DEPARTMENT OF HEALTH AND HUMAN SERVICES
Meeting of: Secretary's Council on National Health Promotion and Disease Prevention Objectives for 2010
September 12, 2000, Proceedings

Agenda Item: Panel: Translating Healthy People 2010 Objectives into State and Local Action

DR. SATCHER: Following up on Randy's comments, for the rest of the morning and afternoon sessions, we will attempt to address particular subject areas or sectors of society in which we need to increase outreach to other partnering organizations, or potential partners in some cases, and to orchestrate their energies with the energies here. So we're going to begin with organizations, states and localities.

Forty-seven states had their own Healthy People 2000 plans. What we are trying to do now is to make sure we get all 50 states to develop 2010 implementation plans. So, as our agenda item: to follow the challenges to seek out and explore new pathways for translating Healthy People objectives into action.

Each of the panel discussions to come will include a moderator, who will introduce and interact with several invited guests, who will then make their presentations about their special field of interest or occupational experience. For the rest of the present hour allotted, the Council members are invited to join in after these discussions with an exchange of comments and questions.

The first panel dealing with states and localities will be moderated by Dr. David Fleming. David is the Deputy Director for Science and Public Health of CDC, and a former state public health director for Oregon. David...

David Fleming/CDC (Moderator)

DR. FLEMING: Thanks, Dr. Satcher. It is a pleasure to be here. Good morning, everybody. Welcome to the panel presentation on Translating Healthy People 2010 into State and Local Action. This morning's presentation is of special importance to the success of Healthy People 2010, because it focuses on how we as public health practitioners can work together across federal, state and local lines to get the job done that needs to be done.

As you heard this morning, Healthy People 2010 provides us with a wide range of possible public health opportunities for the 21st century. In the best of all worlds, Healthy People 2010's 467 objectives and 28 focus areas represent a vision for where we need to be heading in public health. But that's in the best of all worlds.

The cynic, and perhaps even a realist or two among us, might say that right now, Healthy People 2010 is just words on paper. They are going to stay that way -- good ideas with little relevance unless and until the front lines of public health adopt them, build on them, and use them to get done what needs getting done.

We are going to be hearing today from those front-line folks throughout the day, starting with state and local public health departments. Now, as you've heard, and in the interest of full disclosure, although I have been on my job for a full two months now at CDC, my past has been at the state and local level. I served at the Oregon Health Division for the last 14 years, so I confess I do come into this with a little bit of a bias. But even so, I think I can safely say that the success of Healthy People 2010 will in large part be determined by state and local health departments, and the extent to which they build on the foundation that is laid by this document.

Healthy People 2010 is going to remain words on paper unless and until it is used -- it is used for advocacy; it is used for community mobilization, in the adoption of best practices and for evaluation. So in short, and to summarize, Healthy People 2010's real value is going to be its ability to influence the way that we do the nuts and bolts of public health practice. This morning's panel is uniquely qualified to talk with us about how they have begun to do that.

I understand that we have some problems with our PowerPoint. So, what we are going to do is go with the panelist that is not counting on a PowerPoint presentation as the first one. I believe that's -- George? Christine? Elaine?

MS. O'KEEFE: All I can say is, that's why we say, when the going gets rough, we count on local health.

DR. FLEMING: That's right. What we are going to do is invite each panelist to give up their presentation. We are going to have them sit up at the front to have an opportunity for a group discussion afterwards. Elaine?

Elaine is going to be going first. She comes to us from the state of Connecticut. Ms. O'Keefe is the President of the National Association of County and City Health Officials, and the Director of Health in the Stratford, Connecticut health department. For her last 15 years, she has worked on public health at the local government level. She has been the principal author of several innovative projects in the past decade, including the first legal needle exchange program to emerge in the state of Connecticut. She is nationally regarded for her work in HIV prevention, primary health care initiatives, community-based health care planning, tobacco prevention, and environmental health efforts.

Under her leadership, the Stratford Health Department was selected as the recipient of two national awards for outstanding achievement, one for advocating primary care services, and another for excellence for creating healthy communities. Ms. O'Keefe holds a Master's degree in Public Health from the University of Massachusetts at Amherst, and she's a graduate of the CDC Schools of Public Health, Public Health Leadership, and the Institute of Scholars Programs. Elaine?

Elaine O'Keefe, Stratford (CT) Health Department

MS. O'KEEFE: Thank you for that flattering introduction. I thank you also for the opportunity to speak with you today on the implications of actually trying to implement Healthy People 2010 at the local level. I also want to say, as an aside, that I think the fact that I am starting first is really appropriate, because if we are talking about bottom-up planning, we should begin with local perspectives, and not go from national to state to local, which unfortunately is more the norm.

I am here, as you know, representing local public health from a national standpoint as the President of the National Association of County and City Health Officials, which is otherwise known as NACCHO. But I am also here, first and foremost, as a local public health practitioner who has devoted her entire public health career to working in local governmental public health. I have been working in local public health agencies for nearly 20 years, in various settings, urban, somewhat rural, and suburban.

I speak today very much from that intimate experience, working with local communities. Stratford, Connecticut is a community of approximately 50,000 people. It's a very blue-collar industrial community, but in many ways, I see it as a typical community, the kind of community where the goals will play out and the work will play out in implementing the objectives that are provided in Healthy People 2010.

I wanted to talk a little bit, though, also about NACCHO as an organization. This organization represents approximately 3,000 local public health agencies across the country which are governmental public health agencies. The principal mission of NACCHO is to serve as the national voice of local public health. I think, very importantly, NACCHO is increasingly visible in Congress in advocating for progressive public health policy that will ultimately have an impact on improving the efficacy of local public health practice, which is the other main function of NACCHO, that is, to enhance our effectiveness as local public health practitioners. I would submit that we are increasingly doing that better, in large part due to partnerships with many of the people and agencies that are represented in this room.

The local public health system in this country, if you want to call it that, is quite diverse, as I'm sure you realize. In every state you will find a different system. There are states that have county health departments. There are states like Connecticut where you have a multitude of very small health departments representing a single municipality, or health departments that comprise a number of small communities that are known as health districts.

But if you look at this, I think this is a sobering statistic, in that the median size of a local health department is a staff of 20. So that speaks to our capacity. The size of the population served in the majority of local health departments, that is, 67 percent, is less than 50,000. Yet, we are responsible for a whole gamut of public health services, most importantly, improving the health status of the populations that we serve, and insuring that our populations also have access to a wide array of public health services.

