Healthy People 2020 Comment System

Other comments on the Vision, Mission and Overarching Goals not related to existing comment topics.
This section is closed for comments.

evsanabria on 9/15/2008 7:33:35 AM
I don't know if this is the area to address this:  why is there no discussion or focus area that deals with community economic development?  Am I missing something?  It's an important part of addressing the 2 goals and falls in line with WHO's Ottawa Charter.  Gracias

Coalition for Improving Maternity Services on 9/2/2008 4:57:09 PM
The Coalition for Improving Maternity Services (CIMS) appreciates and values the U.S. Department of Health and Human Services’ (HHS) collaborative, inclusive, evidence-based, and transparent Healthy People 2020 process towards the development and eventual recommendations of national goals to improve the quality of the nation’s health and eliminate disparities. CIMS is specifically concerned about Maternal, Infant, and Child Health issues. As appropriately stated in Healthy People 2010, the health of mothers, infants, and children is of critical importance, both as a reflection of the current health status of a large segment of the U.S. population and as a predictor of the health of the next generation. CIMS welcomes the opportunity to comment on this critical issue and strongly urges that the Healthy People 2010 Goal 16-Maternal, Infant, and Child Health continues to be included in the national health agenda for 2020 and respectfully recommends that the guidelines committee include the CIMS Ten Steps of Mother-Friendly Childbirth as a national framework to help meet the goals of Maternal and Child Health as defined in Healthy People 2010. Both the Healthy People and the Mother-Friendly Initiative are wellness related, based on sound research, developed by a coalition/consortium, and set achievable goals based on the evidence. HP 2010 gave us the targets and the MFCI outlines the steps needed to achieve many of those goals.

CIMS is a coalition of organizations, professionals, advocates and families who share a commitment to Making Mother-Friendly Care a Reality. Our mission is to promote a wellness model of maternity care that will improve birth outcomes and substantially reduce costs. The Mother-Friendly Childbirth Initiative (MFCI) evidence-based mother-, baby-, and family-friendly model focuses on prevention and wellness as the alternatives to high-cost screening, diagnosis, and treatment programs. In 2007 the publication of systematic reviews of the evidence, The Coalition for Improving Maternity Services: Evidence Basis for the Ten Steps of Mother-Friendly Care ( Journal of Perinatal Education, Winter, 16(1), Supplement, available on-line at www.motherfriendly.org) supported the founding principals of the MFCI first established in 1996. The Ten Steps outlined in the Mother-Friendly Childbirth Initiative are the goals we must set as a nation if we are to overcome the obstacles which stand in the way of safe childbirth leading to optimum outcomes.

Research recently published by the National Institutes of Health and Human Development Maternal-Fetal Medicine Units Networks has concluded that increasing numbers of cesarean sections progressively increases maternal morbidity – placenta accreta, cystotomy, bowel injury, ureteral injury, illeus, hysterectomy and blood transfusions for mothers. For newborns postoperative ventilation and admission to an intensive care unit is higher. Their published evidence also concluded that women with one successful VBAC are at low risk for maternal and neonatal complications during subsequent labors including a lower risk for uterine rupture. Therefore the 2010 HP goals of reducing cesarean rates and increasing VBAC rates should continue to be included in the HP 2020 national agenda.

The acting U.S. Surgeon General Steven Galson and the NICHD recently hosted the Conference on the Prevention of Preterm Birth to develop a strategy to reduce the increasing rate of premature births. Researches from both the CDC and the March of Dimes have concluded that the rise in late pre-term births (34 to 37 weeks’ gestation) is the result of medically unnecessary cesareans. Routine repeat cesareans can probably be included in this category (http://videocast.nih.gov/). The HP 2010 goals of reducing infant morbidity and mortality should continue to be included in the HP 2020 national agenda.

