Transcript of the Healthy People 2010 Regional
Meeting
Sacramento, California
December 9-10, 1998
U. S. Department of Health and Human Services
Office of Disease Prevention and Health Promotion
Session II:
Improving Systems for Personal and Public Health and Preventing and Reducing Diseases and
Disorders
DR. GRANADOS: I am Al Granados, and this session is Chapters 14 through 26, and we will be hearing comments on the chapters. To help assure a fair opportunity for everyone to participate in today's hearing, we will be using the same procedures as were identified in the other room, but just to go over them for you, first, each oral statement will be limited to 3 minutes so that we can hear from the best number of participants or the greatest number of participants.
The light will turn yellow when 1 minute remains and red when your time is ended. Second, each individual and organization will be limited to one oral statement for each focus area.
During the plenary session -- hold on, I have got the wrong page. Remember to give your name and where you are from. I would, also, like to ask you when you come up to the microphone to take your turn, and we will get right to you, and this session should go, I think, fairly quickly, and I would like to introduce the members of our panel and starting with No. 14, Public Health Infrastructure, Pom Sinnock, and he will, also, handle health communications. Pom is from CDC.
Chapter 16 would be arthritis and osteoporosis and chronic back conditions. We have a substitution here. We have Amy Holmes from CDC.
Chapter 17, Cancer, we have Martina Vogel Taylor who is, also, a coordinator, and she is from NIH. She is Steering Team Coordinator.
Chapter 18, Diabetes, we have Amy. Is that correct and Disability and Secondary Conditions, Chapter 19, Larry Burt from CDC. I am trying to look at this, and I apologize. There is a lot of write ins here, and I am losing track.
No. 20, Heart Disease and Stroke, Martina Vogel Taylor, HIV from CDC, Carmen Villar, 22, Immunization and Infectious Diseases, CDC, Theresa Rogers and 23, Ron Roma(?) NIH. He is a little gun shy on that one. On 24, Respiratory Diseases Martina Vogel Taylor, NIH and 25, Sexually Transmitted Diseases who is that. Okay, that is you again, Carmen, and 26, Substance Abuse, Dorita Sewell from SAMHSA.
Let us begin.
Yes?
PARTICIPANT: Just to make it as simple as possible, what we are going to do is have people queue up here, if you want to make a comment, up this aisle and then return that aisle, just so we have more efficiency. If anyone needs a hand-held microphone, we will be happy to provide it.
PARTICIPANT: Is this by chapter?
DR. GRANADOS: Yes, by chapter. Chapter 14 would be the first one.
PARTICIPANT: And you will sign in Irene Randell at the end of the table. Thank you.
DR. GRANADOS: Chapter 14, Public Health Infrastructure?
Okay, Chapter 15. Oh, there is somebody.
PARTICIPANT: I was hoping to get out early. I am substance abuse. Is there any chance that we could do this --
DR. GRANADOS: No, we are going to take them one at a time.
Chapter 14?
MR. RUBIN: I understand my time is 1 minute?
DR. GRANADOS: You have 3 minutes, and your name and location.
MR. RUBIN: My name is Jeffrey Rubin. I am the Chief of Disaster Medical Services for the State of California, Emergency Medical Services Authority here in Sacramento.
As I mentioned in my statement this morning, emergency health services is a critical function, a core function of public health in the United States.
As such, we think it is important as we look at Chapter 14 that leading health indicators be developed for a skilled work force for effective public health organization and for resources to deal with the issue of disaster medical and emergency public health services.
Planning and preparedness must be done throughout the county's response to emergencies, be they medical, public health, environmental health. This planning and preparedness as far as trained personnel has in its form and function the development of planning committees, interaction and integration of various disciplines to bring together the most effective public and emergency medical response to a disaster.
We believe that the issue of emergency health services must be made important as it is here in California throughout our local health systems in preparing the community and preparing the government organizations that will be necessary to be integrated, trained and prepared to respond in a disaster.
Thank you.
DR. GRANADOS: Thank you.
MR. SOULELES: My name is David Souleles, and I am with the city of Long Beach Department of Health and Human Services, representing the Department this morning. We were pleased to see public health infrastructure included as an objective area in the Healthy People 2010 draft.
We have a couple of comments, however. One is specifically related to Objective 11, I believe, the health improvement plan objective and our concern there really is not that doing health improvement planning isn't a good thing but that we all at the local level and state levels are doing a variety of different types of categorical plans, whether it is for HIV prevention or HIV care or MCH programs or immunization or on and on and on, and what we find ourselves doing, particularly in smaller communities is planning ourselves to death, and there needs to be some effort at, I think, linking, coordinating all of these categorical efforts into this type of overall health improvement plan for a community.
The other point we wanted to make this morning was related to the Objective 16 spoke to partnerships in prevention research, and we see that as, also, a valuable instrument for local public health in identifying new opportunities for behavior change. However, we think that other partnerships need to be encouraged as well and an objective that speaks to different types of partnerships that helps us build constituencies in public health and advocates in public health to better do our programs and to better advocate on behalf of public health is important, and finally something on marketing of public health.
We only hear about public health often when things go wrong. You know it is the Harris Poll, I think it was in 1997, indicated most people don't know what public health is, and it would be nice to see an objective included in here that spoke specifically to marketing the role of public health in the community.
Thank you.
DR. GRANADOS: Thank you.
This is public health infrastructure?
MS. KLAYMAN: Yes. Thank you. Good morning. My name is Karen Klayman. I am the Director of Nurses for Nevada County Public Health. I am actually representing myself.
