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 II:
Improving Systems for Personal and Public Health

MR. ALBA: Good morning. I would like to open this session. This is session II, public comment on improving health systems for personal and public health.

The first thing I would like to tell you is most important. While we won't be having a break, the coffee will be refreshed around 10:30. You can feel free to get a cup of coffee at that point and just bring it back to your seat.

This session covers chapters 10 to 15. To help assure a fair opportunity for everyone to participate in today's hearing, we will be using the same procedures as we used this morning.

First, each oral statement will be limited to three minutes so that we can hear from the greatest number of participants. The light will turn yellow when you have one minute left.

Second, each individual and organization will be limited to one oral statement for each focus area.

Third, we will allow 20 minutes of comments for each focus area. If time permits at the end of this session, we will continue for one additional hour.

I might add that the first focus area is very complex. It has four sub-parts. So, if for some reason, those of you that will be commenting on the first portion, which deals with access to quality health services, if we get to a point where we cannot hear everyone at the conclusion of 20 minutes, we will revisit that during the last hour.

Once again, I would like to ask each of you to introduce yourself by name, state of residence, and also please let us know if you are commenting on behalf of an organization or on behalf of yourself.

I would like at this point to introduce the federal experts that are here to clarify any points with respect to interpretation of the objective.

Theirs is an interpretive role, a role of clarification. We really intend to have comments here, rather than lengthy questions. I think everybody understands that.

If there are points of clarification that have to be made, it will be done in the following fashion:

Melissa Clark is here from HRSA. She is a work group coordinator for the focus area on access to quality health services and also is a member of the steering committee.

Evelyn Kappeler is here from the Office of Population Affairs in the Office of Public Health and Science, and is a work group coordinator for this area, that of family planning, and is also a member of the steering committee.

For maternal and infant health, Stella Yu. Dr. Yu is a work group coordinator for the focus area on maternal and infant health.

For medical product safety, Eileen Parish, from the FDA. She is a work group coordinator for medical product safety.

For public health infrastructure, Pom Sinnock from CDC. Dr. Sinnock is a work group coordinator for the focus area on public health infrastructure.

If you begin to queue up to the microphone, we will begin this session momentarily.

We are going to begin with the section concerning access to quality health services. Our first component is preventive care.

For those of you who would like to comment on preventive care, we would invite your comments at this point.

MS. THIEL de BOCANEGRA: I am working for the task force on immigrant health. Immigrants come from increasingly diverse countries and speak very different languages.

What we have found is that language systems and the services to provide linguistic access for preventive care as well as for primary health care, it is very haphazard.

In some states it is very excellently provided because there have been complaints at the Office of Rights. In other states, there are emergency systems developing. In a lot of states nothing is happening.

Now that we know that the immigrant and refugee populations are increasingly coming to every state all over the United States, not only to the east and west coast, but as well to other states like the Midwest and so on, I think it is very important to include objectives which address specifically the issue of linguistic access.

Things like; every non-English speaking patient should receive care with the help of a trained medical interpreter. Then it has to be defined later on what trained medical interpreter means.

Waiting time for a medical interpreter should be a maximum of whatever amount of minutes, or a facility that serves a certain percentage of non-English speaking patients in their patient population should have interpretive systems in place.

These are just some examples of things that we really should think through and should be included to that section.

Some federal agencies have developed guidelines -- the Office of Minority Health, for example, and I am surprised that I don't see it in there.

Similarly, in terms of developing cultural competency and how to measure cultural competency. Our suggestion would be to include developmental objectives for cultural competency, that systems have to be competent not only for the immigrant population but also for the disabled, gay, lesbian, for poor people, anybody who is different from the typical set of providers. Thank you.

MR. ALBA: Thank you. Additional comments on prevention?

I would like to invite comments on the second component, which is primary care.

The third component is emergency services.

DR. LOWE: I am Robert Lowe. I am a member of the faculty in epidemiology and in emergency medicine at the University of Pennsylvania and I chair a public health task force for the Society for Academic Emergency Medicine. I speak on behalf of the society.