The CDC has, as have other health organizations, established cesarean section as a risk factor for the initiation and continuation of successful breastfeeding (The CDC Guide to Breastfeeding Interventions, 2005). The quality of care provided in the first 24 hours after birth is critical to the success and continuation of breastfeeding. Maternity care labor, birth, and postpartum practices can facilitate or discourage the initiation, establishment, and continuation of breastfeeding. The June 13, 2008, CDC findings from Breastfeeding-Related Maternity Practices at Hospitals and Birth Centers-United States, 2007, found that many birth facilities have policies and practices that are not evidence-based and known to interfere with breastfeeding. In 2007, only four states met all five Healthy People 2010 targets for breastfeeding. Increasing breastfeeding goals need to be included in future goals to improve the nation’s health.

A HP 2010 goal is to increase the proportion of pregnant women who receive early and adequate prenatal care. Research indicates that access to midwifery care improves maternal and infant outcomes and increases rates of breastfeeding (The Coalition for Improving Maternity Services: Evidence Basis for the Ten Steps of Mother-Friendly Care, 2007). The Mother-Friendly Childbirth Initiative recommends that all women have access to midwifery care.

The MFCI states that “society, through both its government and the public health establishment, is responsible for ensuring access to maternity services for all women, and for monitoring the quality of those services.” It is CIMS' opinion that, while broadly appropriate and grounded in good sense, the mission and framework for HP 2020 is seriously lacking where maternal-child health is concerned. The United States ranks lower than more than 30 countries in terms of infant and maternal mortality rates, low birthweight rates, and neonatal mortality rates, with more money spent per mother than any other nation in the world. If we wish to reverse the alarming trends toward our unconscionable rate of prematurity (especially late-term prematurity caused by elective) cesarean sections and the concomitant morbidity and mortality we need to create specific objectives around those issues.

If the Ten Steps for Mother-Friendly Childbirth were incorporated as public policy, it would go a long way toward bringing the United States to the top of the maternal and infant health list, where we should rightfully be, considering our resources.

From pre-conception, through the prenatal period, through early initiation and follow-up of breastfeeding, and through the first weeks of life, we need a framework to guide the care that women and babies receive and to protect the health of both in each stage of the process. The Ten Steps of Mother-Friendly Care provides such a framework, and are an ideal tool because they are founded on the best available evidence.

Below are the Ten Steps. We hope the Advisory Committee will take them into consideration and contact CIMS for further guidance or information regarding these important guidelines for the future well-being of our tiniest citizens and their mothers.

Bibliography

Coalition for Improving Maternity Services, Evidence Basis for the Ten Steps of Mother-Friendly Care. Journal of Perinatal Education, Vol. 16, Supplement, 1S-96S, Winter 2007.

M. Enkin, M.J.N.C. Keirse, J. Nielson, C. Crowther, L. Duley, E. Hodnett, and J. Hofmeyr, Effective Care in Pregnancy and Childbirth , Oxford University Press, New York, 2000.

B.A. Hotelling, and S. Humenick, Advancing Normal Birth: Organizations, Goals, and Research. Journal of Perinatal Education, 14(2): Spring 2005, 40-48.
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1595246

B.M. Mercer, S. Gilbert, B. Mark, M.B. Landon, et al., Labor Outcomes with Increasing Number of Prior Vaginal Births after Cesarean Delivery. Obstetrics & Gynecology 111 (2008): 285–291.

R.M. Silver, M.B. Landon, D.J. Rouse, et al, Maternal Morbidity Associated

Keith Whyte National Council on Problem Gambling on 6/6/2008 1:08:35 PM
Problem gambling is a significant public health concern and should be included in Healthy People 2020. The National Council on Problem Gambling defines problem gambling as a disorder characterized by increasing preoccupation with gambling, a need to bet more money more frequently, restlessness or irritability when attempting to stop, "chasing" losses, and loss of control manifested by continuation of the gambling behavior in spite of mounting, serious, negative consequences. The American Psychiatric Association defines pathological gambling as: “Persistent and recurrent maladaptive gambling behavior” that meets at least five of 10 criteria.