In Chapter 14 you do talk about a skilled work force, and I would specifically like Healthy People 2000 to look at actually looking at the number of public health nurses per the community numbers.
Often we are expected to do work, and there aren't very many of us out there, and as the school nurse representative spoke this morning if you are looking at the number of school nurses versus children in schools we would like you to look at the number of public health nurses in each community.
Thank you.
DR. GRANADOS: Thank you. Would you come over here and sign in?
Thank you.
Are there any other comments for focus area 14?
If not, we will move on to focus area 15, Health Communications.
Any comments for focus area 15?
If not, we will move on to focus area 16, Arthritis, Osteoporosis and Chronic Back Conditions.
MS. NYE: I think I can handle it. My name is Suzanna Nye. I am a registered dietitian. I think I am talking to you, Amy, and I am a member of the California and American Dietetic Association, and my one love in life is bone health, and what I would like to really encourage is I think that as professionals we understand that bone health is a mystery to the general population, in that a lot of people think that bones are dead and that they are non-living tissue. They do not understand the concept that like any other tissue they require daily nourishment and, also, physical activities and stress on them to remain healthy.
I, personally, would empower and encourage you and, also, all of us as professionals to really support a womb-to-tomb type of approach to bone health and quite frequently the emphasis on bone health is for the elderly, and you think of hip fractures and displacement of seniors and their quality of life and unbeknownst to the general population, you know, the quality of life is throughout their lifetime.
So, the two areas that I would encourage, womb-to-tomb type of specific focus are on daily physical activities, more to CDC's recommendations of accumulative, I think it is 30 minutes a day at least which of course our nation is failing and, also, to have a calcium-rich diet on a daily basis. In fact, some of the groups that I have been participating in were encouraging a calcium-rich food source at each meal, and I have heard in other sessions that there is concern about calcium in the form of dairy products, and I have talked to several specialists, endocrinologists at Stanford, and it is really a misnomer that calcium consumption and lactose intolerance, and in small amounts over a day many people who are lactose intolerant can consume those and that speaks to the needs of our special populations because calcium in the form of dairy products is the most bioavailable, but there are other sources of calcium-rich dietary products.
So, calcium in the food form at every meal and also physical activity on a daily basis.
Thank you.
DR. GRANADOS: Thank you.
Next?
MS. LEONG: Good morning. My name is Amye Leong from San Pedro, California. To you I may be just a petite Asian American woman who took the time here to fly in to present at this hearing, but please I ask you to look a little closer. I am one of 43 million Americans living with arthritis and from one of the largest minority groups in the United States, not cultural, not ethnic but a person with a disability.
I am Chairman of the California Arthritis Foundation Council representing over 4 million Californians with arthritis, a health motivation speaker and an organizational consultant, a research adviser on a NIDA-funded study on aging with a disability and a volunteer and spokesperson for the Arthritis Foundation.
I am basically here for two reasons, one, to strongly support the inclusion of the arthritis objectives in the arthritis chapter, Chapter 16 and two, to strongly support the retention of Chapter 19 on Disabilities and Secondary Conditions.
In the past arthritis has not been a part of the Healthy People framework. Arthritis has, also, been associated with several myths, that it is an older person's disease, that there is nothing that can be done about it, that it is minor aches and pains, but in fact, this is very, very far from the truth.
Arthritis is the nation's leading cause of disability. It affects 43 million individuals, people of all ages, ethnic and racial groups. I was diagnosed with rheumatoid arthritis at age 18 and fight daily with the painful ravages of this disease as I age.
While arthritis affects 50 percent of the elderly population, the majority of the people affected by arthritis are like me, young adults and baby boomers under age 65 trying to lead a productive life.
Arthritis exerts a tremendous personal and societal cost. Arthritis related medical care, lost productivity amount to $65 billion, that is "b" annually, equivalent to a moderate recession every year.
CDC projects that in the year 2020 nearly 20 percent of the population will be affected. That is nearly 60 million Americans. While many believe that nothing can be done about arthritis, in fact, many prevention strategies and treatment strategies are available, but the problem is that intervention are under utilized.
If a person aging with arthritis has access to the appropriate interventions much excess or secondary disabilities along with its societal and personal costs can be prevented.
So, I salute the authors of Chapters 16 and 19 for including objectives that address functional needs, risk factors, evidence-based health promotion and disease prevention education and strategies to minimize the effects of aging with a disability like arthritis.
Growing old with arthritis, indeed, with a disability should not be an early death sentence in this country. Therefore, it is paramount that both Chapters 16 and 19 remain prominent in this document.
My future depends on it.
Thank you.
DR. GRANADOS: Thank you.
Are there any other comments?
All right, we will move on to the next focus area, cancer. Any comments on focus area 17, Cancer?
If not we will move on to the next focus area 18, Diabetes.
MS. YAMASHITA: Hi, my name is Brenda Yamashita. I am with the Diabetes Control Program with the State of California, and we just want to express our appreciation for being included in the Healthy People 2010, and we are working to do what we can to help with that.
We do have some comments regarding content and certain ways things are phrased, but they would probably be suited in writing. So, I will leave it to that.
Thank you.
DR. GRANADOS: Thank you.
DR. ARSHAM: I am Gary Arsham from San Francisco. I am here as a representative of the Diabetes Coalition of California. The Diabetes Coalition of California has no specific comment. However, I am, also, president of the American Diabetes Association, Western Region. I am a national officer of the American Association of Diabetes Educators. The AADE does have several comments which will be submitted in writing. However, I would like to offer AADE's general support and highlight one main concern that we have about Goal 23 which is to increase to 52 percent the proportion of persons with diabetes who have received formal education. AADE believes that this goal implies a one-time formal educational program.
