Agenda Item: Public Comment

MS. SHEEHAN: I am with the National Association of State Alcohol and Drug Abuse Directors. I want to first of all thank the Department for inviting us to come today and listen to this fascinating discussion.

In the area of substance abuse, the federal government contributes one third of the resources and states kick in the other two thirds. I am sure for a lot of other public health arenas, that is also the case. So, I want to encourage the Department to look carefully at how they can more engage -- I know some engagement has already taken place -- but how they can more engage state officials in becoming involved in this particular effort. I know that there will be opportunities during the public comment period to do that, but look at maybe a more concentrated way of engaging the states as partners in these goals and the accomplishments of these goals.

There are two particular arenas that show up for me in that regard. One is, I think that federal officials and state officials are very concerned right now about how you provide services to recipients of Transitional Assistance to Needy Families (TANIF). How do you actually get those people jobs? How do you keep them going? What Clem was just talking about a minute ago in terms of jobs -- many TANIF recipients have a substance abuse problem.

In the current objectives right now there is just one objective regarding treatment. It just says, close the treatment gap. I guess I would like to see some way to sort of look at how we provide services to working moms that are in TANIF. I know they are probably covered under some of the low-income goals. But I think that something in particular that may not end up in the objectives should be discussed and brought to the table.

The second is the issue of the data and performance measures. We are looking at, through different pieces of federal legislation, the mandating of performance measures. I think that we all need to pull together in terms of not only talking about how we need more data, but how we find the money to do the data. How do we do data across systems in terms of really being able to create those kinds of cross-system exchanges of data?

The last thing, which I think has been really powerful about what you all have done here today, is you have really brought together an integration of the different public health systems that we don't always see.

At the state level, the same thing happens. The people who do public health go one way. Substance abuse goes another way. I think that by engaging the states in this process, you will really see it. I looked at one of these state reports; it said that only 29 states have put substance abuse objectives into their plans. It makes me think about how my folks at the state level -- what can we use to bring them together with other public health officials?

DR. SATCHER: Marty?

MR. WASSERMAN: Marty Wasserman representing ASTHO, and State Health Secretary from Maryland. First of all, I want to, again, compliment you. I was an alumnus of this Council's predecessor. So, it is nice to see how far the group has come. I just want to make some comments as to how this will play out in our state, and in other states as well.

We will have a panel this year. For the first time, ASTHO and NACCHO are having a joint national conference. In one of our sessions, there will be a panel discussion dealing with 2010 objectives. So, all of the information in the book will be helpful as we plan that scenario.

In looking at the elimination of racial disparities, racial and ethnic disparities, in our state, we have gone through pretty much the same exercise that you all did today. What I learned from today's session is that it may be possible to eliminate the notion of elimination and still work with closing the gap.

By picking -- I talked to Ed and there may be a mathematical way of doing this -- picking the distances of different ethnic gaps and accelerating the closure rates. If you could look at -- in Maryland, for example, if we are achieving a certain decrease in infant mortality of X percent, we could have X percent as a goal for 2010, and then X times 1.2 for -- if you are one standard deviation -- or X times 1.4. So that you would accelerate the difference in closure toward elimination and maybe not necessarily reach the end point by 2010, but still embrace an audacious goal and still have it be somewhat realistic.

The other notion that we are wrestling with in our state didn't come as any of the notions, but in thinking about prevention. An awful lot of money and an awful lot of thought is going into the whole notion of holistic health or alternative medicine or complementary medicine. As I look forward to scenarios in 2010, I think this is a good time and a good group to begin to wrestle with the whole notion of what -- in addition to today's kinds of health care -- we are going to deal with.

Along the same lines, what are the technologies that we will have? What are the implications -- I think Clem mentioned it at the end -- of genetic engineering, and what are those possibilities? Also, I think in our state we have a Robert Wood Johnson grant to look at death and dying and the whole bioethical issues around that.

Merlin made a comment that I found -- today you said at one point that you didn't think -- people might not have access to the Internet. I cannot recall exactly when you made the comment. I was thinking that eight years from now, in the year 2005, we will be doing a mid-year review. In the year 2005, I would certainly hope that everybody has access to getting on the Internet through their television set. I was thinking, people will be going to Camden Yards. They will have a television set. They will be accessing the Internet during the seventh inning stretch or something.

When we look at scenarios and we look at building for 2010, we ought to be looking at the context of what kind of technology changes, what kind of media changes, what kind of communication changes we have as well.