We are delighted by the recognition in Healthy People 2010 of the role of emergency medical services in public health, including objectives concerning poison centers, emergency treatment of myocardial infarction, emergency care of children, emergency mental health services, recognizes the role of emergency medical services, promoting the health of the public, and such laudable goals for which the emergency medicine community can strive.

At the same time, I wish to point out a misunderstanding in draft objectives A-1 and C-2 concerning access to emergency care.

These objectives appear to confuse two issues. First, barriers caused by lack of insurance and second, barriers caused by insurers themselves.

The barriers to emergency care fall almost entirely into the latter, the insurer group. Emergency departments provide a disproportionate amount of care to the uninsured.

It is against federal law, contrary to standard emergency medical practice, to refuse care to the uninsured.

We are concerned that Americans in managed care plans do not have the same access to emergency medical care as do the uninsured.

Data that will be summarized in the written comments that I will submit to the web site later this week suggest the magnitude of the problem.

The limited data available suggests that about 750,000 Americans a year may be denied authorization to emergency care by their managed care gate keepers.

There is evidence that these participants are at increased risk of adverse outcomes.

We urge that objectives A-1 and C-2 be revised to more thoroughly differentiate the barriers to preventive care, primary care and tertiary care due to lack of insurance, compared to the barriers to emergency medical care due to managed care gate keeping.

We further urge that the goal for access to emergency medical care be set at 100 percent of Americans. We urge that data be collected through NHIS and other instruments to monitor access to emergency care. Thank you.

MR. ALBA: Thank you.

DR. FORSTATER: My name is Alan Forstater. I am a practicing emergency physician here in Philadelphia. I work at Thomas Jefferson University.

A couple of years ago I was the president of the Pennsylvania chapter of the American College of Emergency Physician, which represents 1,000 emergency physicians in this state. I am speaking on behalf of the Pennsylvania Chapter of the American College of Emergency Physicians.

My ER helps form the health care safety net for those people who don't have proper access to health care and require care emergently.

I commend the consortium for its wisdom for incorporating language in its documents which would promote access to the ER for the average prudent lay person, who is concerned that he or she has a medical emergency.

As you know, this standard was adopted as mandated in the balanced budget act of 1997, which governs coverage for managed care plans that participate in Medicare and Medicaid.

However, people with other managed care plans may not get that same coverage, and may not go to the emergency department when they truly need it.

I know of a senator in this particular state who was reluctant to go back to the emergency department, when he went to the emergency department for chest pains and was sent a bill because the managed care company refused to cover him for that chest pain.

Congress recognized how important the safety net was when it mandated the federal anti-dumping statute as part of the Social Security act.

Thus, there is no real barrier to care in the emergency department. Some people, though, are reluctant to seek that care in an emergency because their managed care insurance company has policies and procedures that impede that access.

What we need is a uniform definition of an emergency as in the balanced budget act, so that all managed care plans provide the same guidelines and provide the same basic information to their members about their rights as emergency patients.

In addition to mandating a uniform definition of an emergency, I would also ask the panel to recommend some minor but important changes to the final document.

In C-2, as referenced earlier, I would leave out the phrase by their insurance status. I never did turn those people away, the people who did not have insurance. Now I am forbidden to do so by law.

If you were to leave this phrase in, it creates a misperception that the lack of insurance creates a barrier, when in reality it is the managed care companies that create the barrier. Thank you.

MR. ALBA: Thank you.

DR. BERNSTEIN: I have a question. Can I speak to another section as a representative of the Association of Academic Emergency Medicine, since someone already spoke as a representative.

MR. ALBA: We would like to stay on the topic of emergency medicine at this point.


MR. ALBA: Go ahead, please.

DR. BERNSTEIN: I would like to speak to C-6, increase to 75 percent the number of hospital emergency departments that provide or arrange follow up mental health services for persons treated for mental health problems. We definitely support this.

