Secretary's Council on Health Promotion and Disease Prevention Objectives for 2010

DR. BOUFFORD: I will try very quickly. The next section was to really look at how the operating division heads, and we weren't going to make everybody speak if they don't want to, but I do think that because of the kind of specialness of this event, and the need to really hear from colleagues who have not been involved in this process up to now, and I wanted to ask Olivia for ACF and Bill for AOA and Sally for HCFA to speak first, and then invite perhaps David to lead off, but then have other people representing the offices add in if they wish to. Olivia, could you just--

DR. GOLDEN: Let me just say a couple of things. I'm going to ask Jim Harrell who is here from the--

DR. BOUFFORD: That's not fair, though, because he was involved in Healthy People before he was reincarnated.

DR. GOLDEN: And Bob Williams is here from the Administration on Developmental Disabilities. I would actually like both of them to comment. But my completely unprepared thoughts are a couple.

The first is that I was delighted to be invited and to have the chance to learn. I guess my first observation about how Healthy People 2000 has affected ACF is that, particularly with you being so generous as to give us Jim, we've been trying to use the structure and the lessons as additional input into our own work on measuring outcomes and results and bringing people into the experience. I think we've learned a lot. There are some things that are typical on the human services side, there are some areas of knowledge or data where maybe we have something to teach, but we have an awful lot to learn. There's been an awful lot learned and accomplished and that has been enormously useful for us. It's helped us, for example, get our thinking about Head Start performance measurement to a whole other level.

The substantive comments I would make, without having spent enough time to have any kind of detailed comments--the first is, of course, to underline what Julie Richmond said. We had the joy of working together on the early Head Start Advisory Committee. In fact, is it widely known that you named that key initiative that the President highlighted?

But I guess I want to underline as well my sense of concern, but also of timeliness, around focusing on very young children, and on children's development. As someone who has always come to the health data world from the human services background, I am always struck that you can measure something about children when they're born, and if they die very young, and then again when they become teenagers and perhaps have a child too soon. In between, it's very hard to know very much even though those are incredibly critical years with important developments happening. There's been some thinking about that in the education and early childhood world, thinking on the health side, and I just want to underline that I think that's enormously important.

The last overall thing I guess I would underline is that, as we move into substantial change in the nation's welfare systems, thinking about what are the networks that we have that are looking at outcomes, the broad-based outcomes for children and families will be especially important. I think our keeping in close touch with the health world, as well as with the education world and others that are looking at results will be really important for us to have a sense of what's going on.

So I was delighted to be invited and really look forward to continuing to be involved. Bob, should I go to Jim first? Do you have anything?

MR. HARRELL: I guess the only thing I would say is, when I was in the Public Health Service, ACF frustrated me, because I was pretty convinced that a lot of things that they were doing were really very relevant to public health. Now that I'm there, I can understand why it's difficult to make the connections, to make the coordination, but I'm more than ever convinced about the relevance of the issues and the importance of making the effort to coordinate across the Department and having ACF involvement in the development of Healthy People 2010, or whatever it turns out to be called.

The areas of connection, just to name a few, were--the first one, early childhood is there in Healthy People 2000, but it's kind of there in name only with maybe one objective. It could be a lot more fleshed out. Violence is another area of mutual concern and a lot of effort, and probably we could make our efforts even better if we were collaborating and using some of the framework of Healthy People in doing so.

Bob can speak to developmental disabilities. I recall that during the process of developing Healthy People 2000, perhaps the most vocal set of interest groups that existed were the people with disabilities. I feel as though we let them down to a great extent because we didn't have ways of measuring the things that they were most concerned about. I hope that we've made progress enough so that we can do something about that imbalance this time.

MR. WILLIAMS: I am coming to this fairly new, but as I read through the materials, it occurred to me that, as we become more disabled as a people, we need to start out to use this framework to set some goals, but realistic goals, in helping individuals sustain their independence.

DR. GOLDEN: You've been doing a lot of outcome and results with a variety of constituencies and audiences, so again there's work that could be linked there.

DR. BOUFFORD: Thank you very much.

DR. BENSON: Thank you, Jo. I'm new to Healthy People 2000, but fortunately the Administration on Aging is not. In fact, several of our staff have been very, very involved in Healthy People 2000 and are here in the room, Irma Tetzloff and Nancy Wartow and Lois Albarelli. So, on behalf of our agency, I'm just very appreciative of the work that they've done with all the people that have been involved.