A meta-analysis of prevalence studies in North America indicates a past-year prevalence rates of pathological gambling in adults of 1.1% and an additional 2.8% were estimated to meet criteria for problem gambling in the past year.

In addition to the devastating financial losses adult problem gamblers face as a result of gambling, they are also five times more likely to also be alcohol dependent, four times more likely to abuse drugs, three times more likely to be depressed, eight times more likely to have bipolar disorder, three times more likely to experience an anxiety disorder and have significantly elevated rates of tachycardia, angina, cirrhosis. Between 17% to 24% of members of Gamblers Anonymous and individuals in professional treatment for pathological gambling have attempted suicide.

A relationship between pathological gambling and substance use disorders is suggested by phenomenological similarities, including tolerance, withdrawal, cravings, chronic relapsing courses and impaired frontal cortical functioning.

Several groups have been found to be at higher risk for gambling problems. Adolescents are one such group, as 2.1% of youth are classified as past-year problem gamblers, and another 6.5% are meet two to four criteria and are therefore considered at-risk for a gambling problem. Adolescents with gambling problems are twice as likely to binge drink and to use illegal drugs and 3 times more likely to be involved with gangs, fights and police.

Other high-risk groups include males (prevalence of problem gambling in men has been found to be 2 to 3 times higher than in women) and racial/ethnic minorities ; individuals with a family history of gambling (elevated rates of problem and pathological gambling have been found in monozygotic and dizygotic twins of males with gambling problems) ; veterans and individuals with disabilities.

Individuals with problem and pathological gambling, compared with other gamblers and non-gamblers, had higher rates of receipt of past-year unemployment and welfare benefits, bankruptcy, arrest, incarceration, divorce, poor or fair physical health, and mental health treatment. Based on estimates developed by the National Gambling Impact Study Commission, the National Council on Problem Gambling estimates the social cost of gambling problems was $6.7 billion in 2007, including job loss, bankruptcy, criminal justice costs.

Problem gambling is significantly correlated with other risky behavior in adults and adolescents, including substance use and mental health issues. As an emerging issue, more research is needed to better define factors that predict the development of problem and pathological gambling and its relationship with other disorders.
Sincerely,

Keith S. Whyte
Executive Director
National Council on Problem Gambling
References:
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
Shaffer H, Hall M, Vander Bilt J. Estimating the prevalence of disordered gambling behavior in the United States and Canada: a research synthesis. Am J Public Health. (1999) 89:1369-1376.
Petry, N. Disordered Gambling and Its Treatment. Report to the Washington State Department of Social and Health Services, Division of Alcohol and Substance Abuse (2008).
DeCaria C, Hollander E, et al. Diagnosis, neurobiology, and treatment of pathological gambling. J Clin Psychiatry. (1996) 57:80-83.
Potenza, M, Kosten, T, Rounsaville, M. Pathological Gambling. JAMA (2001) 286: 2.
Welte, J, Barnes, G, et al. The Prevalence of Problem Gambling Among US Adolescents and Young Adults: Results from a National Survey. J Gambl Stud (2008) 24:119-133.
Gealt, R, O’Connell, D. Gambling with Delaware’s Kids. Report to the Delaware Council on Gambling Problems (2006).
Cunningham-Williams, RM, Cottler LB, et al. Problem gamblers and mental health disorders-results from the St. Louis Epidemiologic Catchment Area Study. Am J Public Health. 1998; 88:1093-1096
Potenza, M. The neurobiology of pathological gambling. Semin Clin Neuropsychiatry (2001) 6:217-226.
McCormick, R. Testimony to the US House of Representatives, Committee on Veterans Affairs, March 11, 2008.
Morasco, B, Petry, N. Gambling problems and health functioning in individuals receiving disability. Disability and Rehabilitation (2006) 28: 619-623.
Gambling Impact and Behavior Study. National Opinion Research Center, University of Chicago (1999).