I would like to add a friendly amendment, if it would be accepted. The emergency departments see over 370,000 ED visits associated with substance abuse or drugs, and over 10 percent of our patients are documented as being intoxicated at the time of admission.

There is an opportunity here for brief intervention counseling, obviously screening, and referral to care.

I would like to add to this amendment that we would include substance abuse in this objective so that it reads: provide or arrange follow up mental health and substance abuse services for persons treated with mental health and substance abuse problems.

MR. ALBA: Thank you.

DR. BERNSTEIN: I also want to support strongly the comments by my colleagues in emergency medicine. In reading this new document called the Institute of Medicine Report on Managed Care and Behavioral Care, shockingly they admit to behavioral health skimming, cost saving and dumping of their patients. I think the access issues are really critical in the managed care environment right now.

DR. DALSEY: My name is Bill Dalsy and I am an emergency medicine physician in Philadelphia at the Albert Einstein Medical Center, speaking on behalf of myself.

I would like you to consider the phrases placed in C-2 relating to barriers for patients who are uninsured or under-insured.

In practice, our hospital serves that community primarily. Every day, when patients come in who are uninsured, we have no problems taking care of them. There are no delays in their care.

It doesn't represent a problem for us in coordinating their care or finding the best things to do for them.

The barriers exist because of the administrative policies of insurance companies and managed care plans. I think it is very misleading the way it has been stated in the guidance. Thank you.

MR. ALBA: Thank you. Are there any other comments on emergency services?

I would like to invite the group to comment on long-term care and rehabilitative services.

Are there any other comments on the session concerning access to quality health services?

Okay, at this point I think we can move on to the next focus area, which is family planning. I would like to invite those of you who would like to make comments on family planning to be at the microphone, please.

MS. GORDIS: Hi. My name is Deborah Gordis. I am the director of government programs for Planned Parenthood in Metropolitan Washington. I am speaking on behalf of the D.C. Title X project.

I would like to urge you not to rephrase the family planning objective that describes the reduction in the number of unwanted pregnancies we are seeking to achieve.

It has been rephrased to increase the proportion of wanted pregnancies, which I think is a viable public health message, but not useful as an objective, for those of us who are struggling to provide family planning services in a hostile political environment.

The chapter presents very effectively the negative health outcomes associated with unwanted, unplanned pregnancies.

It is not a useful measure for those of us who are working to prevent -- cut poor neonatal outcomes and infant health outcomes off at the pass.

I think it is a case of the tail wagging the dog. While I don't disagree that it is the message that family planning providers need to be promoting in communities, as an outcome measure it is not going to help us do the job that we are trying to do.

The other comment that I want to make is that I am happy to see that there is a development objective on ECP, on emergency contraceptive pills.

I would recommend that the goal be that 100 percent of family planning clinics make this method accessible directly, and that it also be accessible in emergency rooms.

We have had experiences in Northern Virginia where several women have been turned away at hospitals, who come to hospitals seeking ECP.

They were told that it was either illegal or a lack of planning on their part, and did not constitute an emergency on the hospital's part.

It is a real problem and it is a very, very, very useful method for preventing unwanted pregnancies.

On that note, I forgot to mention that when you are dealing with teens, which is a real priority of Title X, I think it is really hard to think about what proportion of teen pregnancies would be wanted.

I don't think it is an effective way to deal with the adolescent pregnancy rate, which has been coming down. I think we should keep trying to prevent those unwanted pregnancies and maintain that as our objective. That is what I have to say.

MS. MULFORD: If I speak now, can I speak again on maternal and child health? I am the only person from my organization.

MR. ALBA: You can speak on each focus area.

MS. MULFORD: Thank you. My name is Chris Mulford from the International Lactation Consultation Association.

In Section 1220, there is a section on post-partum visits, lines 27 and 28. It says, during the post-partum visit, the woman should receive counseling about breast-feeding and family planning.

I would propose that we say, she should receive encouragement to continue breast feeding, and counseling in family planning methods compatible with breast feeding.