I would like to just make a couple comments if I may. The Older Americans Act, which is the principal program that we administer at the Administration on Aging, includes a part-- one of the titles is dedicated to disease prevention and health promotion. I must say that it's been very much at risk as we're going through our reauthorization process. One of the important ways in which Healthy People 2000 has been incorporated into our agency is to try to use Healthy People 2000 as a very important argument as to why we should maintain this particular piece of our legislation, because it's very much at risk, particularly in the House. I think to the extent that our network, as we call the groups that we work with across this country, is integrated into Healthy People 2000 it has helped us to keep a very strong focus on maintaining this very important part of our act. It's small, it's $15 million nationwide, but I think we're very proud to say that our network of 57 State offices on aging, 660 area agencies on aging, and approximately 27,000 local service providers and some 228 tribes that we fund around the country have really used this small pot of money to do some really remarkable things for older people in their communities.

Picking up on Mr. Harrell's comments about violence, first I would like to just commend ACF who, together with AOA, are jointly funding the first ever national incidence study of elder abuse in this country. Unfortunately, the topic of elder abuse doesn't get seen as often as it should in the context of violence. Again, to mention the reauthorization of our legislation, there's a part of our legislation that's dedicated to preventing elder abuse and exploitation, and those provisions which have been around in the Act for a number of years are also very much at risk. So the linkage between Healthy People 2000 and public health and elder abuse and exploitation is a very important one for us to make, if we're able to hold onto that particular small but important part of our legislation.

We have some 12,000 senior centers around the country that are funded in one way or the other through the Older Americans Act. We're pleased to say that they, in the main, recognize the importance not only of public health, but of doing as much as they can to begin thinking about the goals of Healthy People 2000.

The 1995 White House Conference on Aging, which just was concluded 2 years ago--many of the recommendations that came out of the White House Conference on Aging clearly echo and mirror the recommendations and the goals of Healthy People 2000. That was an opportunity to engage at the grassroots level several thousand activists, older people from around the country, so that they can begin to incorporate in their own communities and advocate for the kinds of goals that Healthy People 2000 envisioned and that we can do the same with our network across this country.

Just last May in 1996, the Administration on Aging and ASH held the first Healthy People 2000 Older Adults Progress Review. We're still getting a lot of inquiries from the public, service providers, older people themselves, professionals and universities requesting the briefing book that was produced as a result of that progress review. I think out of that came the recognition that we need to do a lot more to get Healthy People out to the older person directly in communities all over America.

I might mention just two other things that we're working on currently and some thoughts that run to my mind in listening to the distinguished former Assistant Secretaries for Health, and that is, we are about to enter into a memorandum of agreement with the Environmental Protection Agency, along with several aging organizations, the National Council on Aging, as well as the Corporation for National Community Service, and organizations dedicated to involving older people in environmental issues. The intent of this memorandum is to try to mobilize as many older people as possible, particularly volunteers, to address environmental issues. I see now we have a wonderful opportunity to link Healthy People 2000 and its goals with that environmental effort.

And then another initiative I just wanted to mention is that under the Bilateral Commission between Mexico and the United States and the Health Working Group, we've added a fifth core group to that, dealing with aging issues between Mexico and the United States. I think one of the key areas that we should clearly be focusing on is those matters that are related to Healthy People 2000 as we work with the government of Mexico. Folks on both sides of the border need to address a lot of issues that we have in common in facing the problems of an older society.

So I think AOA has enjoyed their work on Healthy People 2000 and I think you can expect it in the future to accelerate more involvement, and so we appreciate this opportunity.

DR. BOUFFORD: Sally.

MS. RICHARDSON: I'm not quite sure which came first the chicken or the egg, but I do think that there's no doubt about the fact that this Administration, the Secretary's emphasis on collaboration and HCFA's being asked and being involved in things like the Public Health Council most certainly gave some impetus to our own understanding that, in this new world of health systems delivery that we are wrestling with in terms of managed care, that you could no longer just be a payer of bills, sitting back and letting the program run as its benefits determined. It caused us--perhaps those two influences--to begin to venture beyond what I think the agency had historically been, and begin to think that perhaps one of the things that we needed to do was to begin to focus on how the services that we paid for were actually impacting our beneficiaries in terms of the outcomes of their health.