Dushanka Kleinman on 5/31/2008 12:12:07 PM
Comments on Healthy People 2020 Draft Materials
Bethesda, Maryland
May 28, 2008

Dushanka V. Kleinman, DDS, MScD, Professor and Associate Dean for Research and Academic Affairs, School of Public Health, University of Maryland, College Park

Written Comments on the Process for Developing Healthy People 2020

My name is Dushanka Kleinman. I am currently Associate Dean for Research and Academic Affairs, and Professor, at the School of Public Health, University of Maryland, College Park. Formerly I was the Deputy Director of the National Institute of Dental and Craniofacial Research, National Institutes of Health and Assistant Surgeon General and Chief Dental Officer of the U.S. Public Health Service Commissioned Corps. I appreciate the opportunity to comment on the Healthy People 2020 draft documents.

I have participated in work groups to develop and monitor progress toward the Healthy People 1990, 2000 and 2010 objectives and have seen the benefits that have accrued as a result of this process. I commend the Secretary’s Advisory Committee on National Health Promotion and Disease Prevention for its thoughtful Vision and Mission statements and Goals.

I have four recommendations for the Committee’s consideration.

Recommendation 1: Expand the Vision Statement

I recommend an edit to the Vision statement to recognize the value of our lives. The edited version would read “a society in which people can live long, healthy and productive lives.” Health is essential to all facets of society, and our productivity depends on and is indebted to our health.

Recommendation 2: Add to Healthy People 2020 Mission Statement

From the perspective of our School of Public Health whose focus is on translating science into action, I recommend a complementary addition to the first mission statement. The current statement calls for increasing the public’s awareness and understanding of underlying causes of health, disease and disability. While increasing awareness and understanding is certainly necessary, knowledge alone is insufficient. My recommendation is to add an essential and complementary statement for the public that reads:

• Increase the public’s awareness of and the public’s skills needed to access health promotion and disease preventive and treatment services

By adding a statement that speaks to enhancing the public’s ability to take appropriate actions and to access appropriate services the mission of Healthy People 2020 can give attention to health literacy and mobilize the public and make major strides toward a society in which the vision and goals of Healthy People 2020 can be achieved.

Recommendation 3: Include Oral Health as a Topic Area

The National Opinion Research Center’s (NORC) report of the assessment of the objective setting framework and process suggests using a health determinant and common risk factor approach and also proposes 12 topic area categories, including oral health.

From the perspective of my background in oral health, I highly recommend that oral health be considered as one of the key topic areas.

• Poor oral health is a risk factor for conditions such as septicemia and management of diseases such as diabetes.

• Oral health is essential to general health and well-being. This was clearly documented in the 2000 Oral Health in America: A Report of the Surgeon General, a report for which I was co-executive editor.

• Oral health is the virtual “canary in the coal mine.” The status of oral health is an indicator of society’s capacity to promote health and recent events demonstrate that we are in trouble. This was witnessed most recently in Maryland where a 12 year old boy died from the sequelae of an abscessed tooth and the lack of care. This tragedy illuminates a major health systems failure – including lack of public and professional knowledge and skills, limitations of health care services and their reimbursement, and boundaries created by policy. Since the visibility of this event in Maryland, other untreated dental disease-related deaths of children have been reported.

• Evidence-based approaches for public health community action to improve oral health exist but require constant vigilance. These approaches include school-based dental sealant programs and community-wide water fluoridation programs and can promote oral health across all groups. With continued visibility and support these programs can strive to achieve health equity.

• Programs that support oral health -- and programs that would be enhanced by integration of oral health services -- are scattered throughout multiple agencies and thus are vulnerable to budget and priority shifts. The Healthy People process provides the critical matrix and the impetus for linking and integrating programs, stimulates much needed inter-professional action and ensures a systems approach to improve overall health.

Recommendation 4: Maintain HP2020 as National Objectives

The Healthy People 2020 objectives must remain national and should not be federally structured. The “national” aspect has been the Healthy People initiative’s legacy and its power since its inception. It has driven local and state action and support.

