Transcript of the Healthy People 2010 Regional Meeting
Philadelphia, Pennsylvania
October 5-6, 1998

U.S. Department of Health and Human Services
Office of Disease Prevention and Health Promotion

Session III:
Preventing Diseases and Disorders

DR. MEYERS: Hi. My name is Linda Meyers. I am here with Dixie Deter and a host of federal representatives on this session III on prevent and reduce disease and disorders.

We will be discussing 11 focus areas. They are focus areas 16 through 26, I believe. The plan is 20 minutes per focus area. That is about six or seven comments. Then, if there is extra time at the end, we will open the floor up for comment.

I have been told that coffee will be refreshed at 10:15. Feel free to wander in and out if you want coffee or need to leave to check out.

There will be a representative from the focus area being discussed alert and listening during your focus area presentations.

The persons on the stage may also wander down to get coffee or water or whatever, but there will be someone listening during your time. I will make sure to introduce that person, so you will know who your listener is. Are we ready to begin?

The ground rules are the same as they were in the morning session, each oral statement limited to three minutes, so that we can hear from everyone.

We will be getting a timer. That will give a one-minute warning and then we will let you know when the time is up.

Until the timer arrives, we are just going to use a clock with a second hand.

Each individual and organization will be limited to one oral statement for each focus area. As we did before, please introduce yourself by name and state of residence, and let us know if you are commenting for yourself or on behalf of an organization.

We have staff with microphones. Casey is at the back. If you would like a hand-held microphone, just let us know by signaling. Okay, we are ready to begin.

The first focus area, focus area 16, arthritis, osteoporosis and chronic back conditions. Chad Helmick, from CDC, is your listener. He is a work group coordinator for this focus area. Any comments on focus area 16?

MS. MYARICK: Good morning. My name is Annette Myarick. I live here in Pennsylvania. I am here on behalf of the Arthritis Foundation to support the Healthy People 2010 agenda, and the inclusion of arthritis objectives and an arthritis chapter in the Healthy People document.

In the past, arthritis has not been included in the Healthy People framework. Unfortunately, many misconceptions and myths are associated with arthritis, and our organization is faced by these challenges on a daily basis.

Foremost, it is a disease that is often viewed as minor aches and pains or an old person's disease, and that many people believe nothing can be done about arthritis. So, they think they just have to live with the pain.

However, arthritis is the nation's leading cause of disability. It affects more than 40 million individuals, all ages and races and ethnic groups.

Also, while arthritis affects 50 percent of the elderly population, the majority of people with arthritis are under 65 years of age.

Arthritis costs the nation almost $65 billion annually in terms of arthritis-related medical care and lost productivity, and it is equivalent to a moderate recession.

By the year 2020, the Centers for Disease Control and Prevention predict a dramatic increase in the incidence of arthritis, affecting nearly 20 percent of the population.

Most of the public believes that nothing can be done about arthritis when, in fact, something can be done.

There are effective interventions that do make a difference, interventions that help people to live better with arthritis. These interventions are under-utilized.

Given its high prevalence, its staggering social and economic impact, and the existence of effective interventions, arthritis is a significant public health problem.

That is why addressing arthritis in the Healthy People framework is critical, so that the nation can hope to achieve the Healthy People 2010 goal of increasing years of healthy life, and not just life expectancy.

Therefore, it is paramount that Healthy People 2010 include arthritis and arthritis objectives prominently in the document. Thank you.

DR. MEYERS: Thank you. Other comments on arthritis, osteoporosis and chronic back conditions?

Let's move on, then, to focus area 17, cancer. Dr. Barry Portnoy is on the stage, ready to listen. He is a work group coordinator for this focus area, focus area 17, cancer.

DR. FRELICH: Dr. Frelich, medical oncologist. I am representing the Medical Society of Delaware.

I was just interested in knowing a little bit more about how some of the projections were made, some 30 percent, some one percent, particularly in prostate cancer, which was only expected to be improved by a one percent margin. It seemed to me that was somewhat small.

Also, I am somewhat interested to know whether there has been any effort in this program to coordinate women's health problems and male problems, so, one is screening or talking about prevention and talking about more than one site at a time.

DR. MEYERS: Thank you, sir. Might I suggest that if you have concerns that are the reasons why you are raising the questions, that you make sure you raise those concerns with us in the comment period. Go ahead and write them and let us know what they are.

I might also suggest that you might want to talk more specifically after the session with Dr. Portnoy on some of the specific questions. We thank you for raising those.

MS. COLLINS: Good morning. I am Sylvia Collins. I live in Philadelphia. I am a volunteer for the American Cancer Society.

I work with the Corporation for Aging and I am speaking for myself.

When we are talking about women's health, particularly breast cancer, most women do not seem to understand that aging is really primary, second only to gender, when it comes to breast cancer.

I think that one of the problems is that when we look at the graying of America, and we know that the centenarians are the fastest growing population in America, most of the literature, the pictures for breast cancer, show young breasts.

Older women think that those breasts have nothing to do with them, because they don't look like theirs.

I would implore you that if you are going to talk about cancer of the breast, that you really need to put the emphasis on prevention and all the kinds of things you have done, but you really need to highlight that aging is the most common risk factor next to gender.

I think older women do not understand that. When we give true and false quizzes and we ask them, they do not understand that.

The pictures, when they are talking about aging, the pictures look like women who are 40 to 55. We are talking about many women who are 35 and 85. I think we really have to do something to dramatically make sure that American women and men understand the importance of aging as a risk factor.

I also would agree that we need to do some co-educational kinds of things. We know that most men need to be nagged to the doctor by the women in their lives.

So, if you are going to talk about prostate cancer, you need to talk about it with the men, certainly. But women need to know, because they are the ones that nag the men in their lives, usually, to health care. They very often make the health care decisions in their family's lives.

I think that we need to know. They are the ones that nag the men in their lives, usually, for health care. They very often make the health care decisions in their families' lives.

I think that we need to do a lot more education that is co-education.

DR. MEYERS: Thank you for those comments. Other comments on cancer? If not, let's move on to focus area 18, diabetes. Dr. Bill Foster, who is the work group coordinator for this area, is on the stage, ready to listen to your comments.

DR. KELEPOURIS: I don't know if this is nagging, but I feel I should -- Ellie Kelepouris, MD. I am a physician. I am a nephrologist, and I am chairman of the advisory board of the National Kidney Foundation.

I speak on behalf of myself and the National Kidney Foundation and the 350,000 patients in the United States on dialysis or having undergone transplant, based on the USIDS data.

I guess I would like to stratify my comments on awareness, prevention and treatment of kidney disease as an isolated, leading indicator independent of diabetes.

I will include diabetes in my comments because it is just the nature of the focus groups, but I would urge that end stage renal disease be considered separately.

I think children and adults are different in prevention and awareness. I think that in terms of both diabetes and kidney disease what is missing in your draft document is a well visit check up for children, to screen for the onset of both diabetes and kidney disease with the major indicator being proteinuria.

My own children are seven and five years old and, if I weren’t a nephrologist, they never would have had a urinalysis for protein.

I feel that should be part of a screening procedure for diabetes and kidney disease, as a hallmark indicator for both of these destructive processes.

In terms of adults, I think it is very important that large populations of patients at risk and not at risk be screened for kidney disease. Obviously, diabetes would be one of the causes, and only a small cause; perhaps the leading cause, 40 percent, but 30 percent recognize hypertension.

Three to four times the incidence of renal disease is by African Americans rather than Caucasians. So, there are both racial, ethnic and gender differences in this disease that are not present in diabetes.

I urge that the screening maneuvers be present not only in the high-risk populations but in the general population as well.

Kidney disease strikes unexpectedly. I have spoken to people in this room who have experienced it personally.