It also occurred to us that we were a source of enormous data and that we ought to start using that data to really begin to take a look at where we were providing services that were improving health and where we were providing services that should be improving health, but our customers weren't perhaps taking the best advantage of that, so that we could really begin to inform our customers on, as a matter of fact, things that they could do to use us better and use our programs better so that they could have healthier lives.

As a result of all of this, we've been actively involved. Our Associate Administrator for External Affairs, our Health Standards and Quality Bureau, our Bureau of Program Operations, and most of our regional offices, plus the Medicaid Bureau, because it runs the other side of our house, the Medicaid Program, have really been quite actively involved in the last 3 years in initiatives to begin to use the whole concept of customer information as a tool for our programs to actually provide better service to our beneficiaries, better information to our beneficiaries and help them improve their lives and their health.

Two of those initiatives have been underway in the Medicare Program. One relates to mammography, since breast cancer is the second leading cause of death and most common in women over 65. We began to take a look at the data to see how many of our beneficiaries actually were receiving mammograms, once we had begun paying for them. That was in the early nineties, and we found that, as a matter of fact, less than half of our beneficiaries were using that benefit and, as a matter of fact, that was much more pronounced in African American and other minority beneficiaries than it was in our Caucasian beneficiaries.

So we put together a consumer initiative to go out working with the Public Health Service and a variety of its agencies, with major national organizations. The Secretary was enormously helpful to us in providing the leadership for this initiative, and persuaded the First Lady to join her in that. We initiated in 1995 a nationwide mammography consumer information strategy. Basically, we are just now beginning to get the results in of that. We are still working off anecdotal evidence, but it has been sufficiently successful that we are actually expanding the sites, going out to more regions. We actually will move from the initial work that we did in about four sites around the country to a big six-city project, which is getting underway this year.

We are using a variety of techniques that we have never really used before. We've used customer research; we've used public relations techniques. We have involved State departments of health; we have involved local advocacy organizations. This is a whole new role for the Health Care Financing Administration and we're finding very much that we do enjoy it and that it is having the results that we hoped it would.

So, secondary in Medicare has been our pneumonia and flu vaccine programs, which have also been underway in the last 2 years. We have a goal of the non-institutionalized population having a 60 percent vaccination rate, or immunization rate, by the year 2000 and for the institutionalized population, an 80 percent rate, and we are sharing in that goal. It is one of the goals 2000 that we just bought into and said that we would like to begin tracking our population and making that a goal for the organization.

Again, we have been doing a variety of interventions through our regional offices. We've been working very closely with CDC and the National Coalition for Adult Immunization in this project, and we are very pleased with some of the results and some of the reactions. Again, we are finding when we begin to look at our data, that there's an enormous disparity between what our Caucasian population receives in the Medicare program and what minority populations, primarily African Americans and Hispanics receive.

So we began to put together something that we have called the Horizons Program. We started it in the immunization program. It's expanding now into mammography, as well. It's a collaboration between the historically black colleges and universities and our peer review, provider review, organizations across the country. This Horizons Project is going to be working both in pneumonia, flu and mammography information primarily targeted to minority populations in the eight southeastern States. We again are doing all of the best techniques that we can contract for and hope to have a real impact with this.

In the Medicaid program, we have a whole different situation because of our relationship with the States. This is a federal and State partnership, and so we have moved a little bit more gingerly in terms of the kinds of things that we've undertaken, since during this same period of time our relationships with the States have been improving in the way of partnerships that have been somewhat indeterminate because of the variety of federal Congressional initiatives to block grant or not block grant the Medicaid program. It kind of held us up for a while.

The one thing we did begin was a Maternal AIDS Consumer Information Project based on the National Institutes of Health findings related to AZT, HIV, AZT and the transmission of that in pregnant women to infants. We began that in 1995 and, as a matter of fact, it is now--we began in four States along the east coast--it's now expanded into eight more States. We're finding that there's a real kind of intersect between our program dealing with counseling and testing and then counseling again, or consumer information, HIV testing and then counseling of pregnant women in our program, in our Medicaid program-- there's an intersect between that and the States need to meet their 1998 Ryan White reduction in infant AIDS goals.

