Reduce Diseases and Disorders, the way you do that, in large measure, is through promoting healthy behaviors and promoting healthy communities and improving access. So, having it like a separate thing is like mixing apples and oranges. Because of the categorizations that I feel uncomfortable with, I favor option B, unless there was another way to display it. Because the diseases just don't seem to fit with the other categories, I have a problem.

DR. FOX: I think what we are going to do is actually put this out for bid. Then we won't have to worry about paying for the special reports that we want to issue. [Laughter.]

Let me just further complicate this by saying that there are other ways of displaying this. I think part of the question is -- and some of this comment, I think, again, reflects the diversity of opinion -- are we using the right five sections?

The CDC right now is working on the Community Guide to Preventive Services, which is the community document analogous to the Clinical Guide to Preventive Services. Claire, I think those subsections there are contributors or risk factors, disease and disability, environmental and cross-cutting, which would include data and communication. That is another way to look at it.

I think the question is, do we want to look at other options beyond this? Are these the right five?

MR. HARRELL: I would speak in favor of A, too, on another kind of reason that we just haven't heard. I think there is some policy protection in having these categories.

There have been times when people, even leaders in this Department, have kind of over-emphasized one part of what it takes to have good health, to the detriment of others. That is, saying personal responsibility for health is where it really is; it is not these other kinds of things.

I think the balance in Healthy People 2000 was the intent to address this by having the categories of health promotion, health protection, and clinical services, the three big sections, to say really, you can't have the final goal unless you have all of these parts of it contributing.

Having that built into the structure helped us to be able to say, you know, it really isn't all just a matter of personal responsibility. It is a matter of immunizations and that is a matter of there being a doctor available, or a nurse.

So, I would speak for that on the grounds of kind of protecting us over a 10-year period.

DR. HARLAN: I would speak in favor of A for many of the same reasons. We have discussed this with CDC in terms of the way it might be assembled.

I would just point out that, when you talk about prevention, you are talking about large measures that influence a number of diseases. Nutrition influences cancer, heart disease, osteoporosis and a number of different diseases. So, it is nice to have it in that categorization. The other thing that is very true now is, with a good search engine, you can parse through the option A and come up with option B quite easily, if that is what you wish to do.

I would make one other comment, and that is that there is already a movement to take issues from some of these categorical areas and put them into Promote Healthy Behaviors. I would just say that some of the cancer and heart disease objectives are actually shown under Promote Healthy Behavior. So, we have started to make the kind of movement that favors A, and it seems to be working quite well.

MR. SMITH: Are we limited to a one-page table of contents? I mean -- half of the first page, down to objectives -- could we put both of them and give the people who read this the option of looking at it alphabetically or looking at it categorically. We would only add another half a page, basically.

DR. FOX: Really, we are only limited by what we decide to do. This whole ball game is open at this point, in terms of what we are putting on the table.

MS. DONAHUE: I, too, would like to speak in favor of option A. I think having the categorization does, as has already been pointed out, say that you have got to have all the parts, rather than just the pieces.

The comments concerning the tendency toward moving toward the body part approach, or the tendency toward moving toward one or more institutional kinds of approaches, the tendency toward looking only at health care delivery -- all of those things are problems that we have been faced with in the past when we look at the overall picture of health. At least having the categories will help us to see this as a larger part of the whole.

I would like to further say that what I believe Jim has said and what I believe was said at this end about the importance of being able to see these things -- the fact that we will have this on the web and it will be able to be searched independently is very important. Also, there are going to be a lot of people who are going to be needing to use this, that will not have access to that. So, thinking through how we might be able to do that, so that people who do see things more will be more comfortable with an alphabetic listing, I think would have a lot of merit.

DR. RICHMOND: I was playing around with a visual conceptual model here. If one takes the five categories and collapses them into the three -- promoting healthy behaviors, promoting healthy communities, and prevent and reduce disease and disorders -- if one keeps this to three categories -- and incidentally I think the other two in this section A can be collapsed into these -- if one keeps those down to three, one can have the arrows going both ways, showing the interactions; again, if one thinks of web sites.

Later on, one could certainly connect these, but it seems to me it makes it more dynamic. I think in-house you may want to play around with something like this.

DR. FOX: Other comments on the five areas or the focus areas? I am again feeling the need to keep us moving along here because we have got a series of presentations on the individual objectives the rest of the day. Again, I am not going to comment, but I would ask, maybe, that additional comments we provide individually, rather than verbally as part of the group. I certainly want you to feel free to do that.

Before we move forward, any other comments on either the five sections? I think there are some good suggestions on the 26 focus areas. The other thing that some of you have commented on already that we have had as an issue for discussion is the number of objectives.

Again, any further sense of paring it down? I think that we have heard from a lot of groups since back last October and, quite frankly, the number of objectives that we have on the potential docket right now is slightly more than the ones that were in Healthy People 2000, but not a tremendously larger number. I, for one, had started this process out by saying I thought we ought to put it on a diet and reduce them. The public has spoken contrary to what I thought, and everybody seems to want to continue the diversity, the breadth and depth, of the document. Again, it is open for further discussion.

DR. SONDIK: What I have been struck by in this, with Healthy People 2000, is the way that health departments have taken this and then they have modified it in a variety of different ways. I think that is just going to happen many-fold over what happened in the last decade. I think the advantage of more objectives -- not more, per se, but something that is more detailed -- is that it provides more for health departments to work with.