The screening should be in place before the actual onset of the disease. There are screening maneuvers available. They are published.

There are treatment modalities that have been helpful both in the pediatric and adult population, and we really would like to see those included in your document.

DR. MEYERS: Thank you for your comments.

DR. SWEENEY: My name is Monica Sweeney. I am a physician in Bedford-Stuyvesant, Brooklyn. Although I have not read the document, because I didn't get it until I got here, I hope that obesity will be considered as a leading indicator.

In order to treat diabetics, or to prevent diabetes from occurring, we need to treat obesity as a chronic disease.

In Bedford-Stuyvesant and other communities around the country, diabetes is increasing at an alarming rate. It is directly associated with the increase in obesity.

In order to decrease heart disease, which is contributed to by diabetes, we have to decrease obesity, which contributes to diabetes.

They sort of all lead one into the other, and you cannot have a success rate in closing the gap or decreasing -- not closing the gap; we are going to stop the disparity -- without addressing obesity as a separate issue which will then impact on the incidence of diabetes.

The other thing about diabetes is that both the public and doctors have difficulty accepting diabetes. When I do talk about it, I talk about deny-abitis, because both the physician and the patients don't recognize or act on the seriousness of it.

We need to have some way of addressing this so that, when physicians see blood sugars of 190, won't say, you have a touch of sugar, and will start to treat patients appropriately as outlined in the ADA guidelines.

So, there needs to be public education as well as professional education around the issue of diabetes and preventing the end organ and end stage diseases that have already been mentioned.

DR. MEYERS: Thank you.

DR. FRELICH: Dr. Frelich, again. One of the problems I have had in diabetic screening -- I have been involved in this from a public health point of view -- is the inability to use a glucometer for any screening purposes.

I think it would be well to ask the FDA why that has to persist. It is good enough to regulate the blood sugars.

We can't use anything simple like this for screening purposes. Unless you have a lab technician on hand who is going to do a real laboratory study, trying to identify the high percentage of people who are diabetic who don't know it through some simple screening blood test is not feasible.

DR. MEYERS: Thank you.

MS. COLLINS: I am Sylvia Collins. I also serve on the local diabetes African American committee.

One of our major problems is that people do not get a strong sense of urgency about the disease, its chronicity and its dangers, from the health care providers.

I just get so tired of people telling me that they have a little touch of sugar. I say to them, there is no such thing as a little touch of sugar. It is like a little touch of pregnancy; you either are or you aren't.

They do understand that. I think it would be good if federally we came out really strong and said, there is no such thing as a little touch of sugar.

People latch onto that and they believe that. They have a little touch of sugar for eight years. They are borderline diabetic for eight years. All the time, they are not taking care of themselves.

We really need to do a job of educating the providers of what not to say to people, and we need to really teach the general public that.

I think also the general public does not seem to understand the relationship between diabetes and dialysis, a lot of them.

There needs to be much more, I think, written about diabetics having their eyes tested by having their pupils dilated.

They do not recognize the difference between the Snelling eye chart or some other kind of test if they are being tested for glaucoma. That is what they think they are looking into their eyes for.

I think it is very clear that people who have diabetes and their care takers, their care givers, need to understand that there is a very serious need for diabetics to have their eyes tested by having drops put into their eyes and their pupils dilated. Thank you.

DR. MEYERS: Thank you. Other comments on diabetes?

MS. VITERI: Hello. I am Jackie Viteri. I am with the American Obesity Association. I wasn't going to comment on this section, but I wanted to reiterate the comment that was made earlier.

Our organization does believe that obesity should be recognized as a leading indicator. It is associated not only with the many co-morbidities in this public comment session on preventing and reducing diseases, but also on the other two that are being held concurrently, on promoting health behaviors and promoting healthy and safe communities, and also in improving systems for personal and public health.

That is basically what the statement is. I was going to wait until the end, after the 26th one, to see if we could add the 27th as obesity, but I thought it was appropriate to do that now. Thank you.

DR. MEYERS: Thank you. Let's move on, then, to focus area 19, disability and secondary conditions. Lisa Sinclair, from the Centers for Disease Control and Prevention, is on the stage. Comments?

MR. MARGE: I am Michael Marge. I am president of the American Association on Health and Disability.

I wanted to reiterate my comments of this morning on the fact that the document is really quite an improvement over what happened for Healthy People 2000, which was insensitive and it almost entirely excluded concern for the needs of people with disabilities, not only the disparity in health care, but also their actual needs and access to health care.

This document is an improvement, but not that much of an improvement. We hope that that will be changed, because we are submitting a fairly substantial statement regarding our position with reference to the goals, the leading health indicators, and the objectives.

In the time that I have limited this morning, I would like to just make reference to several items with regard to the objectives themselves.

I find some of the objectives are relatively unclear. For example, objectives one through six are acceptable as they are in the section in the chapter on disabilities and secondary conditions.

Objective 11 is unacceptable, because it is as if we have no evidence to support establishing specific time lines and specific objectives to accomplish over a period of time.

I would like to have objective 11 to read, to increase to 90 percent the proportion of persons with disabilities who report that they are not limited by environmental factors, to include physical environment -- I would mean full access to buildings, housing, recreation facilities and transportation.

I helped write part of the ADA when I was a member of President Reagan's National Council on Disability. The section on transportation said that within 20 years all transportation should be accessible.

What are we waiting for? By the year 2010, everything should be accessible to people with disabilities. Why are we afraid to say that?

Secondly, learning environment. There should be full access to educational programs and relevant information systems throughout a person's life.

That is something we are very concerned about because they are not accessible at the present time. We don't use alternative formats for people who are partially sighted or who are blind.

In our communications systems, people who are deaf or who have hearing losses, we don't have alternative communication systems available to them. The ADA says that we are supposed to have that; it is a law.

The next item is economic environment. Most people, in a number of studies that we have done, a majority of people with disabilities wants to work. They want to be independent, want to earn a living and want to be citizens who are integrated into the society.

DR. MEYERS: Time is up.

MR. MARGE: I will continue when I have more time.

MS. HAMLIN: Lisa Hamlin. I am from the Center for Health Care Access for the Hard of Hearing. Again, I thank you for this opportunity to comment.

We will, in addition, send written comments. As you can see, three minutes is not nearly enough.

One of the things I saw immediately in looking at this section on people with disabilities was that right away it said that you expected a declining number of people with disabilities as they age.

That is not the statistics that we see. Of people who are hard of hearing and deaf, we see one in 10 in the population at large.

We see that shoot up to one in four when you hit 64 and it goes up again at age 75. I don't really understand where these statistics come from.

The second thing I wanted to say is that people tend to think of people with disabilities as mobility impaired or sight impaired.

I would love to see this document look at people with hearing loss. That doesn't just mean people who are deaf.

People who are deaf need communication systems. If I were deaf, I would be asking for a sign language interpreter.

Because I am hard of hearing, I have a different set of needs. We have one system up front. I am patched into your sound system, which works with my hearing aid.

Those are the kinds of things that the health department needs to be aware of, to make things accessible to people with hearing loss.

If you are going to communicate, if you are going to have educational programs, if you don't speak the language, you are not going to get through.

If I can't hear you, I am not going to get the message, and that goes across the board.

I am happy to be in this section because I see there are a number of things. Mental health disorders, people with hearing loss have greater stress, tend to have much more mental health issues.

They tend to have issues with substance abuse. There are all kinds of systems.

We can talk about cancer and diabetes. Again, the education has to be there. I would love to see something where there is a greater linkage with people and their learning ability, so that we can understand how to get across, how to get the communication access across.

Let me try to see if I have anything else to say really quickly. Hearing loss prevention, noise awareness is something that should also be, I think, part of the document, because you can prevent hearing loss, given half a chance.