The big problem, as Dr. Lee pointed out, is that the States have very little information. We are finding that this maternal AZT initiative is actually beginning to provide the States with some information they need so we have more and more States that want to participate.

Finally, I would say so far as the future goes, Dr. Lee also mentioned that we are the 800-pound gorilla.

MR. THURM: Very friendly, though.

MS. RICHARDSON: I understand that, and I really didn't take it personally. When you get us going, you have to watch out.

[Laughter.]

In this area, we are just really beginning. We have come to the recognition in the Medicaid program, for instance, again thanks to the influence of our increased understanding of our responsibility in the areas of public health, that the oral health of our children and some of our adults is really a factor that we ought to begin considering as we put together our benefit packages and as we do work with the States, particularly if we move into managed care. So with the help of the Public Health Service, we are now identifying an oral health--a dentist who is going to be detailed to HCFA. If he likes it, or she likes it, I don't know which, we may get them to stay.

We're doing the same in mental health. We have never really had benefits expertise in our program, and we are recognizing that we really need to do this.

The dual eligible is a whole other component that we had never really given much thought to, and particularly the area of people with disabilities, not only the adults in our Medicare program, but also disabled children. We have been working very closely with some of the other agencies here in the Department to begin to understand the needs of our individuals with disabilities and to recognize that our programs have to begin to accommodate those needs, which are quite often not clinical needs at all, but actually quality of life needs that our health care provision needs to support.

Of course, managed care is a world into which we are really being led. As a matter of fact, we decided a couple of years ago that, if we were going to go down that road, we needed to provide the leadership. We were going to provide it willy-nilly and we might as well begin to determine our own course and provide leadership for some of the country. I think we have been very active in the world of quality and what it means to be a quality purchaser. The private sector tends to be a cost purchaser. We want to change the marketplace to be a marketplace not only of cost effectiveness, but of purchasing real value which includes the quality of the services provided.

Data is a big issue for us. We are now talking about encounter data with the plans with whom we contract in the Medicaid program through our Medicaid waivers. We are beginning to talk about encounter data in the Medicare certified HMOs. We are probably going to be talking with States about requiring encounter data in the programs they contract with.

I think a final area beyond data is also beneficiary protection. I think, here again--as we provide leadership in quality, leadership in consumer information, not only for using their benefits well, but also for being able to make good choices in managed care, being able to understand what quality is in plans, the whole issue of the data that underlies that--that we will also provide leadership in setting the standards for what beneficiary protection and beneficiary rights ought to be in the world of managed care.

So that's where we think we're going in the future.

DR. BOUFFORD: Thank you. David.

DR. SATCHER: I seriously want to say how much it means to all of us to really have the former Assistant Secretaries here participating in this process. I think we owe you so much in terms of your contributions to the health of people in this country and things that we're trying to build on. Now, on top of that, to have you here to give your perspectives on where we are with Healthy People and where we need to go is special, and I just want to say thank you for that.

It's really hard to overstate the impact that the Healthy People program has had on CDC. I think you know in part that's because we have been responsible for 12 out of the 22 priority areas and we share the leadership for two others. So this program has really had a major impact on the way we do business at CDC.

Phil mentioned the importance of the Guide to Clinical Preventive Services. Recently, we have initiated a process with the task force meeting at CDC, but representing the Department, to develop guidelines for community preventive services, recognizing many of the things you've said about the importance of the community coming together with the government in terms of moving these goals and objectives forward.

From the outset, I guess I would say that the impact of Healthy People on the priorities of CDC I think is quite obvious. We have over the last few years been working with a set of what we call evolving priorities, trying to make the point that they were dynamic and we were continually revisiting them. But I will just share with you those five evolving priorities.

The first one is to strengthen the infrastructure of public health, strengthen the central services of public health. In large part, that has involved our agency in working with State and local health departments and trying to strengthen information systems and very prominent, of course, is the INPHO Project, the Information Network for Public Health Officials, which I think is making quite a difference in terms of the way States are able to respond. I think we saw some of that last year with the e. coli O157:H7 outbreak from apple juice and the rapid response of the State of Washington, which is one of the INPHO States, in terms of being able to identify--within 6 days really--being able to define that epidemic and to get a handle on it.