Given what we know about learning, about the nature of chronic disease, about self-management and behavior to change skills and strategies and the many recent changes in diabetes self-management, skills and treatment we don't believe that a one-time injection of diabetes education will immunize the person with diabetes for life.
We would suggest that additional boosters are needed, that the vaccine may need to be modified from year to year and that in place of the goal as stated we would suggest might add the phrase, "In the most recent or in the last 5 years" to the end of the goal.
We, also, have some concerns about the validity and reliability of the baseline data which will be submitted in writing. Finally, AADE, the American Association of Diabetes Educators which represents over 11,000 diabetes educators would like to offer our support to help evaluate this goal and commit to promoting this goal as a priority for AADE.
Once the chapter and goals are final, we will share these with our membership and challenge diabetes educators nationwide to promote these for people with diabetes whom we serve. We are a diverse and large group who can promote nationwide efforts like this because it is not just the job of public health, and finally, I would like to say, and I believe I can say on behalf of all three organizations that I am here involved with the Diabetes Coalition of California, the American Diabetes Association, Western Region and the American Association of Diabetes Educators as well as personally as a physician who had type 1 diabetes for 45 years that we are just delighted and pleased that the Healthy People 2010 has a chapter on diabetes.
Thank you.
DR. GRANADOS: Thank you.
DR. JENSEN: Good morning. My name is Ronald Jensen. I am a podiatrist from Modesto, California, and I represent the American Podiatric Medical Association.
There has been information that has already been provided to the Committee regarding some of our feelings related to the objectives and I stand today to support some of those objectives.
On Objective 9 which deals with the reduction of ulcerations to diabetics and Objective No. 10 which deals with reduction of amputations, we feel that this is certainly something that everybody agrees on and no further discussion is necessary, and we simply support those very strongly.
We do, however, feel very strongly about Sections 20 and 23 and would like to re-emphasize or strong support of both of these.
In Section 23, as you just heard from the previous speaker it relates to diabetes education. We feel that the reduction of ulcerations and amputations hinges on public education.
As stated in the document, the time that the diabetics spend with their doctors is severely limited in terms of their life span and therefore through education, hopefully, we can meet the goals of 9 and 10.
As it specifically relates to Section 20, I would like to address my comments to this section. This deals with the concept of a yearly foot exam. As discussed within the document the phrase is used that a foot exam should occur at least once a year. We absolutely support this and would like to see this go even further and have what constitutes a foot exam be further defined. That information has been provided to the Committee already, but just to re-emphasize, we feel that it should involve a physical vascular exam, a neurological exam, and we would encourage the use of the LEAP(?) program monofilament for diagnosis of a neuropathy. Certainly the visual inspection is part of it. We would, also, like to see some tracking of whether those conditions when significant findings are discovered are either treated by the attending physician or referred for appropriate care.
The last phrase of the document states that this should be tracked. As we are all aware when something is finally tracked and given attention it finally gives it the emphasis that is necessary for it to occur, and we feel very strongly about Section 20 and would like to see that moved forward.
Thanks very much.
DR. GRANADOS: Thank you.
Are there any other comments for diabetes?
If not, we will move on to the next focus area which will be disability and secondary conditions, focus area 19.
MR. BOZARTH: My name is Elvis Bozarth. I live in Santa Rosa. I am here representing the FATE(?) Association for retarded citizens around issues concerning people with developmental disabilities and aging.
Most of the people of my acquaintance who have disabilities have secondary conditions due to causes that we can deal with and I think help to overcome. We have had an initiative nationally for many years for aging people to age in place and in developmental disabilities to have supported living and independent living. Those are positives. There is a down side to that in that people who are living alone or with just couples in isolated areas they do not visit their doctor often enough. They do not get the immunizations that they need. They have no coordination of their medications. They do not have an adequate diet, lack of weight control, engage in substance abuse because of their loneliness and depression.
I think that there needs to be more focus on some of those prevention efforts, and I thank you.
DR. GRANADOS: Thank you.
Would you please sign over here, sir?
MS. STRONG: Hi, I am Patricia Strong. I am here today under the auspices of the California Office of Women's Health on whose Women's Health Council I serve. I am, also, a consultant on aging with disability issues and an adviser on the team of research advisers to the 5-year NIDA-funded study on aging with disability.
Perhaps most importantly I come as a member of the largest minority in the United States, one that has never been tracked before by the Healthy People Project, and that is persons with disabilities.
I am very encouraged that there is a Chapter 19 and advocate for its inclusion. We with disabilities are a growing population despite the fact that those aging into disability, folks usually 65 and up have a lowering incidence these days, but those of us who are aging with long-term, chronic disability are a growing group and are for the first time in history actually living long enough to age and to develop secondary conditions.
We are pioneers. Like pioneers we are discovering both good news and bad news. The good news is we are old enough to age. The bad news is we have secondary conditions that are now complicating our lives, reducing our function, giving us more disability days, more pain, more fatigue, more depression, less quality of life.
The good news, however, is that there are interventions, and these are not always medical although some of them are surgical and drug related but others are non-medical. They include things like fully accessible architecture, adaptive equipment and personal assistant services. It does not have to necessarily follow that a high impairment level equals a high disability level so long as these interventions are indeed accessible and are given timely. However, there is more bad news and that is that these interventions, whether medical or non-medical are not equally accessible.