People who are hearing need to know what to do to prevent hearing loss. I think that is a major thing that should be dealt with before someone has a disability.

Of course, I was very pleased to see the newborn screening as part of one of the goals.

With that, I will submit written comments and, again, I thank you for this opportunity.

DR. MEYERS: Thank you.

MS. LEE: Myaungja Lee, president of the Korean-American Organization for the Rehabilitation of the Disabled.

I would like to mention of the learning disabled, the definition established for the learning disabled youths.

Generally, we are looking for vocational rehabilitation for the learning disabled youths after they have graduated from the school.

It is very hard to find out the services, because the services are not available for the learning disabled youths.

Also, there was no follow up after they are graduated from the school. When they go to the society, the society has not accepted them at the level of the ordinary people.

They are not eligible for the mentally retarded disabled category. They are also not eligible to meet the categories.

So, this group, they are hangers-on in the society. Also, few people get the job for stockman or some other jobs, but it is very hard to look for a job.

Also, they deny the SSI. They deny it because the organization is told by the administration of the Social Security that they are able to work.

Actually, they don't have a job in the society. So, we have to focus on how we can be of assistance for the learning disabled youth.

When they cannot get in the society, they are in the home. It is getting worse. I would like to mention that we also have to have something for the learning disabled youths.

DR. MEYERS: Thank you very much. Mr. Marge is asking if we are allowed to continue. What we are going to do, we will go through the focus areas, and we will finish early. That will give you another opportunity to comment.

I should mention that for those of you who may have come in, we are just going to begin focus area 20. If there is an earlier focus area that you had wanted to comment on, and we are moving faster than we had anticipated, we can pick it up after we finish focus area 26.

While I am on the microphone, let me also mention that the Office of Disease Prevention and Health Promotion staff, those of us with the yellow badges, would be happy to take any written comments that you would like to give us; that we are available to do that.

Then focus area 20, heart disease and stroke. Dr. William Harlan from the National Institutes of Health is the formal designated federal representative for this focus area today. Dr. Harlan is a member of the Healthy People steering committee. Comments on heart disease and stroke?

MS. SHAPIRO: I am Ruth Shapiro. I am with the advocate group, Better Communications, which is an advocacy group for the hard of hearing.

I would like to suggest that the public health sector look at hearing loss as a high stress-inducing factor. There are 28 million people, as was mentioned, with hearing loss, and 26 million of us are hard of hearing.

As a hard of hearing person, I find that the difficulty of coping every day is certainly a stress inducing factor.

Since I have lots of friends who have to cope with me, and they find it very difficult, I think this is something that you really have to think about and include in your overall plan for the next 10 years. Thank you very much.

DR. MEYERS: Thank you. Other comments on heart disease and stroke?

MS. WALLER: My name is Sandra Waller. I am just kind of speaking spontaneously, as the daughter of someone who had a massive stroke some years ago.

I just would like to see that there is access to technology for stroke victims, those especially who are aphasic and are unable to speak again.

My mother can say simple things like yes and no and she has much expression. I just have become aware recently that there are mini-computers and there is a phone system and different things.

I am a person who is out there and I hear a lot more than a lot of people. I would just like that somehow there be access to these things. Of course, that means funding as well for people who cannot afford it.

I know I have on loan a machine that is about $3,500. My mother could never afford that. I don't know what she is going to do. We are hoping that we can teach her something by way of this before we turn it in.

For all those people who are stroke victims that I see daily, I am from the North Philadelphia area and there are stroke victims innumerable.

For those people I would like to see that there be some kind of program in place where they could be rehabilitated to the best of their ability so that they can function as well as possible.

My mother, her mind is as clear as mine and probably even more sharp, even though she is disabled. She cannot communicate and it is much frustration to her and my family.

If there could be some kind of way to help people to communicate, I would appreciate that. I think that is a major undertaking, but is something that needs to be done.

DR. MEYERS: Thank you. Let's move, then, to focus area 21, HIV. Eva Seiler from the Centers for Disease Control and Prevention is the federal representative. She is also a work group coordinator for this focus area. Comments on focus area 21, HIV?

MS. ESTEPA: I am Sondra Estepa. I will be, I guess, testifying as an individual more than with the U.S. Public Health Service Office of Women's Health.

I think there are several issues in terms of HIV. I think there need to be objectives that are aware of the range of places that people enter into care in terms of prevention strategies.

There are a number of hard-to-reach populations -- homeless folks, substance users and others. While the objectives are very important, I think that in terms of prevention, the hard-to-reach populations are really particularly challenging.

Further, in terms of the disproportionate effects of HIV on women and people of color, it is important that the strategies in prevention are diverse and that they are also, for minority communities, culturally relevant.

I am particularly concerned about new immigrants and the challenges that they face in terms of HIV prevention, and that the objectives really need to be multifaceted in their approaches in order to reach the objective standards. Those are just some comments.

DR. MEYERS: Thank you.

MR. MARGE: Michael Marge with the American Association on Health and Disability. In reading the document and looking at the chapter on HIV and the chapter on sexually transmitted diseases, I got the impression that the area of sexually transmitted diseases is not as critical as the area of HIV.

I think we should not send the signal, as public health officials, that sexually transmitted diseases are not important.

I know we have a major epidemic in this country of HIV, and it should be addressed. I think for political purposes as well as for other purposes you have a separate chapter for that particular disease.

Don't give the impression, please, that other diseases that are sexually transmitted are not important. As you review the two chapters, please try to identify that they are both significant public health issues.

DR. MEYERS: Thank you.

MS. COLLINS: I am Sylvia Collins, speaking now about HIV and AIDS. I am trying to skim the report, but it seems as though the age 44 seems to stop.

We are certainly becoming aware that there are older people who have HIV. That group is probably increasing for a couple of reasons.

People have had blood transfusions and are now becoming positive. Also, older men in particular are having sex with younger women. So, we are seeing a lot more older adults with HIV.

I think you need to start asking questions about and making it reportable for people beyond the age of 44. That is really young when we are talking about the aging of America.

The same thing about sexually transmitted diseases. Older people really need to have that kind of information. We know that many older people -- grandparents -- are now becoming parents against their will.

They really do not know about chlamydia, because chlamydia wasn't around when they were younger. They don't know about a lot of the sexually transmitted diseases that are current today.

They are scared because their children and grandchildren that they are taking care of have them, and they don't know how to cope with them.

We really need to do a better job of informing the public, not geared only to teenagers and their parents. We need to include the older folks because they really do not know about many of the newer sexually transmitted diseases.

DR. MEYERS: Thank you for your comments.

MS. FONZI: Hi. My name is Patricia Fonzi and I am here on behalf of the Family Health Council of Central Pennsylvania.

First, I would like to commend you on the section on disparities in health care. I think from a public health perspective, HIV and AIDS is the perfect example of a disparity in health care.

As the trends in the epidemic continue, I think we that serve people with HIV and AIDS are seeing this trend continue to grow. I was very glad to see that that was well addressed in the overview.

I was, however, concerned, in reading the overview, in talking about the incidence of AIDS versus the incidence in HIV. This is from a public health perspective as well as a media perspective.

People are hearing over and over again about the incidence of AIDS decreasing, which is true. That does not mean that the incidence of HIV is decreasing, and I am not sure that that is adequately addressed in the overview.

Although the overview talks about protease inhibitors and the expense of drug regimens, it doesn't necessarily say that the reason that deaths due to AIDS is decreasing is because of health care, not necessarily HIV infection.

I think that that needs to be highlighted from not only a health care perspective but also from a prevention perspective.

People hear of Michael Jordan having no detectable virus and the papers say people are cured. We, from a public health perspective, need to address that not only isn't there a cure yet, but the incidence continues to rise, especially among the select groups. Thank you.