The other thing that stands out, I think, is the Public Health Training Network that we put into place, and the role of distance learning. The fact that we now, when we have a new set of guidelines in immunization or any other area, can bring together thousands of physicians and nurses at one time to our Distance Learning Network, our satellite downlinks, and provide information and get feedback, get a give and take from people who are on the front line providing these services as to how we can improve these services. The Public Health Training Network I think is a major step forward for all of us.

Then we have our leadership training, recognizing that there are many people who have responsibilities at the federal, State and local level who are not necessarily trained or prepared to provide leadership. So a few years ago, we started the Public Health Leadership Institute, and I think it's making a tremendous difference, again because it brings the best minds together in public health to share ideas, to share challenges with people who are on the front line. So first we started with a national program, and now of course we funded several States and regions for leadership development in public health. But all of those things come under the priority of strengthening the central services of public health.

The second priority at CDC is to enhance our capacity to respond to urgent threats to health. To a great extent, as you can imagine, that has focused on dealing with the emerging infectious diseases. Certainly, that has been the most well-funded component of that effort in terms of really strengthening laboratories throughout the country, at CDC, at the State level, putting together community planning initiatives, like the HIV/AIDS community planning initiative in which we try to identify community groups to become involved in our strategies, enhancing our ability to respond to urgent threats to health.

In addition to infectious diseases, however, we have also been working in the area of injury, unintentional and intentional injury prevention, including violence. I was just looking at the way the Safe America proposal has developed. There is now a concept called Safe America which enhances all of the aspects of the prevention of injuries. It focuses on, as Phil knows, safe at home, safe at work, safe in the community, safe at school and even safe alone, recognizing all of the areas in which people suffer injuries. Of course, safe alone recognizes that clinical depression often leads to suicide or attempted suicide. So all of these areas in which we're working, from domestic violence, to youth violence prevention in the community, to school violence, to violence and other forms of injuries in the workplace, have been subsumed under Safe America as a strategy.

But also under enhancing our propensity to respond to urgent threats to health, we have been involved of course with environmental hazards. You remember that the Superfund Act created the Agency for Toxic Substances and Disease Registry, which is a sister agency to CDC. I serve as Director of both. We also have the National Center for Environmental Health at CDC. So we have become involved, especially with EPA, in terms of looking at environmental hazards from the standpoint of the impact on human health, and how we measure that impact and how do we intervene. The environmental health laboratory at CDC is a major laboratory for monitoring that, along with the NHANES survey.

The third priority at CDC is the development of nationwide prevention strategies to try to really deliver those programs that we know work, like immunizations. Julie mentioned the Childhood Immunization Initiative, which has been a major focus of our efforts at CDC over the last few years, implementing the Vaccines for Children Program, implementing registries to try to track children so that physicians and parents know where they are in terms of their immunization schedules, providing community programs to get schools and churches and communities to work together with physicians in immunizing children, but also research to continue to develop new vaccines, and especially new combinations of vaccines, so that we can achieve our goals and at the same time reduce the number of shots that children have to experience in maintaining their immunization levels. All of these things have been included under the Childhood Immunization Initiative.

As Sally pointed out, we have been quite involved with HCFA in terms of the Adult Immunization Initiative, which is going well in some ways. And yet we still, just as with immunizations in children, we still struggle with the disparities, we still struggle with the gaps. That has to be one of our major topics for the future.

Let me say one of the best pieces of news I think we have when we try to look at the future with a lot of hope is that we have been quite involved with the Global Polio Eradication Program. I think in many ways that program is one of the best examples of partnerships between the public and the private sector. Obviously, the Department has played a leading role working with WHO, in efforts to eradicate polio. Also, Rotary International, as you know, a private group of business leaders, has probably raised over $350 million. But more than that, as I found out when I went to India in December to participate in an Immunization Day, in which we immunized 119 million children, I really came to appreciate--it wasn't as easy as it sounded. Some people have been working on this day for 2 years. I just went there for the day.

[Laughter.]

It was a busy day. But what really stood out was really coming to understand the role that Rotary is playing, the role that they played in getting the government, the legislature to really support this, to get community organizations, schools, involved, and they were out there in the streets during that day. So it's an excellent example of a public/private partnership.