Those of us who are women and ethnic minorities and people in poverty, precisely those very subgroups which are more at risk for both disability and its complicating secondary conditions have grave barriers to access. Furthermore those of us who are aging with long-term chronic disability, those of us who are for the first time in history able to age are now in midlife, and because in this country our policies have been age based toward services and interventions, those interventions are often inaccessible to us, and so, we need to shift from age-based policies to more function-based policies for services and interventions for secondary conditions.
Thank you.
DR. GRANADOS: Thank you.
Are there any others, Chapter 19?
Then we will move on to Chapter 20, Heart Disease and Stroke. Are there any comments for heart disease and stroke?
Okay, we will move on to HIV, Chapter 21. Are there any comments for Chapter 21, HIV?
MR. SOULELES: I have to earn my air fare from Southern California.
(Laughter.)
MR. SOULELES: Again, my name is David Souleles, representing the city of Long Beach, Department of Health and Human Services, and I have a couple of general comments about the section on HIV and then a few specific ones.
Generally speaking we were concerned in the city that there appear to be very few objectives that look at specifically targeting populations, and it was alluded to earlier in the general section about a lack of anything really addressing men who have sex with men and particularly men of color as it relates to HIV, and in light of in particular the activities that are taking place throughout the country around HIV prevention planning where state and local health departments and local planning groups are being asked to identify very specific targeted populations and interventions it seems like we should have something that reflects that in Healthy People 2010, that gives local communities something to measure against when they are designing their interventions and setting their priorities.
The other thing is there has been so much work done at the community level, both in HIV care, planning and HIV prevention planning that there ought to be a way to link the good work that has been done in all of these communities setting priorities and identifying target populations and interventions into this document here so that all of that work that is done by all of the public health partners throughout the country can somehow be reflected into this document, the priorities that have been established by different states, etc. It just seems like there ought to be a way to link those together a little bit better.
In relation to Objectives 1A, 1B and 2 that speak to looking at AIDS incidence and, also, HIV incidence and prevalence I think that it is no secret to anyone that the AIDS incidence data is no longer a particularly useful tool in looking at the leading edge of this epidemic and understanding where this epidemic is going, in that we really do need to focus more effort on looking at HIV measures and focus on ways that we can get more comparable data from each state in this country so that we can do a better job of projecting where HIV is going.
In terms of the objective on condom use that talks about sexually active unmarried people one only has to look to the White House these days to know that not only unmarried folks are the folks that are sexually active and there might be a better way to phrase that objective that talks about people who have perhaps more than one sexual partner as opposed to making it exclusive of a marriage relationship, and finally the objective on classroom education seems to focus on quantity of education as opposed to the quality of the education that is delivered and perhaps setting some specific content standards that should be included because that is really where the battles are at the local level is getting into the schools with appropriate content, appropriate behavior change and educational messages.
Thanks very much.
DR. GRANADOS: Thank you.
MR. BAU: Ignatius Bau from the Asian and Pacific Islander American Health Forum. I, also, want to talk about objectives that really need to target where the risk for HIV is and in many ways these objectives do not address those primary risk factors.
As I said earlier in the general session, no mention of men who have sex with men; there are objectives around condom use for heterosexual adults but no mention of condom use among men who have sex with men, one of the proven ways of prevention, the premise of many, many prevention programs.
The other issue which you don't need to hear more about, needle exchange and the availability of sterile needs for injection drug users, again, scientifically proven as a prevention method needs to be at least addressed despite the politics around that issue, and finally, similar to the last comment when we talk about youth and school-based programs, the availability of condoms with a discussion of condom use also, needs to, again, something that the science, the prevention science has proven to be effective, but if it is not addressed in the objectives, then we will continue talking to our young people about HIV but not giving them the method to prevent infection.
Thank you.
DR. GRANADOS: Thank you.
Please sign?
Any other comments on HIV?
If not, we will move on to focus area 22, Immunization and Infectious Diseases.
MS. MOES: Good morning. My name is Pamela Moes. I am the Coordinator for the California Coalition for Childhood Immunization, and we are a statewide organization comprised of public and private partners, nearly 200 in the state, and we are, also, joined by nearly 47 local and regional coalitions for childhood immunization in California.
My comments this morning with regard to objective for Section 22 about ensuring that all 50 states achieve immunization coverage of at least 90 percent was for the various antigens that are listed there, and my first concern would be in conjunction with comments that were made yesterday at the ethnic disparities breakout session, and that the way that statistics are collected, data are collected in the states often varies or isn't the same means as with the Federal Government, and while the national statistics indicate that we are at 90 percent levels many of our states don't indicate that in their data collection.
My next concern is that in order to achieve a goal of this nature that the seeds that were planted a few years ago in a number of our local coalitions and regional and the statewide coalition in the way of programs and activities, they are really starting to come to fruition now, and we are seeing the impact and effect that they are having in the community.
The education and outreach is developing to an extent that it is making this goal achievable. However we are not there yet, and in light of 38 percent budget cuts to the states from the Centers for Disease Control I am concerned at how achievable this goal will be in our states if budget cuts continue toward immunization efforts, that we won't be able to continue the programs that we have in effect now. In fact, many public health departments and other agencies have lost, I have lost half of my staff already to budget cuts and I am just concerned how achievable this goal will be in ensuring that our children are protected from vaccine preventable diseases, disability and death if we are not funded to continue our efforts and increase those efforts.
Thank you.
DR. GRANADOS: Thank you.
Next, please?
MS. DE BRUYCKER: Yes, I am Noreen DeBruycker. I am the Director of the Shots for Tots Regional Coalition. We are a seven-county coalition who are advocating for 90 percent immunization rates for infants and toddlers.