I think the issue is really how to put them in some kind of hierarchy to make sense of them. I think that is one reason why I like the categories or some set of categories that way. I think that is what health departments are going to do, and others are going to do. They are going to categorize them in a variety of different ways. I would favor that it be svelte, but detailed.

DR. FOX: You brought up a good point, Ed. It is the fact that virtually every group that has taken and used Healthy People 2000 has not adopted it verbatim. They have taken it; they have modified it. If you look at the individual states, if you look at the state lab directors, if you look at other groups that have used various parts of it, they have taken and shaped it, and maybe still refer to the national goals, but they have modified the document to fit their own needs.

I don't think that is a bad thing. I think the bottom line of what I would hope to see come out of Healthy People 2010 is the same thing that has happened with Healthy People 2000. It is, one, the attention to prevention and, two, as Mike McGinnis and others early on tried to do, to think about management by objective, and what the goals are, and to have targets and to have a way of striving toward those targets. I think that has been a real value of the document to date, and it really has come through that virtually nobody has taken it and used it without some change and modification.

DR. RICHMOND: I think, just in that context, we shouldn't omit mentioning the utility of the document for ministries around the world. I think all over the world the ministries of health look to this document and see how they can utilize it and adapt it to the health goals of their own country. I think it has played a very major role internationally.

DR. BROOME: I would also like to speak to the importance of the breadth. First of all, I do think that -- without totally anticipating your discussion of the sentinel indicators -- I do think that we do need to focus on leading indicators or something that is a more manageable number.

I don't think I would choose them based on just the five areas, but I think that something that approximates a report card for health and not just the health care system is a very important function.

Having said that, I do think that the large number of indicators -- also, I think there has been an increasing variety in the types of indicators. So, we are thinking more creatively about not just what individuals do, but what the systems do, what we need managed care systems to do in order to meet these objectives. This is very helpful in making 2010 truly for the whole country, not just for federal agencies.

DR. FOX: You brought up another point for an attempt to deal with the size of the document. As many of you may know, Healthy People 2000 had sentinel objectives. They weren't sentinel and they really didn't, in my sense, get pulled out and have something done differently with them as a national report card. There has been a lot of discussion around that and, in the period of time I spent in ODPHP, I know that a lot of others have looked at it as well, to really try to do that.

Look at a set that could be issued, perhaps annually, that could receive a tremendous amount of visibility. Again, it wouldn't address all the areas, but would give some indication of where this nation is heading. That is going to be part of the discussion this afternoon when Dr. McGinnis comes and talks with us and shares with you kind of what process we are moving toward. That is another way to deal with having a lot of objectives in this document.

Let me mention that one of the things that has been looked at is how we could issue the reference document itself. One of the thoughts has been -- I hesitate to say this -- is that it would be issued in a three-volume set. This is very painful for someone who wanted a smaller document to have to discuss. The bottom line would be that there would actually be three documents, of which the second document would really contain the objectives.

The first document would be for public policy makers. It would cover population groups, the life stages, race, ethnicity, socioeconomic status, as well as maybe some community settings, like schools and work sites.

The second document, as I have already said, would be principally the objectives and would be a resource for many, including the public health community.

The third document would really be, for all intents and purposes, the National Center for Health Statistics tracking and the data tracking, which would include what NCHS does, which would display the race and ethnic groups, age groups, and it would basically have that kind of information in it.

It obviously could be constructed in different ways. The thought is, we could segment it in a way that would lay it out like that. I don't know, Ed, if you want to comment further on that. That has been looked at as one way of actually putting the set of reference documents forward that might make sense.

DR. SONDIK: And all of that on the web.

DR. FOX: Right. I think the intent is to have it on the web and have all of it indexed in a way that could be very user-friendly.

Let me suggest that, if you have additional comments, that Debbie Maiese -- Debbie, raise your hand, so that everybody knows who you are. Debbie is in ODPHP and has been the point person. We have had a lot of staff, Linda Bailey and others, who are involved in this. I would suggest that you give any further comments to Debbie as we move through the day, realizing that we don't have enough time to have as much discussion.

I am having two feelings right now. One is a sense of urgency to move the agenda, and the second is the frustration that we haven't had enough time to have all the discussion that I would like to see. Trying to take even an entire day and move through all that we have to move through, I would suggest that any other comments that you have, give those to Debbie either at the break or any time during the day or after today, so that we can make sure that everybody has an opportunity -- if you have other opinions, thoughts -- that you have a chance to put that in.

We don't want to miss that. I think what we have had is an opportunity to raise the issue and have some discussion, and allow you the ability today and after today to continue to provide comments, so that we know what you think.

Why don't we take a 15-minute break and then we want to move on, talking about the objectives themselves.

[Brief recess.]

DR. SATCHER: We are going to get started again. We are going to try to stay on the schedule, but we also want to allow more time for discussion, even than we had planned. So, we are going to get started. What we are going to try to do -- I think Earl has already talked to the presenters. So, we are going to try not to spend so much time on the presentations, but to use it sort of to open up the discussion about the objectives on the part of the various agencies.

While you were away, the press release that is going out today -- has already gone out -- on teenage birth rates being down in our states, has been placed at your desks.

Any questions or concerns or comments about the way things are going, anything you want to change?

We are going to start with Sandy Perlmutter from the President's Council on Physical Fitness and Sports (PCPFS).

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