I want to commend everybody who was involved in producing this mammoth effort, this project, Healthy People 2010, and to say that I really believe we can use Healthy People 2010 at the local level and at the state level. There is a gap that we have to cross before we can do that. However, it is something that I hold as possible for a variety of reasons.

First, I want to say that I believe that the overarching goals of Healthy People 2010, and also the philosophy that underlines Healthy People 2010, that is, the goals of improving not just health status, but the quality of life that we lead, and eliminating health disparities, not reducing, but eliminating health disparities, is very much in harmony with the current paradigm and philosophy of local public health practice. Also, the notion that individual health is inextricably linked to community health is very much in keeping with the local public health practice today. So I think that, philosophically and in terms of our values, we are very much consistent, and I think that is very important as a starting point.

However, there are certainly challenges that have to be overcome. Some of these challenges have already been articulated here today. How do you take a document that contains 467 objectives and make that manageable for a local community or a state.

I'm not going to speak so much about state level plans today, because there are others here who can do that better than I. But I can tell you that, I'm sure you are aware, there is tremendous variability in health status from state to state. There is also tremendous variability in health status from community to community.

What will happen, realistically, is that states, as you know, will develop plans that will attempt to align with Healthy People 2010, but have to also reflect the characteristics and needs of their particular state. Because Healthy People 2010 is a national plan, the priorities that are represented in the objectives will not necessarily be embraced as the most dominant concerns and priorities in states and local communities.

Local health departments, in turn, will play a pivotal role in helping to craft state plans that will line up with Healthy People 2010. In fact, oftentimes what we see is that local communities and public health agencies play a critical role in that planning process. They will create plans that will ultimately comprise the state plan, what we call the roll-up.

One example of that that is a good example is the Idaho -- we can talk about that later. There is a plan that has already been produced by the state of Idaho that was actually choreographed by local health departments which came together -- it's a county system -- and have already looked at Healthy People 2010, using the Leading Health Indicators to craft their own plan, which is now the state plan for Idaho. But that just ties in with the whole idea.

One of the ways that we will be able to apply Healthy People 2010 at the local level is by focusing on the Leading Indicators. That's another theme that seems to be coming out here today -- that if we can focus on those and use those as a framework of sorts, we will be able to mesh local plans and state plans into HP2010.

One of the ways that we will do that locally is by going through the community planning process. A lot of local health planning these days, and appropriately so, is very much engaged in creating partnerships with other organizations, and looking at local public health, not only in terms of the governmental public health agency, but in terms of the public health system which, as you know, is also the way that we have created the national performance standards, as standards that measure a public health system, not only the local governmental public health agency.

One of the tools that will really help us in this process at the local level is a tool that was developed by NACCHO called mobilizing action through planning and partnerships. This is an extension of APEX, which I am sure many of you are also familiar with. That is a tool that was used for many years -- a protocol for excellence in public health -- both to look at the organizational capacity of local health agencies to do community work, and then there was a second part of that, which engages communities in actually identifying health issues in their communities and coming up with action plans and measurable objectives.

I had mentioned that there is a plan already in existence based on Healthy People 2010 Leading Health Indicators. That is the plan that was produced by Idaho. I have some copies of it that I brought along with me today, probably not enough for the Council, but I will leave those if you would like to distribute them. I think this is a very good example of the way the Leading Health Indicators can help states and local public health agencies to begin aligning with the goals of Healthy People 2010.

In addition to the Leading Health Indicators, which I see as one of the main features that will excite and interest local public health agencies in embracing Healthy People 2010, the fact that we have an infrastructure chapter is also generating a tremendous amount of excitement. If we really want local public health agencies to become involved in sustained community health planning and working with communities and partners in communities, they have to have the infrastructure to do that. This infrastructure chapter will help us to move towards strengthening the operations of local public health agencies as well as help make the case in Congress that we need more funding for infrastructure.

As I'm sure you know, there is a bill now, the Frist-Kennedy bill -- also a bill in the House, the companion bill -- that will actually address some of the infrastructure issues. I believe that these objectives, as we gather data to support the need for infrastructure, will help us to bring increased attention and resources to bear on building the infrastructure of public health.

One of the concerns about this chapter however, is, because all of the objectives are developmental, we will need to refine those objectives. We have to identify what the infrastructure issues and objectives are and how we can gather data that will tell us more about needs and infrastructure, and also help us to mark progress that we are making in building infrastructure. I want to tell you today that NACCHO is very committed to be part of that process and to poll local public health agencies and to come up with ways that we can do that together.

They put up there a local example of Stratford, Connecticut. I'm not sure why they did that. I don't know if they want to point us out as an organization that is weak in infrastructure or one that is strong. I have to tell you that the state of Connecticut has far to go in building infrastructure. I know that I am in good company, unfortunately, when I say that. At present, the state of Connecticut contributes a range of 50 cents to two dollars per person per year for the local public health system.

So what are some of the opportunities that we have to begin really engaging local communities in Healthy People 2010? I think there are many.

First, I want to thank everyone who was involved in creating the marketing plan, because you have done a wonderful job. I talked to my colleagues; they are aware of Healthy People 2010. Many of them actually had a voice in commenting on Healthy People 2010 during its formative stages. So the knowledge is out there; people are aware of it. The CD-ROM has been very helpful; you can get it in the hard copy. As you say, 7,000 have been distributed. And we can do a lot in NACCHO to promote it even more.

But I really would encourage those of you who will be making decisions about how you are going to promote it further, to keep focusing on the Leading Indicators, and to even raise those indicators, so that we can look at those as a starting point. Looking at the 400 and some objectives can be paralyzing; it really can be. It can be very intimidating. So if we use the Leading Indicators as a starting point, we have a much better chance of engaging the enthusiasm of local public health practitioners.

We also need to highlight more the infrastructure chapter because, as I mentioned, that is going to generate a great deal of enthusiasm and commitment.

Another way that we can secure local participation is to promote the use of the tools that I just mentioned, the map tool that was developed by NACCHO. There is a tool that is very similar that is focused on environmental health issues, called PACE, which I will talk about on the next panel presentation. Then there is also a tool that was produced by the Public Health Foundation, a toolkit that many of you may be familiar with.