DR. GIROIS: I am Susan Girois. I am a second year resident in internal medicine at the University of Pennsylvania. I am here completely independent and speak for myself.

About HIV, and I again was given the chapter also last night, in speaking of prevention and disparities in health, I find it was a little disappointing not to have a clear mention of hopes for a vaccine.

I think that is the hope for decreasing the disparities in this disease, and not only access to these expensive, non-curing regimens.

DR. MEYERS: Thank you.

MS. BEATTY: Good morning. My name is Alicia Beatty. I am the director of the Ryan White Title IV project in Philadelphia, Circle of Care.

Two things. Prevention. We know that the prevention models that were originally designed for men do not work for women.

There needs to be an emphasis on creating prevention models that work for women, to bring women not only into care, but also to help women know their status. That is number one.

I notice in your objectives there is not a particular objective for women. I would like to see women as a set aside objective because they are the fastest growing population now contracting the virus. Thank you.

DR. MEYERS: Thank you.

MS. STURGESS: Hello. I am Lakesha Sturgess from North Philadelphia representing the Women's Christian Alliance of HIV and AIDS Prevention Case Managers, specifically working with African American women.

I just want to reiterate what was said about education. Although I work for African American women, I believe that we do not have the message that HIV is rapidly growing in our rates.

I also think that we need brochures and culturally sensitive information.

I believe that we need public information as well as professional. I work with women who have multi-faceted issues, such as mental illness, substance abuse, homelessness, domestic violence.

I think that HIV should be addressed from a multi-disciplinary approach. I believe the same information should be reiterated by several different health professionals, so that these women are receiving the same information from everyone and it is often received. Thank you.

DR. MEYERS: Thank you very much.

DR. FRELICH: Perhaps -- I couldn't quite believe it; perhaps I missed it. It is hard to see an HIV section that doesn't mention pregnancy and the problems of detecting positive HIV in pregnant women and their treatment.

DR. MEYERS: Thank you. Other comments on HIV? Let's move on to focus area 22, immunization and infectious diseases.

There are two representatives, Chris Benjamin and Martin Landry from the Centers for Disease Control and Prevention. Both are work group coordinators for this focus area.

MR. WILCKE: I am Burton Wilcke with the Vermont Department of Health. My comment on this area really spans some other areas as well. It relates to the issue of antimicrobial resistance, and the development of antimicrobial resistance.

Although we deal with this in specific terms, like dealing with nosocomial infections in this area as well as inappropriate use of antibiotics for colds, and I think we also address it in the food safety section, there is no comprehensive approach to what is really a major concern and a major problem.

There are no apparent objectives dealing with the need to change our behavior in the pharmaceutical area, the agricultural area, and the health and animal health care delivery areas. Thank you. Other comments on immunization and infectious diseases?

DR. MEYERS: Thank you.

MS. COLLINS: Sylvia Collins again. I haven't had time to go through the immunizations, but one of the things that I needed to mention is that we have a terrible problem getting older folk immunized against pneumonia, because of managed care.

We have opportunities where we bring seniors into our centers who may be disabled, may live alone. It may be much more difficult for them to get to their provider that has been identified by managed care.

Yet, when we are able to bring someone, like the Visiting Nurses Association, who are willing to immunize the person at the center where he can get there easily, managed care will not pay for the visiting nurse to give that immunization. I think that is a real barrier.

In Philadelphia, at least, we have a significant number of older people on Medicare that belong to Medicare HMOs.

Yet, when we provide an opportunity, we have great difficulty being able to give them the immunization if they belong to managed care.

I have had talks and fusses on the telephone with representatives from managed care.

Something needs to be really done -- you need to have some teeth in whatever you do with the managed care people. There are many missed opportunities for older folk if they belong to managed care.

DR. MEYERS: Thank you.

MS. NIXON: Good morning. My name is Cathy Nixon. I am director of patient services at the Family Planning Council located here at Philadelphia.

I am speaking about objective five, which is to reduce to zero the number of hepatitis B persons in groups less than 25 years old.

One of the things that I have noticed is missing here is that you have made no connection between the fact that sexually active individuals are seeking health care in family planning clinics.

Here in Philadelphia and the five-county region, what we have done is we have partnered with the vaccine for children program in order to make vaccines available for those individuals under the age of 19.

That has not, however, dealt with the issue of those that are 20 or older. We see about a third of our patients that are in that 20 to 24-year-old category.

What I would like to see you as a body look at is, a, you as a body developing and recommending better partnerships between groups like Family Planning and the immunization folks, but also to deal with how do we deal with the population between ages 20 and 25 when there are no dollars around to provide the immunizations to the uninsured population.

Again, about a third of our patients are uninsured and we have no way to make those vaccines available to that group.

I would like you to really go back and think about how do we develop partnerships, how do we make funding available for the group between 20 and 25 if, in fact, we are going to make any real impact on reducing the number of people becoming infected with hepatitis B. Thank you.

DR. MEYERS: Thank you. Other comments on immunization and infectious diseases?

DR. BERNSTEIN: Edward Bernstein. I am a representative of the Society for Academic Emergency Medicine. I practiced emergency medicine for 25 years.

There is an opportunity in the emergency department to meet people where they are at, when they are ready, and I think that we are missing this opportunity.

I know for pediatric immunizations this has been a mandate, that wherever children show up, they should be immunized. The same thing is there for the elder patient with pneumovaccines.

I think we should take advantage of this opportunity. There are 100 million visits to the emergency department a year.

Some people look at it as primary walk-in care. We might as well get it done while they are there. At the same time, I think we have to refer from the emergency department into the primary care system.

It is not that we want a substitute for it. Until the access is ensured and guaranteed for people, then I think we should do it when we have the opportunity.

DR. MEYERS: Thank you. For those of you who have just come in, we are just about to start focus area 23, mental health and mental disorders.

Gail Ritchie from the Substance Abuse and Mental Health Services Administration is the federal representative for this focus area. She is also a work group coordinator. Comments on mental health and mental disorders.

MS. LYNCH: My name is Irene Lynch. I would like to refer to the goal under mental health and mental disorders.

It says, improve the mental health of all Americans by ensuring appropriate high quality services.

This makes the assumption that there are high quality services for mental patients out there. I am here to tell you, as an ex-mental patient, that isn't so.

There are very few services for mental patients that really address our needs as we know them. Unfortunately, being such a poor population and being so intimidated over history by professionals, we are just beginning to get our voice to speak out to what our needs really are.

Secondly, I could have spoken to every single one of these under prevent and reduce. I have total arthritis, total knee replacement, had no arthritis before I was a mental patient.

My mother and grandmother were diabetic and I am probably pre-diabetic. I have other disability conditions. I have Lyme disease and babesiosis.

The current psychiatric evaluation I had two years ago by a psychiatrist said I never should have been a mental patient, that the lyme disease mimics behaviors that we assume are psychotic or whatever. So much for 23 hospitalizations and 14 years of my life.

I also want to address all the physical health problems. Historically, medical doctors look at mental patients when they complain of physical ailments and say, oh, it is just in your head.

Believe me, it is not just in our heads. The rates of diabetes, the rates of obesity, I could go on -- the rates of kidney disease, they are enormous for mental patients.

I would also like to address that the disparities in our society are a great factor in pushing people into behaviors that are thought to be mentally ill, when probably they are just angry because they are poor or they have had traumatic child abuse, et cetera, et cetera.

The answer is not to just simply stick them with needles and fill them with drugs and put them into a day program.

Research, a very important component of what happens to us, the research is being done by professionals who have not been there.

A great deal of what needs to be done for us needs to be done through the accumulation of personal stories and an examination of what those stories have to say.