In recent years, even with our breast and cervical cancer screening programs, we have enlisted Avon Products and the YWCA. Everybody knows that Avon knows how to sell to women, and so we've asked them to help us sell the idea of mammography and cervical screening, and they've done a great job of knocking on doors and educating women about the importance of mammography, and it's making a significant difference. It's another example of a public/private partnership.

In addition to immunizations and breast and cervical cancers, there are some other areas that we're trying to develop as nationwide prevention strategies. It takes me to the fourth priority, which is to promote the health of women. That recognizes the neglect of the past in many areas.

I think one of the best examples of that, in addition to all that we know about cardiovascular disease and things like that is what we have learned about chlamydia infections, which is probably the most common infectious disease reported to the CDC every year--four million cases a year. You remember the Institute of Medicine Report. We demonstrated in one of the regions a few years ago that we could, by screening in family planning clinics and other areas, significantly reduce the incidence and prevalence of chlamydia infection in women by more than 50 percent. We've done the same thing working with managed care organizations.

Now what we're trying to do is to get the support to make this a nationwide program. It is not a nationwide program. There are only 20 States that have chlamydia programs in place right now. We're trying to expand that to all 50 States. This is a strategy, a technology which we know works, and the question is--can we put it into place. We still have 100,000 to 150,000 women becoming infertile in this country every year because of undiagnosed and untreated sexually transmitted diseases, of which chlamydia is the most common. So it's an example of a real opportunity.

The last priority relates to something that Julie mentioned in terms of the importance of targeting prevention strategies to children and youth. Not only in tobacco are we aware of the fact that by the time children reach the age of 18--90 percent of people who are going to be smokers are smokers by the time they're 18 years of age, and many, of course, are addicted. So, if we're going to be successful in terms of prevention, it has to be very early.

The Surgeon General's Report, I think, pointed out the same thing is true with physical activity. Certainly, the same thing is true with nutrition. This is probably the most inactive generation of teenagers in our history for many reasons, including the fact that not a single State in this country requires physical education from K through 12, not one. So we haven't put enough emphasis on this. The Surgeon General's Report, of course, showed that, through physical activity alone, we can significantly reduce deaths from cardiovascular diseases. We can even prevent the onset of 30 percent of diabetes, let alone discussing the control of complications of diabetes. So there are a lot of opportunities there.

So in summary, the Healthy People Program has influenced program planning at CDC--even our GPRA Program, Government Performance and Results Act--certainly influenced our nationwide planning strategies. It's influenced our approach to violence and abusive behavior. It's also helped in guiding the national agenda. CDC references Healthy People 2000 objectives in every program announcement, including the Office of Smoking and Health's Impact Program for Smoking Prevention, but also in forming the preventive health and health services block grants. We use the 2000 objectives to track the use of those funds, and the States use the objectives to report on all of their expenditures. So they're an integral part of what we do.

In developing collaborative efforts with EPA, in terms of our environmental activities, EPA has developed something similar to Healthy People, a program it calls Environmental Goals for America. CDC has worked very closely with EPA in working toward those goals, looking at it from the standpoint of human health effects.

Lead based paint--we've made a lot of progress there. We still have some ways to go again with pockets of need, but, again, the Healthy People 2000 Project has guided that.

The Youth Risk Behavior Surveillance System measures 26 of the Healthy People 2000 objectives. As Ed will point out, in all of our surveys, the data sets are in great part related to Healthy People 2000.

DR. BOUFFORD: Okay. Yes, please.

DR. RICHMOND: Can I make one very brief comment? In my effort to be brief, I didn't really say enough about CDC's role in the initiation of the development of health objectives. Once we established the goals, CDC took the initiative in quantifying those goals and objectives, and we never could have done it without CDC's participation. It's to the great credit of CDC that they didn't view it as only an in-house kind of exercise. I can recall very vividly 500 people from all around the country having been assembled to shape those goals.

I mentioned that all too briefly, and I think that the involvement of people from around the country, I think in part, was responsible for the very excellent reception that we had from our ordinarily very critical groups like the professors who were part of the process. So they had a sense of ownership.

I can't help but add the role of the National Center for Health Statistics. I think we're in all of our discussions here taking that for granted, but I always referred to that as our compass, because without that center and its database, we really can't go to sea. It's that directional compass that we have in the form of the national center, now at CDC, that really is so important to us.

DR. SATCHER: Thank you.

Transcript Continues...

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