We need to start getting those out, and not just distributing them. I think back to when the EPA distributed the Tools for Schools kit. Many administrators, including those in my town, had that kit sitting on their shelves, but they didn't go deep enough; they weren't actually using it. We had to find ways to run workshops, for instance, to make personal appeals to people so that they begin to use those tools, and it wasn't just a piece of paper sitting on a shelf. NACCHO, again, can help tremendously through workshops around the country, through conferences and publications, to promote the use of these tools.

Another way that we can work together on Healthy People 2010 is to look at local success stories. If I have a few moments, I'd like to show you just a few slides from my own Healthy Stratford initiative.

This initiative was created without any attention to Healthy People 2000, I have to tell you. We just did this. It was a community-driven initiative. We started this five years ago in Stratford. It was the first time we attempted a community-wide health assessment and health planning initiative. We started out, appropriately, with a very diverse group of people from our community, from the faith community, from the schools, people who run neighborhood organizations, environmental activists, a real cross section of community people.

We began with a vision. We asked people to envision a healthy community. Their vision of a healthy community, as you can see, is one that embraces a very holistic definition of health, that is virtually based, that looks at diversity in the community, that looks at respect for the environment, for people from the beginning of the life span to the end of the life span.

We moved from that to a mission for the organization, and we began eventually to look at data. They were interested in the leading causes of death. Now, we pulled this data from the state department of public health, the Connecticut Department of Public Health. I have to tell you that, you can see, it is not very timely. We were starting this initiative around 1995. That was the best data we could come up with for years of potential life lost. So we began with that but, at the same time, we did a community perception survey. The volunteers, who were part of this healthy community group, went out and talked to 900 people in the town of Stratford and asked them what their perceptions were of the leading health concerns in Stratford. As you can see, they didn't focus on disease and disability so much as they focused on the risk factors that contribute to these diseases and disabilities.

Then we went from that to looking at how the council wanted to prioritize its work. We came up with the seven topic areas that are listed below.

The reason I am presenting this to you is that, even though we may not start with Healthy People 2010, I think it is pretty obvious that existing healthy community initiatives will naturally mesh with the objectives you set in these mammoth documents. If we look at the 10 Leading Indicators, and if you look at most of the healthy community initiatives that are ongoing around the country, you will find that it will be very easy to merge these initiatives.

I would also suggest that another way that we could increase the implementation and the connection of Healthy People 2010 to local efforts is to feature some communities that are already doing this work -- you know there are numerous healthy community initiatives around the country -- and ask them to serve almost as a pilot, to see if they can integrate and compare how what they are doing relates to the Healthy People 2010 objectives, and begin to use that. Now, that may not be a novel idea, but it is something that I think we should seriously look at as one of the ways that we could implement these objectives at the local level.

So, thank you.

DR. FLEMING: Thank you, Elaine. Let's move on to our next panelist, Christine Grant. Christine comes to us from New Jersey, where she is the Commissioner of the New Jersey Department of Health and Senior Services. She has been with the Department since the late 1980s, where she started off as the Deputy Commissioner. She brings extensive private sector experience as well through her work at Merck and Company and as a senior program officer at Robert Wood Johnson Foundation. Ms. Grant has a BA in zoology, an MBA from the Wharton School, and a law degree from Rutgers. Welcome.

Christine Grant, New Jersey Department of Health and Senior Services

MS. GRANT: Thank you. Welcome to all of you, and thank you for having me.

I am here today to address with some particular focus what New Jersey's Department of Health and Senior Services is going to be doing to accomplish our helping New Jersey 2010 goals. I am here representing, of course, the Department. I happen also to be sitting on ASTHO's executive committee at this point in time.

New Jersey is a poster state for the diversity of America as it will probably be five years from now. It may be small geographically. It's the most densely populated state in the country, with eight million residents. It is the ninth largest state. It's one of only two states -- despite being called the Garden State, unfortunately -- which has no rural designation. It is also one of the most urbanized states and yet has only three municipalities with populations in excess of 100,000.

We have a complicated system of local health departments, home rule. That's been there for 300 years and is likely to be there for the next century -- 116 local health departments serving 566 municipalities. We, of course, are trying to work with our local partners to rationalize that system through what is probably familiar to many of you, the LINKS initiatives, and other collaborations with our federal and local partners.

We have 83 hospitals. We have, in a sense, the benefit of one statewide university of medicine and dentistry, which has nine schools, including three medical schools and a dental school.

Clearly, we are also diverse racially and ethnically. Fifteen percent of our population is African-American, 12 percent Latino -- and of course the Latino population is the fastest-growing population in the state -- and six percent Asian-Pacific Islander. We have, in fact, the highest percentage of Asian-Pacific Islander residents in the country.

Clearly, we look at diversity as a strength. Those of us who have been part of Governor Whitman's administration -- I would say that this has been a trend for several previous governors -- have focused on what we call "New Jersey: Many Faces but One Family". So we welcome and have embraced the diversity goals of Healthy People 2010.

Parallel to developing 2010, there was a lot going on, as I think you will hear from other colleagues, that is very much aligned with the program. A year ago -- not only as a part of the 2010 process -- a year ago when I took office, I had the opportunity to launch our first African-American statewide summit. The governor was there; we had colleagues from the federal and state governments. This June we had our Latino health summit. We have a long-active Office of Minority Health, which has done such programs as county-specific goals: to have access to minority health services guides and, of course -- as it is a Leading Health Indicator -- New Jersey has a program that was put together to help our minority populations access these services.

We created videos from our summits. It was not a trivial exercise to try to engage the public and get public attention. I think that's a theme. That's something which has to continue every day, day in and day out, and it is not easy to do. Recommendations are coming to me shortly and will go from me to the governor.

As with many states in developing 2010, we developed it with other state health agencies -- health, human services, law, public safety, environmental protection -- brought in, in the process of how to work with partners. It started several years ago when we were developing 2010. Obviously, these are the same partners that will help us achieve these goals -- all our advocacy groups, community organizations, academic institutions and local health departments. I am pleased to say we made special efforts. Our state medical society is not only very active in public health, having taken an active role in the care program, but actually day in and day out was able to engage its members, as have our county pediatrics and AFP groups.