One last thing, please stop turning our babies into mental patients. The issue is not that our children are mental patients. The causes are much deeper. The child is exhibiting something. Let's look at what is causing that child to do it, and not give them a label at three or four.

DR. MEYERS: Thank you very much.

MS. WALLER: This is Sandra Waller again. I am representing the Women's Christian Alliance of North Philadelphia.

One of my roles there is behavioral specialist. As such, I am very concerned with misdiagnosis, as the lady just said before.

I am concerned about the fact that, due to managed care, we can't get access for the children or adults.

Our agency's primary concern is family and children. We have a service whereby anyone who refers a client to us, whether it is within our agency or our community, we have evaluated by a consulting psychiatrist, who then makes a recommendation.

It is pretty futile, because she makes the recommendations and most of the time they can't be followed through, because of a lack of managed care or even though people are on Medicaid and they have access cards, there are problems a lot of time with community behavioral health in Philadelphia and the politics thereof.

I am very concerned that children who are evaluated and don't have access to services after that evaluation.

I am concerned about the mislabeling and misdiagnoses and all the other concerns that contribute to ill behaviors aren't addressed.

It takes a wide array of things -- poverty, lack of health services, lack of concern, the public school system.

I wish that the mental health commissions -- actually, many of these things are just all-encompassing; they just come together.

I just wish that somehow we would take this very seriously, the whole mental illness piece.

The fact of the matter is that we all need some mental health services at some point in time. Most of us can afford it but there are a vast number of people who can't afford it.

I hope that we will put that on our agenda, to provide for the care and the services, and the resources for the follow up of services for people who are thought to have mental health issues.

DR. MEYERS: Thank you.

DR. FRELICH: I apologize for coming up so often. If I can speak, I think the Medical Society of Delaware has come out officially recommending a closer correlation between physical and mental health, and feel that public health people should take the lead in trying to assure that the public can work together so that public health includes mental health.

We recognize that the distinction between the two is very bureaucratic, it is by funding, and that at the local level it is not easy for these groups to work together because of the federal funding approaches.

DR. MEYERS: Thank you, sir.

DR. BERNSTEIN: I have a comment in this area, not as an organizational member but as an emergency physician.

I have read the Institute of Medicine report on managing managed care and behavioral health. I think everybody should read this.

It talks about the concern about skimming, cost saving and dumping the patients out of the private sector into the public sector.

It is quite an important document. Their solution to it is in standards of accreditation and quality monitoring.

I think that we should have some objective that looks at access to mental health services, quality management and the like.

Particularly in the emergency department, we do see this as a serious problem of access for our patients.

DR. MEYERS: Thank you. Other comments on focus area 23, mental health and mental disorders?

Let's move to focus area 24, respiratory diseases. Two federal representatives, Dr. William Harlan from the National Institutes of Health and Dr. Stephen Redd -- he is in the back row -- from the Centers for Disease Control and Prevention.

Dr. Harlan, as you know, is a member of the Healthy People steering committee, and Dr. Redd is a work group coordinator for this focus area. Comment on respiratory diseases.

DR. ARCHIBALD: My name is Cheryl Archibald, and I am a pediatrician at the New York City Department of Health. I am also getting my master's in public health at Columbia University.

I am speaking part as a primary care provider and individual right now.

I am pleased that the Healthy People 2010 document will have a more intensive focus on asthma. I believe that this reflects the importance of adjusting the national health agenda in accordance with the relevant and changing public health issues faced by our country today.

An objective of Healthy People 2010 is to increase the proportion of primary care providers who have participated in continuing medical education on asthma.

A physician could obtain CME credits on asthma through several different routes. You could get it through a pulmonary department, an allergy department, an immunology department, pediatric, internal medicine and family practice department.

Each one of these CME sessions would be on asthma but wouldn't necessarily focus on the NAEPP guidelines.

It is my understanding that several of the asthma objectives of Healthy People 2010 are based on these guidelines.

They represent a consensus of national expert opinion on the management of asthma.

As such, these guidelines could serve to provide a national standard of care for asthma management. For these reasons, I believe that the objective concerning CME sessions should explicitly state that the CME sessions on asthma much focus specifically on the NAEPP guidelines.

The establishment of this as a national health objective raises some other issues, as to how strongly the nation will really promote this objective.

What will be the surveillance of provider attendance at these sessions. Will this information be tracked as part of the asthma surveillance system.

Will there be national funds available to help subsidize regional or local professional entities in the development and delivery of these sessions to primary care providers?

Lastly, would these sessions be therefore required for obtaining new medical licensure or renewal of medical licenses?

Also, in accordance with the guidelines, I believe that the emphasis on the section of asthma should not focus on individuals with severe disease, but with individuals with persistent asthma symptomatology.

These are the individuals most at risk for under-treatment or poorly controlled disease, the individuals most at risk for disproportionate health care utilization.

These are also the individuals most in need of written home management plans, since their armamentarium should contain both maintenance and as-needed medications.

Also, I think that there should be an objective for Healthy People 2010 that should focus on increasing the percentage of individuals with persistent symptoms who use daily anti-inflammatory medications.

I think that this would serve as a good corollary to the objective that focuses on reducing the inappropriate use of short acting inhaled beta agonists.

With regard to the utility of peak flow meters, the evidence in the literature is controversial with regard to their utility as monitoring tools for asthma.

I think that there should be more emphasis on increasing the use of spacer devices. If inhaled medication is not being adequately delivered to the patient's airways, neither the need of provider's education nor written home management plans will serve to improve the health status of individuals with asthma.

DR. MEYERS: Time.

MS. COLLINS: I am Sylvia Collins again. I don't apologize for getting up. Asthma seems to be thought of by many providers and by the general public as a childhood disease.

While it is true that many, many children have missed days of schooling, it is important that America as a whole and providers as well recognize that there is an increasing incidence of asthma in older adults.

Many of them are misdiagnosed or not diagnosed at all. So, I would implore you to really have something more about asthma in the older population, and I am talking about those 60 and over.

DR. BERNSTEIN: This is a personal comment. One of our nurse's daughters, at 14, died of asthma recently. It really brought home to all of us not only the health care disparity issues, but also the fact that the schools are not properly supportive of young people with chronic diseases.

Particularly in the private sector, the private schools have no nursing support. I think that overall the nursing support is being dismantled in public school sectors.

I think this would be an excellent preventive systems-wide improvement, is to be able to have systems in place for monitoring and supporting young people with chronic diseases, particularly asthma, in the schools.

DR. MEYERS: Thank you.

MS. STURGESS: Lakesha Sturgess, Women's Christian Alliance, speaking personally.

I am a person whose parent was diagnosed at the age of 40. However, she was misdiagnosed two years prior. Therefore, I believe professional education, as well as education in general to the general public about asthma, and some of the causing factors, and more professional education because of the misdiagnosis in older women. Thank you.

DR. MEYERS: Thank you. Other comments on respiratory diseases? If not, let's move to focus area 25, sexually transmitted diseases.

Jack Spencer, from the Centers for Disease Control and Prevention is the official federal representative. He is the work group coordinator for this focus area. Comments on sexually transmitted diseases?

MS. MANN: Hi. My name is Dorothy Mann from the Family Planning Council in Philadelphia. I have a question more than a comment.

On item number 14, which suggests that the health department can, in fact, pay premiums to managed care plans for treatment of partners, even though those partners are not plan members, I think it is sort of an interesting notion.

I guess my question is how it fits with the item above it, which would be sort of the reverse of that, which is having state Medicaid contracts for health departments.

I guess my comment really is, whether or not, by putting a goal like this in here, are we assuming that the CDC will enable its grant funds to be used to pay premiums to managed care plans for the treatment of non-plan partners.

DR. MEYERS: Thank you for your comment. Other comments on sexually transmitted diseases?