A big problem that we have is use of various kinds of birth control pills that decrease milk supply and they are freely prescribed by lots of obstetricians who are breast-feeding. It is a big problem for us. Thank you.

MR. ALBA: Thank you. Are there any other comments on the focus area of family planning?

At this point, we will move to the focus area of maternal, infant and child health.

MS. KLEIN-WALKER: I am Deborah Klein-Walker from Massachusetts. I am also representing all the state directors in maternal and child health in the country.

I have really a comment that is more of an organizational one. When I think of maternal and child health, it is a population. In fact, we deal with women of reproductive age, births, infants, youth, children, families, and children with special health care needs.

My plea to all of you working together at the federal level -- CDC and HRSA -- is that I know we will never organize it so that all the objectives for all those populations are under something that is called maternal, child, infant and family.

When this is all done, I would like someone to be responsible for taking the key indicators in each of these areas and producing a document which is like MCH.

This chapter is only a very small slice of what MCH is all about. I think everyone in here knows that. I just want to put this on for the record.

There are key indicators throughout -- physical activity, tobacco use, injury, nutrition, occupational setting, oral health, access to quality health services, et cetera, that relate to this population.

With that, I just want to make sure that in the end -- and we will work with you, our association -- to make sure that is reflected.

One key starting place would be to make sure that the performance measures, the states and the federal government, in partnership, just selective, are included in these. We have made a commitment already to certain things. I didn't check to see that the wording was exactly the same.

My next thing is if I do look at this chapter, I am not sure where the balance is of child health. I think there is an awful lot on the developmental period.

Now, I am trained as a developmental psychologist. I think development is important. Again, I think for us in the field we need a balance across this whole Healthy People 2010 that reflects on the entire population that we are serving. Thank you.

MR. ALBA: Thank you.

MS. MULFORD: Hello, again. I am Chris Mulford, representing ILCA, the International Lactation Consultant Association.

We are breast-feeding specialists with close to 4,000 members in the United States. I am just addressing objectives 29 and 30 on pages 12-28 and 29.

We are real happy to see objective 29. It is an old friend. It retains the targets from Healthy People 2000. These targets are quite modest, but they have yet to be attained by any subgroup of the population.

Objective 29 adds a new target for tracking breast feeding to the first birthday.

We are even happier to see a new developmental objective, number 30, on exclusive breast-feeding.

We need to be clear about definitions here. When we talk about breast-feeding, three measures are important. Initiation, which is how many mothers begin breast feeding, duration, which is how long they continue breast feeding, and exclusivity, how long breast feeding is the sole source of nutrition.

Adding other foods and grains to the baby's diet before about six months of age actually diminishes the protection from infection and allergy, as well as putting continued duration at risk.

You can see by the definition on lines 10 and 11 that objective 29 refers to any breast-feeding. Thus, it captures initiation and now it will follow duration up to age one.

We need objective 30 to complete the picture, by measuring the quality of breast-feeding in the first six months.

I will submit my suggestions in writing, but here are ILCA's suggestions. We suggest a revised definition of breast-feeding for objective 29.

It would say, breast-feeding is defined as either exclusive breast-feeding or partial breast-feeding supplemented with other foods or drinks. Breast feeding also includes feeding with expressed milk.

The words you see currently under objective 30 do not actually say anything about exclusive breast-feeding, although that is that objective.

Those three paragraphs actually talk about why breast-feeding is good and who should or shouldn't breast-feed, and how we are doing with breast-feeding.

I propose those three paragraphs be moved to objective 29, which is about breast-feeding. For objective 30 we propose three new paragraphs that talk about exclusive breast-feeding.

The first paragraph would define exclusive breast-feeding and say why it is important. The second paragraph will describe the kinds of support that mothers and babies require in the early post-partum weeks to get breast feeding well established, and this is the time of biggest drop off in breast feeding in the United States.

The final paragraph would tell what kind of supports are needed from the community, the work place and health care system, so that exclusive breast feeding can be maintained until the baby has a nutritional need for iron rich solid foods in the diet.