We held formal focus groups. We had a statewide poll. We listened to those public comments on the front end. We had published the results in our Web site. We try to use the Web site for interactive dialogue. Our thinking was that the diversity on the front end and the input is what's really going to need the strength that we have to sustain despite the political and economic winds over the next 10 years.

New Jersey's diversity actually was very consistent with the Leading Health Indicators and the focus as we heard it from our population. Cancer, HIV, heart disease were identified by the public as the most troubling health concerns that we should focus on through additional public hearings. We added occupational and environmental health.

I want to take time to focus, just very briefly, on three substantive areas, because I think they illustrate how we are trying to institutionalize this effort throughout our ongoing public health activities, and how we intend to engage our colleagues and our partners as we go through the process. So they are illustrative of the themes which, from the matrix perspective, are necessary to carry out Healthy People 2010 for all of our objectives.

Clearly, we have embraced the goal of eliminating racial disparity in access to and outcomes of health care in New Jersey. However, it was very clear and continues to be clear that, as we struggle with the ability to balance realistic, intellectually honest goals, we had to focus on what was achievable with the national goal of elimination -- that is, reduction versus elimination.

I would say that where we are is that we have remained very consistent with the principle of eliminating racial disparity. But we are prepared to use compromise in a good sense, in how we describe, explain and approach that goal in the intervening years as we move through this decade.

The struggle was evident in our focus groups. I for one embrace that struggle. I think that that helped to get some public attention on what otherwise would have been a ho-hum, we'll just eliminate disparity, and the public would have moved on without having been forced to intellectually embrace and understand what this might mean. It is not always pleasant being on the receiving end of some of these conversations, but I think that that is our role. I say that, because I think that will be a continuing struggle throughout the country.

We obviously also learned that many states have great difficulty setting targets in a constantly changing environment. Eliminating and reducing racial disparity, and access to and outcomes of, not only relates to the speed at which new medical information and technology is uncovered, but also disseminated into the population. We know that, of course, that is an additional factor on top of the socioeconomic status, the differing educational status.

In a state like New Jersey, where we have an ever-increasing influx of residents new to the country -- we say in New Jersey, people for 300 years have made New Jersey their first stop. They tend to be young and poor. They will move in the economic mainstream, but the first few years in New Jersey are difficult years for them and important years for us in public health.

So with this in mind, we created two targets for each of our 142 objectives. One is the target for reduction, which will significantly -- and it always has to significantly -- narrow the gap in disparity. The second is the preferred 2010 target, which would completely eliminate racial disparity. In about 10 percent of our objectives, the interim target is less ambitious than the complete elimination.

In New Jersey, we have, of course, as have many states, targeted the reduction and elimination of the disparity in black infant mortality for a number of years. In 1998, there was a blue ribbon panel convened, which was followed by a commitment of the governor for over a million dollars to be used for a statewide public awareness campaign, not only addressed to African-American women and their families, the general public, but also, most importantly, providers, physicians and nurses, to begin to grapple with this issue. That will continue and obviously fits very nicely into our Healthy People 2010 goals.

So here, very briefly, you will see an example of trying to have both a target, which would be reducing black, non-Hispanic infant mortality from 15.1 to eight, with a preferred end-point that would be identical to all other populations. Clearly, in our state, as I would imagine in some other states, we have special issues related to the current prevalence of HIV, substance abuse, newly-arrived residents who have not previously had nutrition or access to prenatal care that they now will have access to.

That has made this a particularly difficult issue to face with respect to saying -- it would be very easy for me and perhaps more politically correct to easily say -- we will eliminate it. I would love to eliminate it; we all would. But I think that this helps us in our case engage the public to struggle with why we can't eliminate it and then get a little more real about the process.

Eliminating racial disparity starts at home in our own public health family. I have done two things in the Department. We have instituted a planning process, to begin with, to set priority goals. This year, for the first time, I insisted that every division -- even, for example, our senior services division, which is a very large division, and our health services system division -- identify a racial disparity goal that ties into Healthy People 2010. If it's not measurable, it's not going to get done. They are on the hook, for example, in health systems, to address the issue of reducing disparity and access to cardiovascular care, an issue which wouldn't ultimately have come up within that division, had we not focused on that.

In addition, we have institutionalized a cultural competency training program for our own staff in order to assure that we have people well trained -- not only within the public health centers, because they work with the constituent groups -- to really understand. I sometimes think we take for granted that we in public health have the answers with respect to cultural competency, and I don't think that is necessarily so. So that has been very important to us.

The couple of areas I'm going to focus on -- first is our tobacco control program. New Jersey is very fortunate in having a legislature and a governor that have dedicated virtually all of the tobacco settlement to health care in general, over $30 million to tobacco control in particular. So fortunately, the state was well positioned to jump-start Healthy People 2010 with respect to tobacco control.

As was suggested earlier, concerning getting down into the aquifer of our youth, we are clearly going to be emphasizing -- and already have our baselines in place -- to look at baseline smoking patterns among youth. I can go into that if anybody is interested. Our focus will clearly be on seeding the state with youth leaders. We are going to have a 500-youth Kick Ash weekend this fall, as I'm sure you will hear from many states. Those seedling youth leaders will be going back to schools and communities, working in sync with local health departments, community coalitions. Our New Jersey Breathes coalition includes over 40 advocacy groups, heart, lung, cancer society, medical society, as well as our local community societies.

So we are very pleased we are able to incorporate most of CDC's five-part recommendation in our strategic plan. We feel a tremendous sense of urgency, so we don't lose that money, to show early results, as I am sure all states do. So our legislature continues to support it, as will inevitably the next governor in a year or so.

So the point I am making there is how, on the front end, we have already incorporated a cast of characters that we are very committed to working with and funding. Obviously, it is important to put your money where your mouth is. Our local health departments and advocacy groups have already received tobacco control funding to work in sync with each other.

Cancer control is somewhat -- despite the fact that, if we look at Healthy People 2010, look at New Jersey's cancer indicators, unfortunately, we lead the country in a number of cancer rates. So this has been a program that has not been -- we have always had a very good cancer registry, but we have not really had an organized approach.

We have already implemented our internal strategic plan. Once again, it had a matrix approach, so all of our divisions can pull together with respect to focusing on specific cancer objectives. We were very fortunate that Governor Whitman provided two point some million dollars last year to focus specifically on reduction of racial disparity in access to and outcome of cancer care. That is an area in which we are relying very heavily on our faith-based community, as the window of information to and access for many of our African-American population, particularly, of course, African-American women and men who are at risk for prostate cancer.