Although we are involved in many different activities, the issue that we wanted to address today was Objective 32 which relates to immunization registries, and there is a big blank there in terms of a target, and our recommendation is that 100 percent of immunized children would be our target goal.
Immunization registries are useless unless they are populated with all of the children who are adequately immunized, and this is, I think, a concern to us, the fact that within public health we have increased coverage levels and participation in immunization registries, but private providers are overwhelmingly underassessed in their immunization practices and are not on board in terms of participating in immunization registries.
With over 75 percent of the children that are immunized in the private sector it doesn't make sense for us not to be strongly marketing to private physicians.
Why aren't they participating and overwhelmingly we hear it is time and money issues that have been voices as reasons why private providers are not getting on board. Many private physicians' offices, particularly small groups or single offices are not computerized. The computers are outdated. They don't have access to modems.
On average the software that is required to participate cannot be integrated with their existing billing which means that they have to do additional input of data.
So, to ensure that our physicians get on board will require mandated participation or financial incentives for participation, and states and communities and non-profit organizations that have implemented registries are struggling to get a critical mass of private providers to participate and to move beyond the public sector will require funding for sustaining a core registry until it is sufficiently populated to have a market value and an intensive public relations campaign to convince private providers that registry is a worthwhile endeavor, and who will assume these costs? If this is a public health agenda, then it must be funded from the federal level.
If we expect the private health industry to participate, the US Department of Health and Human Services must provide the leadership and incentive to help immunization registries become a list of the important infrastructure needs and one of the tools that is important to achieving a 90 percent immunization rate and ensure that the health industry will support them.
Thank you.
DR. GRANADOS: Thank you.
MS. FOLKERS: Good morning. I am Lena Folkers with the Division of Communicable Diseases for the State of California, and I have got about 20 pages on several of the objectives. So, maybe I will just hand them over?
DR. GRANADOS: Yes.
MS. FOLKERS: And it talks of recommendations of the group.
DR. GRANADOS: Thank you, and you will need to sign this. Thank you.
Are there any other comments for immunizations and infectious diseases?
If not, we will move to focus area 23, Mental Health and Mental Disorders.
DR. DELGADO: My name is Dr. Jane Delgado. I am president and chief executive officer of the National Coalition of Hispanic Health and Human Services Organizations in Washington, DC.
Also, for the past 8 years I have been one of eight advisers to Mrs. Rosalyn Carter on mental health, and I am a clinical psychologist in private practice.
I am here providing verbal comments on mental health on behalf of our 1400 member agencies. We have extensive written comments, maybe a local phone book, not an LA-size phone book like Healthy People 2010.
In general our comments on mental health, I am going to be very specific, we are concerned with Objective 2 that there needs to be a target for Hispanic girls. According to CDC's youth risk behavior survey, Hispanic girls have the highest rates of attempted suicide. There is nothing for them there.
Objective 3, there needs to be a target for each race ethnic group by gender. We are concerned when it comes to major depression. We know there is a problem for Hispanic women, and there is nothing that is specific to us.
The issue on Objective 4, in this country we have a crisis with depression among children and adolescents and there is no specific subobjective on depression. Going on, Objective 9 needs to say that we need to increase to 50 the number of states that can demonstrate linguistic and cultural competence within their mental health delivery system.
We are concerned that the objective reads that states need to have a plan in some states. To have fewer than 50 states that are now providing services, that are linguistically and culturally appropriate is not only unacceptable but as a clinician I can tell you it is malpractice, and to have a document that promotes not having the kind of linguistic services that are required where in mental health language it is not only part of the treatment, it is needed for diagnosis is appalling.
The other thing we are concerned about when it comes to the elderly, again, the document is at best meek when it says that states need to have a plan that can address in some states the mental health needs of the elderly. That is unacceptable.
We need to make sure to increase to 100 percent the number of states that can demonstrate crisis and ongoing mental health services for the elderly, and it is an atrocious situation when in this country mental health services for the elderly, all elderly is still something we have to plan about. It is not like we are not all getting there. I hope we all do.
Thank you.
We have many written comments, and I am sure that you have heard from my staff and many of our members throughout this process, and you will continue to.
We, also, by the way presented in 1990, 2000 and 2010, and if not me someone else will be around for 2020.
(Laughter.)
DR. GRANADOS: Thank you.
Please sign in?
MR. CLARK: My name is Donald Clark. I am the Executive Assistant with the Sacramento Black Alcoholism Center. We are a 25-year-old CDO here in the State of California, and we are rapidly evolving into a state CDO.
I am, also, a mental health consumer. I have been one for the last 30 years and a formerly homeless person, and when you integrate the two concepts of homelessness and mental illness you get an atomic bomb that explodes. It is highly costly in this society. It is a problem that has never been properly dealt with because of inadequate planning at all levels of public government bodies.
Primarily I have a personal opinion because I lived the experience but in a free democratic society personal experiences may lead to good legislation sometimes.
More specifically I am talking about with emphasis that consumer involvement is dreadfully lacking, particularly the consumer involvement of those from the lowest class sector of our society.
The prevalent consumer movement in this society is oversaturated with those who are middle class and don't necessarily know what it really is to be gutter-butt poor and really don't know what it is to be homeless, particularly homeless on a chronic scale, where the continuum of suffering is there for years and years and years.
Let us just look at the modern trend of homelessness in America. It is about 16 years old. The first federal legislation I believe was in 1983, the Emergency Jobs Bill, Public Law 98-8, and now we are getting ready to go into another millennia, and we can race up and down the galaxy almost but we cannot solve basic human problems.