With these revisions that I will suggest, I know that breast-feeding advocates would find these two objectives very useful in their work, and we thank you for this opportunity to be part of the goal-setting process.

MR. ALBA: Thank you.

DR. REID: Good morning. I am Dr. Cheryl Reid. I am here on behalf of the New Jersey March of Dimes, and also informally as a representative of the Council of Medical Genetics Organizations, which is a consortium of all of the medical organizations dealing with genetic issues.

COMGO, the Council of Medical Genetics Organizations, had sent a letter at the time when the lists for the various chapters were being developed, indicating our strong desire to side with the recommendation of people within the Centers for Disease Control, to have a separate chapter on the issue of genetics.

The reason for this is that we felt as member organizations, and agreed with the Centers for Disease Control, that genetics goes well beyond maternal, child and infant health.

In fact, going through the book, there are a number of objectives that we would consider to be part of genetics, and various other chapters which are not cross referenced within the maternal and child health chapter.

It would be very valuable to put together all the genetics objectives and to add several that are relevant to some of the other chapters, such as references to cancer and a number of other adult onset diseases, in a separate chapter.

The reasoning for this is that genetics goes well beyond maternal and infant health and has broad reaching effects.

As you know, a very large amount of money has been put into the human genome project, and as a plan for looking at objectives for the next 10 years, I think the plan here should reflect our hope that what we learn from the human genome project will be translated into public health.

There are some supporting documents that are worthy of reference, one which was developed by the Centers for Disease Control about public health and genetics, a second document which was developed by the Council of Regional Networks in Genetics, called Genetics Services for the Public Health.

I believe that there has been a large amount of work gone into these documents to show that significant attention to genetic issues is quite relevant to a plan for the health of the United States.

I would like to just call attention to one objective I just looked at, which I think has some problems and ought to be re-thought.

That is objective 33 under maternal and child health -- I am sorry, it is 12, reducing the prevalence of serious developmental disabilities arising from events in the prenatal and infant period.

I think the way this particular one is written implies that mental retardation, cerebral palsy, blindness, hearing loss, are all primarily due to events in the perinatal period.

In fact, there is a very large body of evidence that shows that a very small percentage of these is actually due to perinatal events, and a very large percentage is due to other causes, including birth defects and genetic disorders.

The evidence is very clear that the majority of people who have cerebral palsy did not have a problem in the perinatal period. Thank you.

MR. ALBA: Thank you. Additional comments on maternal, infant and child health?

At this point I would like to move on to the next focus area, which is medical product safety. Comments on medical product safety?

Let's move on to public health infrastructure.

MS. KLEIN-WALKER: Again, Deborah Klein-Walker. I am really representing both the State of Massachusetts, in which I actually administer, in family and community health, the MCH, primary care, chronic disease prevention, the broad base.

I also will say that a lot of my comments are from the perspective of MCH.

I think it is great to have a chapter on public health infrastructure. The way these objectives are stated right now, it does not cover the full range of what we do in public health departments.

For instance, in tracking the Healthy People 2010 objectives, number seven and number eight, data collected for Healthy People 2010, I hope those could be expanded to include, again, the performance measures and other things that we are doing.

It says the source of data there is CDC and the National Center for Health Statistics. It is much broader than that.

For instance, I will go back to my comments I just said about MCH. I think the MCH bureau should be given the responsibility for tracking all the MCH objectives, and I mean across the whole life span.

The intent here may be broader, but it comes across narrow, and I want to make sure it is not that narrow.

Next, number 13, access to comprehensive epidemiology services. Epidemiology is one of the methodological services we use. It is not the only one in public health.

I would like that to be restated to include statistics, research, evaluation and many of the social science methods we use including epidemiology.

Public health does not just use epidemiology and it is too narrow. Again, that may be because a lot of us are not just doing the classic surveillance of communicable diseases, but a lot of research and evaluation that involves many social science methods, and enough point made here.

Number sixteen, collaboration and cooperation and prevention research efforts. It is not just prevention research efforts.