Basically, our goals in working with the stakeholders and partners are, obviously, to disseminate information, to collaborate on specific activities. The techniques are fairly typical techniques. We have already had periodic meetings, and we will have regularly scheduled meetings.

One thing we are trying to do, and meeting with mixed success at this point, is to encourage every advocacy group or stakeholder group to look at their own internal strategic plans and identify explicitly, wherever possible, their Healthy New Jersey 2010 agenda. For example, something called the New Jersey Forums Institute, which itself is a coalition of coalitions, is beginning that process. SSOPHE, our State Society of Public Health Educators, has embraced that process and that clearly reinforces and institutionalizes this. We are also looking at our own statewide advisory boards and councils to educate them about 2010 and then to encourage them to begin to set priorities consistent with that as well.

I would say we have not done a whole lot -- business partners are routinely involved in our statewide commissions. We have reached out to Partnership for Prevention, which has Robert Wood Johnson support to have their Healthy People Business Advisory Council, and we are poised as the opportunity presents to really build on that effort.

Wearing an ASTHO hat -- not formally, but certainly as a member of that group -- clearly we all support the rebuilding of the public health infrastructure. We, as I think you will hear from many, many states, are increasingly trying to get up the learning curve and implementation curve to use electronic education. We realize that it is going to have to start with strengthening local health. In our state, for example, we have already provided the hardware and some software, and through the LINKS program and the bio-terrorism activities, are making as best use of them as we can to pull into position local health to then carry out Healthy People 2010 and to improve and share data.

To achieve these goals, we have started what I like to call e-public health. It feeds nicely into 2010. It was started in parallel to 2010, but its goal is to create -- this by the way is our Web site. We have a little matter of West Nile virus, which takes my time every now and then. This will be increasingly our way to communicate with and create a dialogue. We now have an E-mails to the Commissioner screen, where people can write in and talk about 2010 and, I'm sure, many other issues as well.

What we really want to do in e-public health is to create a, one, portable, web-enabled communicable disease reporting system that is user-friendly on the front end, for hospitals, physicians, labs, local health officers to track. I think this is a rate-limiting factor. We can talk easily about some of the 2010 goals, but when we are asking health providers to report over 60 different diseases, in at least 30 or 40 different ways, it certainly sometimes gets in the way of not only their reporting and building the data we need, but clearly stymies us in providing the feedback loop.

We also are putting in place, and hopefully it will be in place in another year or so, what will be one of the first web-enabled immunization registries. We are using our Web technology not only as a way to dialogue with the public, but also to do some of the periodic surveys that we think we will need to use to track public understanding and involvement in 2010 and, obviously, feed into the long distance learning system, in which CDC has taken a lot of the initiative in getting it up and running. We have an electronic lab reporting system as well. And that is our effort to try to strengthen what has become a rather fragile infrastructure with respect to state public health labs.

What do we need? With our national partners, what do we really need? We clearly need leadership to keep focused and to keep our eye on the goal of 2010 so that it will remain bipartisan and will survive through succeeding administrations, which come and go at the state level.

We need to focus on sharing best practices. I think that some kind of system needs to be put in place to really help states in a much earlier fashion understand best practices much more in real time. And clearly -- I hate to be the first one to bring up budget; I notice the word budget hasn't been mentioned, which is great. We've actually been talking about health. But on the other hand, at the state level, we have to make sure that budget priorities continue to match, to be aligned with our Healthy People 2010 objectives. Otherwise we will be distracted to other goals.

Thank you very much.

DR. FLEMING: Thank you very much, Christine. Our last panelist this morning is Dr. Georges Benjamin from the state of Maryland. Dr. Benjamin is Secretary of the Maryland Department of Health and Mental Hygiene. He was appointed in May of 1999 as Secretary, but has been Deputy there since 1995.

In addition, he has worked in the past in the state of Washington and in the District of Columbia. I understand he is the President-elect for ASTHO.

Dr. Benjamin is a graduate of the Illinois Institute of Technology and the University of Illinois College of Medicine. He is boarded in internal medicine and is a fellow of the American College of Physicians. Welcome.

Georges Benjamin, Maryland Department of Health and Mental Hygiene

DR. BENJAMIN: How are you this morning? What I'll try to do this morning is talk a little bit about Maryland's plan and talk about the Maryland Healthy People 2010 process, but very, very briefly, but more importantly, to focus on how we've tried to use a process that we had in place to address two leading health problems. To utilize the grant funding stream -- we would love to get other states to use that same funding stream, similar to the way we've used it. And, obviously, to deal with the issue around the disparity gap.

Our Healthy People 2010 process was very much like everyone else's. It was used to identify health priorities, to try to foster public-private partnerships, to look at Maryland's two prior efforts to do Healthy People back in 1993, where it was done kind of in the health department. We looked at statewide objectives and, then, later our initiative in 1996, where we used those same partners. But we tried then to bring in more of the community and more of the local health programs, and tried to look at some local health priorities using local health data.

Then our Healthy People 2010 process, which we have now expanded to be a huge community collaborative process, bringing not only other members of the health community in, but also non-traditional partners, including business, and ultimately develop a state health improvement plan. You have in your books the first chapter in that plan, and it is also on our Web-site, as well. But, more importantly, then decide that this needs to be something other than the usual Healthy People 2000-2010 plans which, quite frankly, in many places serve very effectively as dust collectors.

We also looked at them ourselves, talked of them amongst ourselves. But no one else really understood those books and understood what to do with them. Our goal now, of course, is to try and use it as a template for everyone in the community to use, process as well as goals, to try to move forward.

This is the Maryland process. We crafted an oversight committee, which consisted primarily of inside-the-department staff and a much broader council, which steered our process. Then we had a huge statewide process.

Now, it may seem as though the state drove the process, but we drove the framework. We then had a huge statewide summit and basically told all of our 24 local health departments -- a little more manageable than what Christine has -- to go out and do this process in the local communities and bring it back to us. Then we would have basically a two-tiered system, where we had our local statewide goals and objectives, looking at both national goals, things that we thought were important in the state, and then to go to each of the local health department for those communities to come together with their local focus objectives and goals. Then, to roll that up into a statewide plan with multiple tiers, to try to give some overall guidance with some focus for the program.