I think we can if proper focus is there, and I don't think that focus can ever get there until you have people who really exemplify consumer involvement at that level of class and peer affinity.
I am looking here at comorbidity which is a very compound problem in the homeless mass, more simply stated as dual diagnosis or as MICAS(?) and the fact that the institutional approach to this problem is way off center, and it costs us a lot of money again, wasteful public expenditure, no good for society going into the 21st century.
In terms of the education of future professionals, clinicians who are already in practice this separation between substance abuse or addictive disorders and more commonly known psychiatric disorders, that needs to cease. The curricula and the trainings need to be merged and integrated.
Where is the integration of services? Why can't it be? Why can't Healthy People 2010 go forward with the proclamation that SAMHSA, the federal Substance Abuse and Mental Health Services Administration which is operating right now without a congressional authorization, I might mention, there is no mandate for it anymore. It ran out a year ago, maybe a year and one-half ago, but it is going to be reauthorized. There is going to be a new mandate one day for this.
Why can't it add a new mandate under the banner of this that mental health and substance abuse training, all that curriculum that leads to that work in tandem be locked together? Personally I think mental health and substance abuse all need to be joined together. I don't see any difference in it. I really don't.
DR. GRANADOS: Thank you, sir, your time is up.
MR. CLARK: Thank you.
DR. GRANADOS: Thank you.
Are there any other comments?
Then we will move on to the next issue, Chapter 24, Respiratory Diseases.
MR. FORDE: My name is James Forde. I am the Executive Director of California Black Health Network, a coalition of five community-based organizations in Sacramento, Los Angeles, the Bay Area, San Diego and the Inland Empire. I am here to very briefly discuss what we feel is an omission in the objectives, and we want to draw the attention of the panel to sarcoidosis which is a lung disease that impacts disproportionately on African Americans.
Any information about that disease that is obtained from the Internet is conflicting in incidence data. It is inconclusive and varies from 8 per 100,000 to 60 per 100,000.
It is a diagnosis that is frequently missed by physicians and persons presenting symptoms are very often treated for something other than the disease until that particular diagnosis is discovered.
It is apparent that additional education on the part of the medical community and the general public is needed in terms of this particular disease which is and can be a very disabling and death-invoking disease, and part of the problem is that the data on incidence is not available, but I can say one thing in my own circle of family and friends I know five people who have sarcoidosis.
Two of them were misdiagnosed by physicians, and the only other disease that I know that has that kind of incidence among my circle of family and friends is the common cold.
So, I urge the panel to take a look at sarcoidosis and its impact on the African American and the general population because if you let another 10 years go by you are going to be missing a very significant disease entity.
Thank you.
DR. GRANADOS: Thank you.
Are there any other comments?
All right, we will move to Chapter 25, Sexually Transmitted Diseases.
Are there any other comments?
We will move to 26, Substance Abuse.
MS. CRAIG: Good morning. My name is Bev Craig. I am Deputy Director of Community Health Services for Yuba County. Yuba County is a small rural county located about 45 minutes north of Sacramento, and while we are a rural county, we have all of the problems of a rural county as well as many other problems of the urban cities.
I would like to address specifically two issues today and encourage that those issues, also, be addressed by the panel.
The first is in the area of collaboration. I firmly believe in collaboration at all areas, but I think that the Feds should, also, collaborate especially when it comes to other federal agencies.
We have a 14 percent unemployment rate in Yuba County and while unemployment is traditionally not a public health issue I would encourage that public health collaborate with the Department of Labor and bring those collaborations down to local levels. The same is true with education. Our educational rates in our county, less than 50 percent of mothers graduate from high school. So, again, that same kind of collaboration should be between public health and the departments of education, and those are indicators that, also, affect the substance abuse problems that we have within our county.
I cannot give you specific statistics on how many substance abusers we have because of the nature of the problem. Not many substance abusers are going to come forth and say, "I am a substance abuser," but I can tell you that we have only 43 people receiving treatment out of a county of 63,000 population. So, the fact that we don't have statistics to prove that we have substance abuse, please do not diminish or place that substance abuse at No. 26 in your whole list of priorities. I feel very strongly that that needs to be moved up and to be addressed as part of your Nos. 1-10, maybe.
Also, I would say that the issue of tox positive babies should be made a very strong issue. That is, also, another result of substance abuse, and the fact that alcohol, cocaine, heroin and marijuana are listed as statistical facts within the big dark yellow document, methamphetamines are, also, a very big issue, and we don't have statistics on those, as well.
So, I would just encourage this panel to not dismiss substance abuse because it is a big issue that affects any number of other public health issues.
Thank you.
DR. GRANADOS: Thank you.
MS. CHUN: Good morning. My name is Catherine and I represent National Asian Pacific American Families against Substance Abuse, and we are like a national organization with 300 members across the US, and what I want to say is that the issue of substance abuse seldom gets addressed for our population when we talk about the overall picture of health needs, and I think it is time to break the silence and the shame and to really prepare ourselves for the 21st century.
As you know this population is very diverse and growing rapidly right now, and the needs and problems are very diverse, and we don't really have an adequate data collection system to really address what are the needs for the specific populations out there, and the problems are being ignored, minimized or politicized right now, and besides funding and resources for training and technical assistance I think that a really important effort should be focused on infrastructure building system effort to outreach and educate and promote early prevention and really decrease the stigma right now, the negative perceptions of racism and discrimination associated with people suffering from addiction or mental illnesses, especially for our population, and we need to integrate and coordinate services especially for dual diagnosed, people who are suffering from both substance abuse and mental health because there is a lot of institutional racism right now and you know making it very difficult to access service, very bureaucratic right now.