We in the states are doing a number of things related to health service delivery, research in evaluation, and prevention research.

I am worried that if we go out with a statement on just prevention research without the bigger pieces, we are going to miss many things we are doing in public health. I would like that to be reflected.

Finally, summary measures, I guess trained as a psychologist, I am very skeptical of the validity and reliability of complex summary measures, and I am not sure we should put a lot of time doing that.

I think it is best to pick a few sentinel indicators and follow them across.

If I were to add an objective, I would like to add one that says, increase the number of states who have an ongoing random household survey, similar to National Health Interview Survey capability; in other words, beyond the behavioral risk factor survey.

So, states will, in fact, have the capacity to track health status, access and utilization, risk behaviors, at the state and sub-levels of interest within that state.

I think that is an important enough piece in terms of what we have to do to collect data, that I would like to see that added.

Again, I think this is a good beginning. But when I read this, it does not look like the full range of the federal partners -- HRSA, SAMHSA, AHRQ, HCFA -- who has truly been at the table to shape this, so that all the pieces of public health -- prevention, community activities, to basically the direct service, quality improvement, assurance -- are all reflected in there. Thank you.

MR. ALBA: Thank you.

DR. TSOU: I am Walter Tsou, a public health physician. I don't know actually where this fits in the document. It could fit in infrastructure as well as anyplace else.

There is a real need for outreach workers in this country to go out there and be promoting and accessing disenfranchised populations, people who are culturally sensitive, people who are language competent, people who can help bring maybe populations who really do not understand how the health care system works in this country, to resources that are available.

It strikes me that it should be almost an explicit part of the training programs for this country that we have training for such outreach workers, and that every health department or every state encourages or tries to have these types of individuals in every local jurisdiction.

We sort of informally do this as a nation, but I think its ramifications go beyond its traditional areas of maternal and child health where they do outreach, the same way they do for sexually transmitted diseases.

We probably ought to be doing it for primary care services in general. I would like to encourage somewhere along the way, some critical thinking about the important role of outreach workers, the training for them, and the need for culturally competent and sensitive individuals for this nation.

MR. ALBA: Thank you. Additional comments on public health infrastructure?

MR. GUARINO: Hi, I am Mark Guarino, a county health officer in New Jersey. Just one general comment, but I think it is important, regarding the language in the narrative.

I think we should speak more toward the roles and the responsibilities of a public health system throughout the nation on a federal, state and local level.

I think infrastructure needs to be defined more in terms of some level of core consistencies throughout America in terms of what public health infrastructure is at all levels of government, governmental public health.

I don't know how we would write an objective around it, but I think it needs to be described better in the narrative, addressing the objectives that are already stated.

MR. ALBA: Thank you. Additional comments on public health infrastructure?

Our next focus area is health communication. Comments on health communication?

DR. WILCKE: My name is Burton Wilcke. I am with the State of Vermont Department of Health. Just a brief comment on the health communication priority area.

It seems like yesterday a discussion on work force needs and infrastructure needs in public health, that the clear need for health communication throughout all the areas of public health is an important one.

It is truly a cross cutting need, and the objectives don't fully reflect all of the skills and abilities and the needs in this area.

There needs to be a communication -- I guess yesterday and at the beginning of this session -- on even what public health is.

I would suggest that the priority area needs some expansion on the objectives related to those. Thank you.

MR. ALBA: Thank you. Additional comments on health communication?

It would appear that the public comment portion of the session is concluded. I would make one last final call in case anyone would like to comment, provide testimony, on any of the focus areas that have been described here. Yes, go ahead.

MS. MULFORD: Thanks for this opportunity. I am glad I was here this morning. I hadn't realized the medical product safety, which no one spoke to.

Definitely there are breast-feeding issues there around medications that can be used in breast-feeding mothers and also the effectiveness of breast pumps. There are good ones and bad ones out there. We will certainly look at that and submit something in writing to see if we can get breast-feeding issues into that section. Thank you.