Like everyone else, we ended up with hundreds of objectives. But I'm not sure that's too bad, because what we ended up with was, every constituency group started off with an agenda that was this big, and they all ended up with focused areas of interest within their own areas of interest, like this. I think that is what you ultimately get when you do that kind of thing.

Then, of course we have done lots of things, and we have continued to disseminate this. On the draft, you will find on our Web page it's out for public comment. We are having public hearings on that document as we speak now. Then, of course, we always want to go back and evaluate.

One of the things that we had in Maryland, which we thought was good, was the Maryland tobacco settlement. In Maryland, we got about $4.4 billion over 25 years. Governor Glendening decided that he wanted to focus that money in a meaningful way, so he basically has dedicated about one billion dollars, dedicated it to health over 10 years. We have had the first year's appropriation of that.

He wanted to focus that in a couple of areas. I want to show you this. This is the FY '01 appropriation. Understand, this is a partial year appropriation. So in essence, some money is for substance abuse and some money is for Medicaid, the Maryland Health Care Foundation.

But what is going to happen in future years is that cancer and tobacco related disease is going to grow. That is annually about a $30 million appropriation for tobacco, and for cancer it is over a $50 million appropriation annually. That is the plan, and there are some other things to fill that in.

We want to focus on these two objectives, tobacco and cancer. Let me tell you why. Number one, tobacco is obviously our top public health threat, just like it is in the nation, 7500 people who die each year, 60 kids die each day, a huge fiscal cost to Maryland. So clearly, tobacco makes sense and makes good political sense and makes good media sense, makes good public health sense, so we are obviously going to focus very much on tobacco.

Cancer of course is the second leading cause of death in the state, with lots of death, lots of people who get it. And actually, from Maryland's perspective, to be such a costly state, to be seventh in the nation in cancer diagnoses with the National Institutes of Health, with Johns Hopkins, with University of Maryland, with all the fine medical resources in Maryland, this is something that we ought not to have in Maryland. We felt that was very important.

Many people say why not focus on cardiovascular disease. The beauty of all this is, by focusing on tobacco, we're going to get low birth rate and infant mortality and cardiovascular disease, and all of those other things wrapped into our tobacco efforts as well. So we thought that we going to get a two-for on that, on the tobacco; we ought to go for the second leading cause of death in Maryland as well. So we have begun focusing those efforts.

We started by having the Governor convene two scientific panels, which are community-based and academically based -- lots of public hearings. We ultimately came out with these two reports. There's actually a third one that the farmers came out with, because in Maryland, as one of our goals, we are racing to be one of the first Southern states to get out of the tobacco business. We are buying those tobacco farmers out as fast as we can, to get them to convert from growing tobacco as a crop. One of our goals is to get them out of that business. Then we can work very hard to get the retail folks out of the selling of tobacco business.

We're going to start with the farmers. It is very, very important that we do that. Also, as you know, many second generation farmers are now looking at the third generation, and their kids don't necessarily want to get into this business. From an economic development perspective, it makes sense to get them out of that business. So we're going to do that as well, kind of hidden behind this big community effort.

The point is that we used the Healthy People 2010 process by getting experts, and then getting to the community to have huge community meetings on what we needed to do. Both of these reports are also on our Web site.

And of course, we came up with goals. We tried to match these goals to both national, local 2010 goals as we moved forward. I didn't put a lot of numbers here because it would get very cluttered. But the point is that clearly we want to look at reducing both adult smoking and youth smoking. We want to increase the number of people who don't smoke during pregnancy. So we have a whole series of goals.

I want to point out also that we've tied these goals to budgets. When we go to our budget hearings now, we are being asked to manage for results, in terms of some of these outcomes. Obviously, one of the problems we have and the challenge we have is that many legislators are going to see changes right away, so many of these goals that we are going to report on early on will be process goals. As we go down the line, we are going to be looking at goals that are more clinically oriented or outcome-oriented from a clinical perspective. And we have similar goals for cancer as we move forward.

Let me also point out that part of our project was to link -- again, because we have all this technical expertise in Maryland, from a scientific perspective -- to link some of the folks to clinical trials. We think that is very important. We know there are lots of clinical trials that are available, and we know that a small percentage of people that are eligible for those trials are getting in. Certainly, women and minorities definitely are not getting in. So one of the goals is to try to link high capacity medicine to the various communities through this process.

We do something different. We gave some of the money to the academic teaching hospitals, but we are primarily driving this process through our local health departments. A fair amount of the money, both from the tobacco side and the cancer side, is going to our local health departments. Our local health officers have now been charged with pulling together local community coalitions and planning councils specifically around these dollars, one for tobacco, one for cancer obviously. In many communities, those coalitions will be the same. In places like the Eastern shore and Western Maryland, many of those counties will coalesce together to have consolidated planning councils. We are beginning to see that occur right now. That is very important, because this is to get community buy-in to these programs.

Then of course, we have looked at the issue of closing the gap. We specifically wrote in the legislation that these planning councils had to come in, as a part of their plans, with a plan to close the gap. We felt that was important. We actually got that through the legislature.

That was because, if you really think about it, if you don't focus on those areas, you don't get any accomplishment in health statistics. You don't get any improvement in health status. So we were able to sell that point to the perspective that, to make a healthier Maryland, we had to have, in essence, one Maryland and bring everybody together. So they have to do this. We have actually set aside dollars for outreach to go into particular minority communities, not just in the urban settings, but in the rural communities, to address this gap.

To show you what I mean by that, here is the adjusted death rate in Maryland in '89 to '98 for African-Americans. Here are the African-Americans here, and here is whites, so clearly cancer is an issue. As you know, a lot of this has to do with earlier identification in communities. So we knew that we needed to focus on finding the cancer, where it is in those communities, and getting people in very early.

I also want to point out that the good news is that African-American children or Asian or Hispanic children don't tend to try cigarettes as frequently, at least in middle school, as others. The real tragedy is, we catch up and then fall behind very, very quickly. Once we get addicted, we stay addicted; we don't quit. Something happens. Obviously, there is a disconnect between middle school and adulthood that happens with tobacco use. So we really need to focus and recognize that dynamic. I know that is pretty much the same dynamic as we see on the national scene. In Maryland, it is obviously no different from the rest of the nation.