Focus area 26 is substance abuse. Gail Ritchie, from the Substance Abuse and Mental Health Services Administration is the federal representative. Comments on focus area 26?

DR. BERNSTEIN: I feel like a jack in the box. This time I am representing the Society for Academic Emergency Medicine.

Over 10 percent of our patients, in national studies, show up in the emergency department intoxicated. About 400,000 have been documented in the DAWN, the Drug Abuse Warning Network, as having drug problems.

I notice that there is a developmental objective for screening, but it applies only to primary care. I would like to bring to your attention the opportunity we have in utilizing these emergency department visits, these teachable moments in crisis, for screening, counseling and referral into the primary care and substance abuse system.

Particularly, there is a technology now that has been well documented, in brief negotiation and brief interventions that have been shown to be effective.

There is an opportunity there. I guess if we had to, we could just add emergency medicine to the primary care objective here, around people over 60.

I think that there is more opportunity than to just address the issue of substance abuse in people over 60.

I am just trying to find the particular objective. Here it is, 19, increase the proportion of primary care providers who monitor and screen patients 60 and older for alcohol and drug abuse, discuss alcohol and prescription drug interactions with these patients and refer them for preventive or treatment services.

Certainly emergency departments have an opportunity for this. Ten percent or more of our patients are elders with substance abuse problems. I would like to extend this throughout the life cycle. Thank you.

DR. MEYERS: Thank you.

MS. BRAUTIGAM: Good morning. My name is Bonnie Brautigam. While I work for the Pennsylvania Department of Health, I would like to address my comments from a personal perspective.

I have been involved in public health for 15 years. I have been involved in substance abuse all of my life, and I have been involved with HIV for the last 15 years.

So, I struggled with where to address my comments this morning, whether to do that to the substance abuse community or with the HIV section.

I decided that, while I like and am appreciative of the substance abuse objectives that have been placed in the HIV section, I am disheartened at the lack of HIV information and objectives in the substance abuse section.

My concern actually is this. We know that in HIV and substance abuse, that those two things are inextricably linked.

We know that harm reduction strategies work incredibly well to not only reduce substance use and abuse, but also to reduce the transmission of HIV.

What I don't see in the substance abuse section are objectives specifically geared to HIV, specifically geared to harm reduction, and specifically linking those two systems together.

What I have found in my professional life is that, if we don't do that, we fail. I think that we do a disservice in these objectives if we haven't strenuously encouraged the substance abuse community to join the HIV community in the way that the HIV objectives address the substance abuse community. Thank you.

DR. MEYERS: Thank you.

MR. FROMM: My name is Charles Fromm. I am with Multinational Business Services in Washington, D.C. I wanted to address the relatively limited issue of drink equivalence.

The standard formula for alcohol equivalence, which is often cited, is 12 ounces of beer equals five ounces of wine, is the same as an ounce-and-a-half of 80 proof distilled spirits.

There is reference to a drink in various portions of the document, not only in the substance abuse sections but in other sections as well.

I think that it is important to clarify what is meant here. The problem with the slogan, a drink is a drink is a drink, whatever the chemical analytical accuracy of that, it ignores evidence that in the real world serving sizes do not comport with that.

The distilled spirits drink, the hard liquor drink, contains significantly more alcohol.

If you look, for example, at popular bartending guides, they will list literally hundreds of mixed drinks that contain more than an ounce and a half, all the way from the martini to the gin and tonic, whiskey sours, marguerites, even scotch and water.

Basic high balls of rum and brandy and scotch and gin all contain two ounces of hard liquor, for example.

As any bartender will tell you, I guess, a weaker drink produces fewer tips. You can understand the bartender's economic incentive in this.

Also, the 80 proof standard also factors into here. If you look at scotch, for example, it is 86 proof. Restaurant owners, bar owners, report increasing sales and promotion of the high-end hard liquor, so-called over-proof vodkas, small batch bourbons, and other kinds of distilled spirits that are well in excess of 80 proof.

The simple fact is that if two people go into a bar or a restaurant and, in the course of an hour or whatever, one has three beers and the other has three mixed drinks, the person who has the mixed drinks is going to consume significantly more alcohol.

Therefore, we would call upon the people who are promoting the concept of a drink is a drink is a drink to come forward with actual data based upon serving size that shows that this bears out in the real world.

If we are going to set national health goals based on the concept of one drink, we need to clarify what we are talking about. Thank you.

DR. MEYERS: Thank you.

MS. SWEENEY: My name is Monica Sweeney from Bedford-Stuyvesant Family Health Center in Brooklyn, New York.

I would like to address the issue of primary care physician being the person or persons to do an evaluation and assessment for mental illness.

It has already been pointed out that it should be done in the emergency room as primary care. But many specialists take on the role of primary care provider, and it is being done more and more in managed care, where the ob/gyn may be the person to take on the role of primary care giver.

I know many surgeons, if the person's entry into the health care system has been through their surgeon for a gall bladder operation when they are 35, no matter what they have that might be the person that they first turn to.

I think it is prudent for the role of physicians to be expanded to include specialists. Wherever the person has an entry into the health care system that should be the person who does an assessment for mental illness, for risk behavior.

For example, ACOG this year has a smoking initiative. Ob/gyns have taken up the banner of doing smoking assessment, even though they have not traditionally been called primary care providers.

It should not just be physicians. It should be anyone in the health care system who gives health care, to have a role in diagnosing or at least assessing and referring for mental health disorders.

The statistics are all there that primary care docs recognize and diagnose only 50 percent of mental illness as is, and only treat about 25 percent of it appropriately.

There is a role not only to have more people included in the people who will address this, but there needs to be a lot of attention to doing it better for everyone doing it.

DR. MEYERS: Thank you.

MS. LEE: I am Myaungja Lee again, Korean American Association for the Rehabilitation of the Disabled. Unfortunately, we don't have any source how many people have drug addictions or involving in the gang activity or STD infections or disease.

We know that so many drug addicts to the young people, we don't know where they have to take. There are a lot of rehabilitation programs, but the community does not know where they have to go.

Also, the language barrier is there. We are worrying that many youths have drug addictions, and no one is helping. We need something, the government, to level more specific approaches to isolated populations, from the very beginning, from the very bottom of the approach is necessary.

DR. MEYERS: Thank you.

MR. WILSON: Ron Wilson, speaking as a private citizen, but one who has been involved in alcohol research off and on for the last 35 years.

I refer to this objective that deals with periodic heavy drinking which for a long time, I think, has been unfortunately referred to as binge drinking.

I think the general public and many of the alcohol researchers do not consider five or more drinks on one occasion, in a row, in one day, as binge drinking.

I think that variable should be called what it is; heavy drinking, not binge drinking. Binge drinking generally refers to long periods of time of drinking more than what you normally drink.

As defined in this report here, a person who normally drinks five drinks every day, day in and day out, is a binge drinker. That is not a binge. That is his normal drinking rate.

I ask you to consider changing the terminology, both in the objectives and probably the source of the data, and that is some of our surveys, particularly BRFS. Thank you.

DR. MEYERS: Thank you. Other comments on substance abuse?

MS. FORD GRIFFIN: Hello. My name is Janice Ford Griffin. I am the deputy director of Join Together, which is a national resource for communities working to develop comprehensive strategies to reduce substance abuse.

I would like to speak to three issues. They are addressed somewhat in the document, but it is certainly worth reiterating and casting an additional perspective on them.

One is parity of treatment for substance abuse with every other disease entity. We must have that, particularly in the private sector, throughout the nation.

I think to a large measure the government has tried to address it, to the extent that it is considered along with Medicaid in many states.

In far too many states it is separate and apart. The substance abuse administrations are not even part of the state public health administrations. That is a travesty.