Finally, while we are engaged here today with our health friends, and welcome the business community as well, we may want to look at what other cabinets, executive cabinets, should be participants in the future in spin-off groups -- certainly as a pediatrician -- working with the Education Department, working with Labor and Commerce, working with the VA, when you talk about older exercise and activity.

In our state, I thank you because Carleissa Huessain, who is in charge of our public health programs -- when we go back tomorrow, we will be starting on Maryland. She told me she has already started on Maryland's in anticipation, but I thank you for what we have gained from today's activities as well.

DR. SATCHER: I think that is a very significant meeting that is taking place, ASTHO and NACCHO, the first time. We are looking forward to that.

DR. MACDONALD: I am Steve MacDonald. I am with the Washington State Department of Health and I am here representing the Council of State and Territorial Epidemiologists, CSTE.

I have two comments. One is on one specific chapter and the other pertains to all the chapters, I think.

The first one, the one that I was sent here to express, is that the evolution from the former chapter on Surveillance and Data Systems into the current chapter on Public Health Infrastructure has resulted in the focus on surveillance and data systems -- particularly in a manner that those of us in states can relate to -- being so submerged as to be lost in the current draft of that chapter. I think it is possible to restore some of that by adding some specific references to data and surveillance systems in, probably, subobjectives in that chapter. That was a little disappointing and I was tasked to clearly convey that message.

My second comment -- that I didn't come here planning to say but that slowly dawned on me as I was listening to folks throughout the day -- was a sense of a false dichotomy between thinking you either have national data systems that are capable of producing national estimates such as those run by NCHS, or you have data systems which are capable of producing state estimates, such as the Behavioral Risk Factor Surveillance System, and a variety of other, say, hospital discharge data systems. You try to achieve some synthesis through some kind of survey integration plan, such as the Data Council is working on, which might undermine in some fashion the state-based systems.

I see that as a false dichotomy because I think it is possible and reasonable and desirable to have both, to have a dual approach, a system which has state-based data systems that focus on state problems that are unique to particular states, and have data systems that are capable of producing national estimates which states can then use to compare against their own data systems. One of the key ways that you accomplish that kind of a dual system, I think, is by making sure that the national health objectives that you have got are worded in a way that they can be used in both data systems.

There was reference to that in more than one place today, about what do you choose, one or the other. I think we can and should change data systems in response to what are chosen as the objectives. Therefore, the challenge is on data systems development folks to craft the data systems. And the objectives ought to be written in such a way that they address what it is that we want to achieve. I think that having objectives written in a fashion that can be used for national level estimates and state level estimates is the kind of goal that I would like to see us strive for. Thank you for the opportunity.

DR. SATCHER: Thank you very much. Is the immunization survey an example of that?

DR. MACDONALD: Yes, I think that is an example of that. Another example of that is the BRFSS, and making it compatible across the states.

DR. SATCHER: Is it national?

DR. MACDONALD: There are tests underway to see whether it can be aggregated in a way to make it national. I think we can do things as simple as being sure that the questions are stated in such a way that they are applicable to states. If there are instruments that are being used in the states, be sure that the questions are compatible across the states, that they are the same. For example, we could have a clearinghouse at the national level that lists questions and the characteristics of those and how they have been used and their reliability and validity and so forth.

DR. SATCHER: Okay, thank you very much.

DR. SONDIK: Also, it's worth pointing out that the NIH is leading up a national task force that is looking at doing that for asthma, trying to get NHIS questions and BRFSS questions identical, so the data can be compared.

MS. MARKIDES: Christina Markides from Pan American Health Organization, which is a Regional Office of WHO. I don't know if it is a public comment, because I am among a lot of friends I've had the privilege to work very closely with on this proposal.

I would like to say that it is very exciting for us to see how the United States has taken on this challenge of Health for All through the proposal of Healthy People 2010. We have, in fact, taken this proposal with Debbie and some other colleagues to other countries in the region, through a symposium that took place in February on national strategies for Health for All. It is difficult sometimes when you are in your own country, to realize the value of it. For us, looking at it from the outside, we have seen its value and shared it in other countries, and we will continue to do so.

The last comment relates to something that many of you have mentioned, that it is the value or the importance of the global nature of Healthy People, the goals of the nation, to the rest of the world. Perhaps this is an issue that needs to be worked further in the book itself.

Thank you.