So, even though you don't see us in the system that doesn't mean that we don't have the problem. I mean the bilingual and bicultural services are grossly inadequate right now, and also, the rural population, right now there are lots of Asians in different rural areas and their health needs and their access to mental health and substance abuse services are not being addressed, and we need to so coordinate, collaborate so that they can access services, and, also, more family type of services, intergenerational kind of funding and inclusion of alternative health and medicine in the intervention would be nice for our population.
I guess the take-home message for me is that it is nice to be included, but I think the action steps and follow through planning implementation is usually not there, that we really need to work together to make it work.
Thank you.
DR. GRANADOS: Thank you.
Could you come over here and sign, please?
Thank you.
Are there any other comments?
Yes, go ahead?
MS. GAZAK: My name is Christine Gazak. I am representing the Women's Information Network at the University of Utah in Salt Lake City, Utah. Our main concern there is the inclusion of prescription abuse into the section on substance abuse.
We have a primarily frontier area that we serve with a fair number of elderly whose prescriptions aren't being monitored, women who are suffering from loneliness, depression, detachment from families and we just want to make sure that that part of substance abuse is, also, recognized, and that innovative community ways are developed to address that abuse that take into account maybe community stigmas against such prescription abuse.
DR. GRANADOS: Could you come over and sign?
Thank you.
Yes?
MS. GORRE: Good morning. My name is Celina Gorre, and I represent the American College Health Association's Task Force on Healthy People 2010, and I just want to --
DR. GRANADOS: You are from?
MS. GORRE: From Los Angeles, I am sorry. I just wanted to make sure that we look at the college population as a particular subgroup for the binge drinking category. It is not specified and we do want to recognize that this is a specific population in which binge drinking occurs on a weekly basis for various reasons, and I just wanted to make sure that the Committee addresses that.
Thank you.
DR. GRANADOS: Thank you.
Could you come over here and sign?
Thank you.
Are there any other comments?
All right. I would like to open it up for any other comments. If you didn't have an opportunity to comment on Chapter 1 through 13 that was taking place in the other room you are welcome to do so.
DR. DELGADO: I, too, have to make my plane fare pay for itself. Jane Delgado, COSSMHO National Coalition of Hispanic Health and Human Service Organizations.
A major concern in Healthy People 2010, we are very happy about the chapter on environmental health. We are appalled at the way that the targets are developed.
We have very strong comments on that, and it is a section where most of the data elements said, "Developed by the environmental work group," and they are inadequate.
Instead of having things which are reduced to, it says, "Reduce by some percent," and most of those targets may be a reduction in number but in terms of the lives of people will have no effect.
We are, also, concerned about just a general lack of ambitious goals throughout 1 through 12. For some sections people are very ambitious, in the primary care section, but in others we find that in the quest to be achievable we do nothing, and I find that appalling in terms of how science is progressing and I think that more people have to be forceful with HHS and require that the Department put out goals and not things that they know they can meet.
Thank you.
DR. GRANADOS: Thank you.
Could you sign, please?
Thank you.
MS. STRONG: My name is Patricia Strong. I am from Los Angeles. I am now representing myself. As I spoke earlier on disability and secondary conditions I would like to strongly encourage the inclusion of the special needs of the select population in all of the objectives.
I would like to speak right now to the objective regarding clinical practice and training and that is that people with disabilities need curriculum included in medical schools, more substantial training for young doctors. We need access to primary care physicians who have the basic understanding that chronic disability is a dynamic not a static condition and therefore as gatekeepers they refer us to rehabilitation specialists in a timely manner.
We need those rehabilitation specialists who, also, understand that re-rehabilitation is necessary on an ongoing basis because of our secondary conditions so that we need on an ongoing basis new, improved durable medical equipment for mobility, self-care such as dressing, toileting and respiration.
We need appropriate assistive technology. We need physical therapy. We need occupational therapy. We need training and hiring of personal assistant services. We need access that is architectural and communication free to medical facilities. We need access to critical care and emergency department personnel who are informed about life-threatening situations for the special needs of people with disabilities, many of whom themselves do not know that they are at risk.
We need access to long-term care whether residential or at home. We need improved health promotion and disease prevention education and accessible formats and locations for those persons with disabilities and for their families on the health risks of secondary conditions.
Thank you.
DR. GRANADOS: Thank you.
MS. GAZAK: Christine Gazak, University of Utah, again. I just wanted to address Issue 10, the access to quality health services and put in a plug for the importance of telemedicine especially in areas such as Utah, Arizona, Montana, Idaho where people are few and far between and access to health services is even fewer and far between, and as an aside to that I just want to address the issue of reducing the liability issue on physicians such as physicians based out of Salt Lake City being able to admit people in Nevada or across state lines and treat them, and treat their radiology exams, also, on line and reduce that liability issue.
Thank you.
DR. GRANADOS: Could you sign in?
Thank you.
Are there any other comments, any general comments that you would like to make?
If not, then I would like to -- oh, okay, sorry.
MS. HUBBARD RUGGIES: Good morning, my name is Effie Hubbard Ruggies. I am public health coordinator with Health Net, a managed care organization here in Sacramento in the MediCal Managed Care Division.
I have actually a comment on behalf of me. In reading the material in the Infant and Child Health Section with regard to prenatal care and increasing the care of mothers and their babies prenatally and other issues around that, I would like to alert the Panel or just raise their awareness or hope that thought is considered to mothers who are incarcerated.