The other issue is access to treatment, particularly with respect to young people. In far too many cities we have absolutely no adolescent detoxification for young people who have no means of paying.

Access to treatment is also important when you look at the involvement of family members and substance abuse.

We have a great deal of effort going on with respect to prevention for young people, but that is often totally disconnected from the access to treatment for a family member who may have a substance abuse problem.

Also, access to treatment with respect to how it has an impact on people becoming involved in the criminal justice system.

For far too many indigent people, the only access to treatment is through the criminal justice system. To the extent that we don't expand those opportunities, they will continue to be at the mercy of the criminal justice system as the only treatment of last resort.

Finally, the issue of self medicating for other disease entities. I don't recall seeing that in the document.

There are quite a few people who become involved in substance abuse as a result of medicating for some other illness or disease entity. Thank you.

DR. MEYERS: Thank you. Yes, sir?

MR. CHIAPPA: Good morning. My name is Joe Chiappa. I am the intoxicated driver resource center director for Camden County, New Jersey, and also the president of the state association in New Jersey. I would like to speak to a couple of issues.

First, the .08 recommendation for driving under the influence. I am speaking in support of that recommendation.

I also acknowledge the fact that accomplishing this on a nationwide basis is a very, very difficult task because we are facing a lot of lobbying against this.

On a day-to-day basis when I am dealing with drunk drivers, I see that most of the people that we deal with are well over .10 blood alcohol content.

I feel that if the .08 is instituted nationwide, that we would be more likely to get the .10s. They would be less likely to have people drinking and driving as a result of that.

Also, the drunk driving program is an interesting program, in that it does combine the criminal justice elements with the therapeutic community, and is the one link between the two agencies, both of whom have great resources in terms of helping persons who are identified as either problem drinkers or alcoholics.

I would support the notion of a more close working relationship between the therapeutic community and the criminal justice system, particularly in terms of drinking and driving. Thank you.

DR. MEYERS: Thank you.

MS. BEATTY: Alicia Beatty from the Circle of Care. In terms of access for women in drug treatment programs, women have children.

One of the problems we have found, certainly here in Philadelphia, is that there is a lack of accessibility for women with children to go into inpatient facilities.

There is a great need for more facilities where a woman can bring more than two children. We find that women do not go into drug treatment if they believe that the Department of Public Welfare will take their children away from them, once they go in and the family is split up.

MS. STURGESS: I haven't had time to read the section on substance abuse. I am not sure that gender and weight is included in the definition as we know it.

A person who is a smaller size can't drink the same amount as someone who is heavier. Maybe it should be included in the definition.

DR. MEYERS: Thank you. Let's give everybody a chance who hasn't commented on this one, and then we will open the floor up. Are there any new comments on substance abuse?

If not, we have gone through the 26 focus areas. We will open the floor for comments on any of these focus areas, or other comments that you didn't have a chance to make earlier.

We are going to keep the three-minute limit, but you are welcome to come to the microphone. Please, again, keep giving us your name and where you are from, and whether you are representing yourself or an organization. And please tell us what topic you are speaking addressing.

MS. LYNCH: I want to say this very clearly and emphatically. Mental illness is curable. Mental illness is curable. I am a shining example.

I have been med free and institution free for over four years, and I know I will never be in that position again.

That leads to my emphasis on research. We need to study those who have recovered. They have more to say than trying to figure out other elements of it.

I also want to say we haven't really looked at obesity in the proper light. As an obese person, I can tell you, it is not my emotional problems, it is not a genetic factor.

I have a nutritional or some kind of chemical -- what is the word I want -- imbalance or lack. I grew up in the goiter belt in Missouri, where I had meat, potatoes and canned vegetables.

It took me many years, and after raising six kids born seven-and-a-half years apart, which also drained from my system, to learn to like vegetables and fruits.

We really need to focus on nutrition as an element and also put toxic substances in our society, the impact on obesity.

DR. MEYERS: Thank you.

MS. MOORE: My name is Barbara Moore. I am with Shape Up America. I just want to follow up on that comment.

I am concerned about the profile of obesity in the Healthy People 2010 document, and I am not sure what the solution is.

I first went to the session on promoting healthy behaviors and promoting healthy and safe communities and the attendance in that session was a good deal less than the attendance in this one.

I think it is because when you talk about disease, people take you more seriously.

There have been two NIH consensus conferences that have identified obesity as a disease. I do think that the precedent has been set for considering obesity a disease.

It may well be that it belongs in this section on preventing and reducing diseases and disorders. I am really not sure about that.

On the other hand, it might belong, if there were a separate chapter on obesity, it might belong in the promoting healthy behaviors and promoting healthy and safe communities section.

Maybe it won't be taken as seriously in that section; I don't know.

In any case, I do want to raise the issue that it afflicts somewhere between 60 and 90 million people in America, adults, depending upon which definition of obesity that you use.

That doesn't even include children. About one out of four or one out of five kids in America is now defined as at least overweight, if not obese.

I really urge you to consider that obesity deserves a chapter of its own. I am not sure where it should be placed.

It may be that if it is going to be taken more seriously, it should be placed in this section represented by you people today.

I would urge you to consider that you need to have a section on childhood obesity and you need to have a section on adult obesity. I would submit that it is unlikely that children, for example, are overweight and obese for the same exact reasons that adults are. Thank you for the opportunity to comment.

DR. MEYERS: Thank you for your comments.

DR. ARCHIBALD: My name is Cheryl Archibald. I am a pediatrician with the New York City Department of Health and speaking on behalf of an individual.

I recently attended a national conference on quality health care for culturally diverse populations, which was sponsored by the New York Academy of Medicine in Manhattan.

I wanted to point out the fact that in the respiratory diseases section, the only culturally competent type objective is with COPD, chronic obstructive pulmonary disease.

I think that is very lacking. This should be something that is probably pervasive throughout the whole document, much less in respiratory diseases obviously, but in every single section here and in every single session, probably, as well.

What I found as a primary care provider is that you need to be able to be willing to engage in dialogue with your patients.

Otherwise, you are not going to know about some of the home remedies that they are trying. They might feel as though those home remedies are a lot more effective than any of the therapeutics that you are giving them.

If physicians are not sensitive to the fact that there could be other things that families are doing, then there is no way that they are really going to be able to have dialogue and have negotiation and come to consensus.

I think that not only should this be expanded upon in the respiratory diseases section, but it should be really expanded upon throughout the whole document. Thanks.

DR. MEYERS: Thank you.

MR. MARGE: Michael Marge with the American Association of Health and Disability. I won't go over all the identified objectives that I think should be revised or changed. That will appear in my commentary which I will submit to the Office of Disease Prevention and Health Prevention.

I do want to indicate that I do believe that there should be a recognition of the population of people with disabilities as one of the populations that should be tracked across all the chapters.

For example, when you look at access to health care, for example, people with disabilities have different kinds of health needs.

When we speak of disparities in health care for people with disabilities, it is quite different from individuals of ethnicity or of color.

For example, the study that was done at Baylor University by a researcher looking at women with disabilities, has discovered that the major complaint is that women in wheelchairs cannot have adequate health care by physicians who are uninformed as to how to do, for example, a pelvic examination of a woman in a wheelchair.

The first question they say is get out of the wheelchair, please, and get onto the examining table. They found that it was impossible.

Also, breast examinations are not easily accessible for women in wheelchairs.

So, the health needs of people with disability are different from the health needs of other groups that are listed throughout Healthy People 2000 and are being tracked adequately.

I urge you please to introduce people with disabilities as one of the populations to be considered throughout the entire document. Thank you very much.

DR. MEYERS: Thank you.

DR. FRELICH: Speaking partially for myself and partly for the state of Delaware, I sit on the disability pension committee of the state.

I would like to point out that we also have a real problem with disabled persons not being allowed to return to work because of minor differences.