We have had various components. As you can see, this is the tobacco component. Forget about the money, but look at the percentage of component that we have. It is pretty similar to what the CDC's guidelines are. Actually, that $30 million figure is basically the floor of the CDC recommendation for Maryland, which is how that figure got put in place. We recognize that there is a huge overlap, so we started with the floor, because we expect over time to build on that in terms of programs that we have.

And the same thing with cancer. If you look at the cancer issue -- a whole range of things, the local public health component. There isn't really a statewide public health component in it. It's in the legislation. We haven't funded it yet, though, for a couple of reasons. We got a surveillance and evaluation appointed, but we are going to build on our state cancer registry. Then the health center component, which is going to be delayed a little bit because of some funding issues we are having with it. This is going to go to both Johns Hopkins University and the University of Maryland to try to focus on cutting edge research, as well as bringing that cutting edge research into our community programs.

Finally, if you really try to get a vision of what this program is in Maryland -- we believe this is a bottom to upward program, where we are looking at the community to become invested over time in both tobacco reduction and reduction in cancer. This is a lot of money going out the door ultimately for these two programs. We are looking at $80 million a year ultimately to go out the door each and every year for the next 10 years for these programs.

We are hoping that, as we do that, the community will see some value in this process. We are hoping that we will be able to loop back into the community as we move forward. There's a lot of evaluation in here. Each year the local health departments have to come back to us with data on their programs, who they serve, how they are doing, those kinds of things.

We have, in essence, a mid-year evaluation built into this program. That was a quid pro quo to not sunset the program. Many in the legislature wanted to sunset it, and we basically convinced them that -- let's evaluate it, and then let's retool it, because obviously we are not going to know anything for three to four years in cancer at all. We will barely know anything from tobacco.

One of the other things they require that we do, of course, is get lots of studies. So we are doing both the youth tobacco survey, the adult tobacco survey, and a baseline study on cancer, which actually will be released next Monday. We will use it to guide our efforts over the next several years.

I'll stop there.

DR. FLEMING: Thank you very much, Dr. Benjamin. We got started quite late so, as a consequence, we're running late. But I think we have a few minutes for questions or discussion.

DR. WINDOM: I'd like to ask him -- what did you ask the legislature for, or what did your coalition members request? You got $30 million, but what was requested? Do you know?

DR. BENJAMIN: Actually, the way this worked was, the Governor laid out a budget request of, in essence, $100 million, and for these two programs, $50 million and $30 million. Our task during the legislative cycle was keeping that request intact. Because there was so much tobacco money around, it was fundamentally a feeding frenzy. Everybody had a great, noble cause for this program.

Literally, what we did, we got all our public health friends in a back room and said, stay with the plan, stay with the program, lobby the heck out of the legislature. Even though heart disease is important, even though school health nurses are important, if we don't focus this money, and if we don't put it through a public health process, and if we can convince them that we can do this right, and cancer rates come down -- at least we can start identifying cases -- and tobacco use rates come down, we will have proven public health.

So I think what we sold them was a big picture. This is the first time I can think of, anywhere, where any public health department has gotten a lot of money focused on a couple of health initiatives, and everybody was kind of behind it. So what we are doing is staking our public health futures on making this work. If we blow this, we will probably blow the opportunity to do anything in public health in the next several years in Maryland. So I think we kind of got them to buy into that.

DR. MASON: You showed the percentage of people by race, of young people, that were trying cigarettes. What do you actually think you can do about that by the year 2010? What will you set up as your objective? What do you hope to achieve with this money?

DR. BENJAMIN: We are trying to cut the growth in those rates in half, if we can. That's pretty ambitious, and we know that we may or may not see that. But again, that's the target.

What we are seeing in Maryland, we think, is that kids in middle school, for whatever reason, were not using that much tobacco, but it's the high school kids. And now, of course, the tobacco companies are targeting new college students. So we are going to try to cut it in half.

What are we going to do differently? We have already had some tobacco programs, and we think we've got our hands around the middle school kids. We're going to focus on the high school kids very much; we're going to focus on parents of smokers.

In the next few weeks, we're going to begin seeing in Maryland some ads that we have targeted -- not with this money, with some other money we had -- targeted to rural Marylanders. They are pretty powerful media spots, focusing on kids, talking about their parents who died from tobacco use. We've got cornfields in the background and a tractor. We focus this on kids in rural communities, who now we are going to go after.

Now, Maryland has a unique media problem. We have to serve two media markets. The Washington, D.C. metropolitan media market, as you know, is very, very expensive. Then the Baltimore media market, which is not as expensive, but very sophisticated. So our money has to be split along with those two media markets.

We are going to spend a lot of money on peer education, peer activities. And, of course, we are working with the Legacy Foundation to re-energize some of these efforts. We think we can do it. Our previous public health efforts have shown some grasp of the problem and some grasp of our data, and knowing that it is going the right way.

Does that answer your question?

DR. RICHMOND: I can't help but just make the comment that it is very impressive that, at both the state and local levels, the health departments have grasped the issues related to establishing priorities. Also, it is very impressive that the emphases in all three presentations are grass roots and involve people at the local level. So I think the message certainly seems to be getting out to the leadership of those state and local health departments.

I'd like to just pick up for a moment on

Dr. Benjamin's comments about Maryland and tobacco control. I was quite impressed - I think it was last week -- just tuning in to one of the national news programs, to see a segment on what's happening with farmers and the state support for subsidizing them in some ways to shift their farming practices and objectives. I thought it was very impressive and very sensitively done. So the message seems to be getting out. It is certainly an important program, because people across the country do worry a bit about what happens to the incomes of farmers.

The other point that I would like to emphasize is, I think the Governor and his staff are to be congratulated on maintaining the priorities and taking so much of the master settlement agreement funding and targeting it at tobacco. I would like to suggest that CDC has developed good guidelines for how to do that and what kinds of programs ought to be involved in that. But we know that, across the 50 states, that's not happening nearly as effectively as what we've heard described here.

So it seems to me there's an important task that we need to engage in. I would suggest, Mr. Surgeon General, that we ought to be in more dialogue with the Attorneys General, who have, in part, seen this as a flow of money for general purposes in the states, the quote, fill-in-the-potholes sort of thing, which I think is a very unfortunate development. I think the Attorneys General ought to be made aware of the fact that there are a lot of people across the country who think that that diversion of resources is not an appropriate one.