It is not something that I deal directly in my work with, but when we read these target goals and it says, "To increase women who enter prenatal care," and we have ages I don't want that population to be overlooked or to be out of sight.
There are many issues that have to do with this population both while they are incarcerated and for their children and the women when they leave the correction system, and there are several issues, and I just wish that that is addressed and that is considered when these objectives are formulated.
DR. GRANADOS: Thank you.
Any other comments?
MR. BOZARTH: Again, I am Elvis Bozarth, from Santa Rosa, and I want to speak concerning elder abuse. The elder abuse laws that include adult dependents which means people with disabilities are generally pretty good.
In many places the mandatory reporting requirements are carried out. Where we are falling down in the prevention and control of elder abuse is follow-up to that reporting.
In my county which has 400,000 population until this past year we had only 1.5 full-time equivalent staff to follow up on all the reports that came in.
We have now about doubled that, but it needs to be doubled and tripled if we are to follow up with the increase of abuse to people with disabilities and to our elder population.
Thank you.
DR. GRANADOS: Thank you.
MS. FOLKERS: I am Lela Folkers. I am speaking on behalf of myself professionally about Chapter 15 which is the chapter on health communications.
Having, also, participated in the 1990 and the year 2000 objectives and watching the progress lo these many years, it has been in some ways exciting and in other ways sort of distressing, but I am wondering when you look at meeting the goals that are outlined in many of the other chapters and knowing that marketing, knowing your target audience being culturally relevant and using proper communication techniques are going to be a part of meeting those goals I am wondering why we have a special chapter on health communications.
I think it would be maybe more effective to integrate those concepts and ideas into each of the other chapters where it is relevant and appropriate.
DR. GRANADOS: Thank you.
Any other questions, comments?
DR. DELGADO: I have got to say that it is amazing I still have passion about this stuff after all these years, you know, but I think another thing for all the objectives, very often it has targets for states, and instead of saying, "All states," the objective is blank, and I think in every place by the year 2010 all states should meet the specific targets that are set.
It won't be acceptable if only some states do, and that is a very ambitious thing, but it should be what we do. We should not say that because we all know there are some good states and some bad states and from the East I can tell you California used to be a good state. Now, we are not so sure, but let us see what happens.
I think that we have to say, "All states" in all those things because otherwise we lose the opportunity, and for those people who are not Feds and who are not here on behalf of our constituents we were very concerned that this was held in Sacramento when the legislature is not even in session.
It was very hard for people to get up here and for people who have limited budgets it was really a stretch to come here, and I want to thank all the community people who really dug into their pockets and our members who came up here to speak.
DR. GRANADOS: Thank you.
MS. PERSON: Good morning. My name is Ruth Person, and I am a school nurse here in Sacramento. I coordinate a Healthy Start Program which is a grant program provided by the state department of education, and it provides integrated, coordinated services at public schools who are low income populated, and I would just like to emphasize on the subject of substance abuse that methamphetamine is a huge problem, particularly in the Sacramento area.
It impacts children very much because when their parents are users there is a lot of school truancy which affects drop-out rates if that is allowed to continue. It impacts children's health because their health is neglected.
They have severe dental decay many times and it, also, is related strongly with child neglect and sexual abuse and I would like to see more education on the subject of methamphetamine use and also more school nursing and school counselor positions so that we can be the sources of care to help get parents and children treated.
Thank you.
DR. GRANADOS: Thank you.
Are there any other comments?
MS. KHANNA: My name is Mona Khanna. I direct occupational health services for the County of San Bernardino. I wasn't intending to comment. I was an observer, but the speaker two or three before me spoke on the health communication portion of Healthy People 2010 and said that she hoped some of those ideas would be distilled to some of the other sections.
I actually think it is very important to have a health communications piece of Healthy People 2010. My background is actually communications and journalism, and I was a medical reporter for the Wall Street Journal for a period of time, and kudos to Healthy People 2000 and 2010 that put that chapter in. I hope we retain it.
DR. GRANADOS: Thank you.
Could you sign, please?
MR. MIRANDA: My name is John D. Miranda, and I am with Youth Power which used to be called Just Say, "No," International, and I am here to --
DR. GRANADOS: From where, sir?
MR. MIRANDA: From Oakland, California, but we are a national program. I am here to encourage the objectives to focus less on substance abuse education but more on building resiliency in young people. We decided to change our name this year from the Just Say, "No" name to Youth Power to reflect that change in how we now think about prevention.
I think gone are the days where simplistic solutions and scare tactics are going to make much difference with our young people. Instead the Youth Power Program and a lot of other programs as was reflected in comments earlier in the other session focus on building the inherent resiliency of young people.
We do ours through engaging them in community service and bonding them more directly in their community to decrease the likelihood of negative behaviors such as substance abuse.
Our findings are encouraging. We have evaluations conducted by the Office of Juvenile Justice and Delinquency Prevention and the Center for Substance Abuse Prevention, and we are not the only program moving in this direction. I don't want to make this sound like an advertisement for our program, but resiliency not education and scare tactics I think is the way to go with our young people regarding substance abuse.
Thank you.
DR. GRANADOS: Thank you.
Are there any other comments?
If not, I would like to thank the participants and the Panel members, and I would like to thank everybody for your travel and your attendance to this conference, and I just want to remind you that comments received today and at the other hearings along with written comments will be reviewed and used to finalize the national health objectives for the year 2010.
I invite all of you to continue participating in this process by submitting additional written comments and by communicating with those responsible for those areas of interest to you.
This session is hereby adjourned.
Thank you.
(Thereupon, at 10:39 a.m., the meeting was adjourned.)