The ADA apparently does not come into effect unless the patient himself has enough energy to appeal. There is no obligation on the part of the employer, including the state of Delaware, to try to make things easier for a partially disabled patient.

Number two, this second item may be inappropriate but I can't help but think about it. We have listened to a number of very valid objectives.

It seems to me that this is a wonderful opportunity -- not this group -- to look at these objectives and from these objectives decide what research activities should take place to reach some of these objectives.

We haven't talked about research at all as part of the objectives. Perhaps that is on purpose because of the way it is set up.

I don't think we should ignore the fact that these objectives actually outline a potential research program.

DR. MEYERS: Thank you.

MS. COLLINS: I am Sylvia Collins. I am speaking on two subjects, primarily for myself. When we talk about older adults and chronic illnesses, I didn't see anything mentioned about the older persons that are in prison.

Older men in particular that have been imprisoned and were given life and have not been paroled have tremendous chronic illnesses.

A lot of the prisons really look like they are nursing homes. I think you really need to pay attention and get them information on the rate of chronic illness and how much it is costing the older men who are in prison.

Unfortunately, it is very difficult to get people to want to take them on who, 40 years ago, was convicted of a murder. Even though the person might be 70 or 80 now, it is very difficult for someone to want to bring that person into their home.

So, I implore you to look at the aging prisoner and the high amount of chronic illness that occurs in prison.

The other topic I want to mention is health education and health literature. It is very important, if we want people to get the message, that the literacy level be addressed.

I think it very important that when the federal magazines and periodicals and pamphlets come out, that the reading level be assessed. I think it is probably higher than fifth grade.

There is no point in giving messages to people if they cannot understand them. It is very important that you really look at the reading level of everything that you put out for public consumption.

The other thing that I want to say is that, when we talk about cancer of the prostate -- and we know that is very heavy in African American men -- most of the pictures on the outside are white.

When you look at lupus, the same thing. Unless the periodical says, lupus in black women, the picture is white. That is giving the wrong kind of message.

If you would not be so bold as to use the ethnic group in which it is most prevalent, then try to at least be culturally inclusive. Thank you.

DR. MEYERS: Thank you.

MR. FROMM: Chuck Fromm, Multinational Business Services in Washington. Two quick points I just wanted to follow up.

My remarks are in the back, the written comments, and attached to that is a list of some 30 cocktails that contain more than an once and a half of hard liquor, if anyone is interested to go look up their favorite drink.

We are also making comments or a presentation at the national meeting next month, and we hope to have some additional data on serving sizes at that time.

Secondly, I realized that I hadn't mentioned the wine cooler issue when it comes to drink equivalence, which isn't even discussed in the formula which has been presented, which is just beer, wine and hard liquor.

That is something that I think also needs to be -- we need to take a close look at that. The popularity of those has ebbed and flowed, but the point about those is that as I understand it, they are quite popular among the younger crowd, and the percentage of alcohol in those is quite high, significantly higher than just wine.

Again, if we are talking about one drink, that is something else that needs to be addressed. Thank you.

DR. MEYERS: Thank you.

DR. SWEENEY: Monica Sweeney, Bedford-Stuyvesant Family Health Center in Brooklyn, New York. Having not read the mental illness section, I don't know if there is any indicator that talks about isolation.

I have a large geriatric population that I take care of. Many of them, most of whom are African American women in their late 70s, 80s and 90s, many of them are isolated.

They would never say they are depressed, even when asked. Isolation, as you get older and live alone and have fewer and fewer friends and outlets, becomes a major problem.

It is exhibited often by somatization, with coming to the doctor for issues other than the fact that you need to get out and interact with someone or call on the phone and interact with someone.

I think we need to be mindful of the aging of the population, of the number of single households, where the elderly will be living alone.

They may have mental illnesses that will not meet the traditional definitions. We need to try and decrease the amount of isolation in the elderly and make provisions for tracking it and having some statistics to address it. If there are no data, there is no problem, I understand.

The other issue addresses arthritis and osteoporosis. When I was in medical school -- and I graduated 20 years ago from my residency -- it was always said that there was no osteoporosis in African American women.

As the population is getting older and people are living much longer, I am seeing more osteoporosis in elderly women.

Someplace there needs to be some basic data collected on this, and it needs to be addressed as we go forward to 2010, a diagnosis to dispel this notion that it is not a problem in African Americans.

DR. MEYERS: Thank you.

MS. WALLER: Saundra Waller, Women's Christian Alliance. I, too, have not had the opportunity to read the manual, just to kind of flip through it. So, I apologize if this is in there, but I suspect that it may not be.

If it isn't, I am concerned with the rise of violence in this society, and most especially among youth and poor economic communities.

I served at one time on a youth fatality committee, a homicide commission here in Philadelphia, where several agencies came together collaboratively to try to determine what are the precursors, what are some of the things that we are overlooking that led to youth fatalities from zero to 21.

On that committee were those from the Department of Human Services in Philadelphia, the school board, the criminal justice systems, from mental health organizations. I represented Congresso de Latinos, because I was directing a program for adjudicated youth.

It is very important that there be collaboration among the different services or different communities -- we have talked a little bit about that in terms of other issues like being labeled and all.

All the other agencies need to collaborate in the area of criminal activity, and especially in the area of violence.

I am also concerned about domestic violence and the national trend of violence on TV and the media. I think that we need to take a look at that, because those are definite health issues.

DR. MEYERS: Thank you. Other comments?

MS. JENKINS: I am Jeanette Jenkins from Maryland, the state health department. I didn't want to miss this opportunity, since you have so many of the representatives from the different areas here.

After this document is put in final form, it will really then begin to be used in the states. As we used it in Maryland the last time -- Healthy Maryland 2000 -- from time to time there would come up questions about a particular objective; you know, how it is structured, what the numerator is, what is the denominator, what is included, what is excluded.

There are lists in there of the different agencies that I guess all of you represent, that are responsible for the different objectives.

Oftentimes, when you called up, there wasn't anyone there to tell you, you know, what your particular -- how to help address your particular concern.

I realize that there is turnover and these are going to be in place for the next 10 years. They represent a culmination of a vast amount of information and experts and so on.

To the extent that you can, if possible, assign an objective to one person and, if that person leaves, all the files get transferred to another person.

When you call up and try to get information so that, in the states as we are trying to use them, either to bench mark or as our starting point for development of our own objectives, all this information is not lost.

I think this is a wonderful process and we are all here trying to benefit from all of the many hours and efforts that have gone into it. I hope that there can be a way of keeping it in place as we start to use it after it is put in final form.

This is not just obviously for this particular section, but overall, in the way we use and maintain the objectives as we go forward.

DR. MEYERS: Thank you for that comment. That is also something that we are concerned about. One of the things we want to do is a better job up front documenting what was done and how it was done. Thank you for those comments also.

If there are no other comments, I want to thank you all for participating, both from the floor and the federal colleagues who are at the front and also now at the back.

Your comments have been recorded and a transcript of this session and the other sessions will be posted on the Healthy People web site. I encourage you to refer to that.

I also want to let you know that public hearings will be held in four other locations: October 21-22 in New Orleans, November 5-6 in Chicago, December 2-3 in Seattle and December 9-10 in Sacramento.

The comments that have been received today and at the other hearings, along with the written comments will be reviewed and used to finalize the national health objectives for the year 2000.

We want to encourage you to continue participating in this process by submitting additional written comments. As I said earlier, that if you have some today, that ODPHP staff, with the yellow badges, would be happy to take those.

Also, if you check the web site, you can submit comments through that or in writing.

Thank you again for your participation. This session is adjourned.

[Whereupon, at 10:55 a.m., the session was adjourned.]

Philadelphia Transcripts and Summaries