MR. ALBA: Thanks very much. At this point, I would like to have an open microphone. We have covered quite a bit this morning on very, very complex areas.

It seems to me that it would be desirable, to the extent that you would like, to have some interaction on the points that were made or, for that matter, general points, which you won't be offering as testimony, but you might like to make.

Maybe to begin this, I could invite the federal experts to make some comments from their perspective. Beginning access to quality health services, Melissa, you may want to make some comments with respect to your observations.

MS. CLARK: Firstly, I would say I am here representing not only HRSA, the Health Resources and Services Administration, but also two other co-lead agencies, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Disease Control and Prevention.

I would like to thank everybody for their very thoughtful comments. Every comment will be considered equally as to content.

Please utilize the web site and the written paper. Be specific in your comments. Submit them. Disseminate the information to your constituency groups, make sure they review the document and comment. The more comments we have, the stronger the document will be.

MR. ALBA: Evelyn Kappeler from the Office of Population Affairs.

MS. KAPPELER: I would just like to reiterate Melissa's comments. Your written comments and suggestions are extremely helpful to us.

If you think we have missed the mark, omitted something important, please be specific, and urge your colleagues also to comment on the relevant chapter.

MR. ALBA: Stella Yu from the maternal and infant health program.

MS. YU: I want to thank you for your comments. I think it has been a fairly difficult task, if you remember the last maternal and infant health chapter for Healthy People 2000. We only have 17 objectives and now we have 39.

I would really like to seek your assistance in refining the objectives and see if we could streamline a little bit, to reflect the MCH priorities of the nation.

Also, I would like you to know that the child health was added into the chapter at the very last minute. The work group really did not have an opportunity to deliberate on child health objectives.

It appears that it is sort of missing. Again, I would like to invite you and your constituents to help with this particular aspect.

MR. ALBA: Eileen Parish from the Food and Drug Administration.

MS. PARISH: I just wanted to echo my colleagues' comments and thank all of you for your participation. We at the agency are looking forward to any comments that come in after this meeting.

If you need to talk to me after this meeting, I will be available. Thank you again.

MR. ALBA: Pom Sinnock from the Centers for Disease control.

MR. SINNOCK: Ditto on thanks for all the comments. These are really not our objectives; they are your objectives. It is extremely important that we do hear your input and they become ultimately meaningful to you at local and state levels.

Public health infrastructure is a new chapter this year. We really value your input really trying to understand and communicate what that public health infrastructure is.

There are sessions. There was a session yesterday morning that dealt with infrastructure,and this combined meeting, I think, has given us some great input that we can certainly take into consideration in revising these objectives.

Again, thank you on behalf of all the work groups that helped put these together.

MR. ALBA: Would anyone like to make any additional comments at this point? There is a continuing session in Wyndham A. I would like to invite all of you to attend that session.

That is the first session and that deals with the promoting healthy behaviors and promoting healthy and safe communities.

At this point, I would like to conclude -- go ahead, please.

MS. THIEL de BOCANEGRA: I would just like to make a general comment concerning getting the information and getting our comments in.

It was referred to us earlier that we are the guinea pigs, so that we are like the first public meeting.

Just from a community perspective, this book is very intimidating. It is very thick. Nobody really has time to go through all the issues.

Some parts, especially community organizations work perhaps only with HIV or only with MCH. Perhaps you might get a larger response if it breaks it down into chapters and sends it to key persons in certain regions and ask them to just review chapters and ask for input of only specific chapters.

I don't have time to read all of it or to see which passages are interesting. Perhaps there are people who are only interested in MCH, working on it, and they are only interested in the 10 pages that relate to MCH. This is something they might be able to review carefully, instead of the whole book, which is sort of a lot.

Just a comment, that is a general comment in terms of proposals.

MR. ALBA: Thank you. I would like to invite you to go to session at Wyndham A. At this point, I would like to conclude this public hearing. Thank you very much. All of your comments will be carefully considered.

The first session has concluded. Session III is in the Conference Center Hall. Thank you.

[Whereupon, session II was adjourned.]

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