DR. SATCHER: Let me just comment briefly, because I think you're right. It's impressive the way Maryland looked at their costs: what was tobacco use costing us -- $1.8 billion a year.

Getting back to Jim's comment and question. When we released the Surgeon General's report on reducing tobacco use, we pointed out that when states used a comprehensive approach -- including educating students in schools, starting in elementary and middle school, fund cessation programs, use regulations appropriately, and economic incentives -- the impact is tremendous, 20 to 40 percent reduction in teenagers initiating smoking.

The problem was that only five percent of schools in the country were using those guidelines. So it's been demonstrated that it can work. The state of Florida reduced teenage initiation from, what -- 18.9 percent? So it's been shown it can work, if we can just convince them to use it.

MS. GRANT: Can I just comment to Dr. Richmond? Having lived through the same process that Dr. Benjamin lived through, I would say that, having watched Governors' behavior, it is extremely important to public health not only to encourage the allocation, but to reward and compliment. I must say that, frankly, that has not occurred to date. I think there is nothing that chills a Governor's enthusiasm to take the kind of risks that you heard of today more than thundering silence, or thank you very much, but it's not enough. That's one comment.

Then secondly, certainly in New Jersey, we went from 20 to 13 percent in middle school initiations. We all know that additional reduction will be tough, but to Dr. Satcher's point -- that comprehensive program -- it's remarkable; if you do it, it works. It's the doing it consistently that makes a difference.

DR. SATCHER: And then we heard your comment about positive feedback. That's a very good point.

DR. LEE: David, this is Phil. Can I ask a question? I'd like to ask Elaine O'Keefe about the report of local public health practice by Glen Mays and Arden Miller and Paul Halverson in which they give a detailed study of local health departments and, in the conclusion, express concern about the diminishing role in health assessment, and the need for additional -- It says, "Small declines in performance of the public health assessment function are ominous signs that these important aspects of public health are not receiving the attention they deserve. Local public health departments, if provided with sufficient resources, are perhaps the only entities that can assure that these important functions are carried out in the public interest and on a community-wide basis."

I'd just like to ask, what do you think is the likelihood that we will see, either with the Kennedy-Frist approach, or with others, that there will be flexible resources coming to local jurisdictions for the improvement of this infrastructure capacity? What can we do about it? What sort of recommendations might we make to facilitate that.

MS. O'KEEFE: Thank you for raising that point, because I think that is one of the Catch-22's we're dealing with here. The fact is that, if local health departments are not prepared to conduct community health assessments, we do not have a great chance at succeeding and achieving the objectives laid out in Healthy People 2010. As you know, health behavior and community behavior change occurs at the community level, so we need local public health agencies to be very involved in that process. While we see ourselves as ready in many ways to assume that role, we lack the resources to do it.

So, unless we can make some progress on the infrastructure side, it's going to be very, very difficult for the majority of local public health agencies to fully assume the role of conducting good quality community health assessment which, as you know, is not something that you do periodically. It's a continuous process; it's a sustained process. So we have to be working simultaneously on not only promoting the tools and the role of local health departments in conducing community health assessment, but also building the infrastructure to enable them to do that.

DR. BRANDT: Two comments. I think Dr. Benjamin put his finger on one thing, and that is that part of the problem we have is, there are too many advocacy groups out there, all battling over the same dollar. It's very difficult to bring them into some kind of coalition.

The second thing is that I couldn't help but comment that, when I moved to Baltimore in January of 1985 as the President of the University of Maryland, there was a bill in the state legislature to eliminate all funding for tobacco control, because it was hurting the tax income for the state of Maryland. So one of my first assignments, on behalf of the state health department, was to go down and testify against that bill, and we were successful. That was half a million dollars in 1985, so you've come a long way.

DR. KIRSCHSTEIN: Like the Virginia Slims ads.

DR. BRANDT: Yeah, but I wasn't quoting that.

DR. KIRSCHSTEIN: I know, but you've used exactly the same phrase.

DR. BENJAMIN: Phil, how are you? This is basically to go back to your comment. If you think about it, the only fungible sums of money that state health departments have -- I know everybody is going to groan and moan when I say this, but it's on my agenda -- is the preventive health block grant. Basically, that is the only fungible money that state health departments have to do anything with. We have always had difficulty explaining what that money goes for, but this is what it goes for.

DR. SATCHER: I think as far as what Elaine pointed out, we need to really keep our eye on the Kennedy-Frist bill in terms of spending, funding for prevention research and prevention in general.

DR. WINDOM: I'd like to point out, it's not the Attorneys General, but it is our legislators that, in the houses of each state - We have a problem in Florida, as I'm sure elsewhere, that we strive to get more money from the tobacco settlement, but then they are bombarded by so many others.

Secondly, we see the CDC guidelines, and we get to the very bottom of the line, not the top. So what I suggest is, David, that you or representatives appear before the National Association of Legislators, the NGA, the Governors Association meetings. Present 2010 from your perspective to them. Each meeting should have a place on the agenda to let these people be aware of the importance of this. Show where other states, how they do vary to a great extent, but those that are getting more are doing better. I think that needs to be brought forth, not just us in the state up to them, but from you all down to the state.

DR. SATCHER: That's a good point. It really helps to have these positive state models to point to.

DR. WINDOM: Right.

DR. LEE: Speaking about this, the information structure that's needed, that's part of Healthy People 2010, should give more emphasis to the need for strengthening the public health infrastructure at the local level. Some of the plans that are in place inadequately reflect the informatics initiative that you've initiated.

DR. SATCHER: I hate to cut this rich discussion off, but as you know, we are running a little bit behind, and I plan to stay in step with the schedule. Thanks a lot.

DR. FLEMING: Would it be appropriate to give the panel a round of applause?

DR. SATCHER: Please. Lots of feedback for a job well done.

DR. MASON: David, could I just come back to Julie's suggestion that, at the Assistant Secretary's or Surgeon General's or the Secretary's level -- can't we find a way to commend those Governors and state legislators that are appropriately using the tobacco settlement money?

DR. SATCHER: I did some of that when I named the states, but we can do a better job.

DR. MASON: I think we need to reward them, because a lot of it is going to potholes, and some states are not doing well at all. There must be a way that we can assist in that process, so it goes for what it was intended.

DR. SATCHER: That is a great point. We need to do more of that, so we will look for ways to do that. Thanks very much.

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