To be national objectives, the objectives must be developed and owned by the public. This can be accomplished by having workgroups whose members reflect the diversity of the communities of interest -- non-federal experts and consumers - for each of the content areas. While the federal role is necessary for coordination and to facilitate measurement and progress monitoring, the federal government does not have the ability to implement the programs necessary for attaining the objectives. Delineating roles and responsibilities among stakeholders – as was done with implementation plans in past iterations – would be a useful exercise for the 2020 initiative.

I thank the Committee for its work and for this opportunity to present comments.

References:

Dye BA, Tan S, Smith V, Lewis BG, Barker LK, Thornton-Evans G, Eke PI, Beltran-Aguilar ED, Horowitz AM, Li CH. Trends in oral health status: United States, 1988-1994 and 1999-2004. Vital Health Stat 11. 2007 Apr;(248):1-92. http://www.ced.govnchs/data/series/sr11 248.pdf

U.S. Department of health and Human Services. Healthy People 2010 Midcourse Review. Washington, DC: U.S. Government Printing Office, December 2006.
National Center for Health Statistics: Health, United States, 2007

U.S. Department of Health and Human Services. A National Call to Action to Promote Oral Health. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention and the National Institutes of Health, National Institute of Dental and Craniofacial Research. NIH Publication No. 03-5303, May 2003.

U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.

National Association of School Nurses on 5/30/2008 4:35:23 PM
ORAL STATEMENT 
 HEALTHY PEOPLE 2020 STAKEHOLDERS MEETING
National Institutes of Health
May 28, 2008


My name is Mary Louise Embrey.  I am the Director of Government Affairs for the National Association of School Nurses.  Based on my 27 years of working in the Public Health Service and my recent years of working with School Nurses, I am pleased to be able to speak on behalf of the health care needs of the more than 50 million school age children.

School nurses want to influence the vision, mission, goals, and focus areas of Healthy People 2020 because when children are guided toward making healthy decisions, the goals for adults will be more readily achieved.

I want to highlight 6 areas we recommend school nursing be considered in the HP 2020 process:  

o	Research
o	Wellness
o	Safety Net for the Most Fragile
o	Emergency Preparedness
o	Health Services
o	Reducing Health Disparities 

•	Research:  Because we know there is a link between lack of education and poverty; and 35% of the population who are living in poverty are children, of which 19% lack any health insurance, we want to promote studies to establish the connection between health and education and make school health data collection a priority.

o	School Nurses are often the only health care for these children.  By using a formula-based ratio of nurse:students, and placing the appropriate number of nurses in the school districts, the theory of “healthy children learn better” can be tested. 

o	There is a huge gap in knowing the types and frequency of health services delivered in schools and its impact on the health of children and families.  School health services have been referred to as the “Hidden Health Care System.” School health data must be captured in national data sets.  

o	In addition, health has direct and indirect effects on school dropout rates.  Evaluation studies are needed to assess the impact of health services on dropout rates, given the known link between dropouts and poor adult health, social justice, and economics.  

•	Wellness:  Because of the established connection between education and health status, we promote wellness programs to address academic achievement and prevent childhood obesity and chronic diseases.

o	Along with our colleagues in the school health field, we recognize the goal of students being healthy in every aspect:  physically, socially, emotionally, and academically.

•	Safety Net for Most Fragile:  Because the percentage of students in federally supported special education programs has increased from 8% in 1977 to 14% in 2006, we promote mechanisms for school nurses to not only work with the children while at school, but to also assist families in locating resources for medical homes, health insurance, and case management for chronically ill children.

o	Each year, with the increasing number of children who are survivors of Neonatal Intensive Care Units entering school systems, the need for school health services increases.  The medically fragile children in school who require ventilators, tube feedings, medication, and other complex nursing care now have become the responsibility of school nurses.  

•	Emergency Preparedness:  Because School Nurses have immediate access to a large portion of the population who are in school buildings daily (both students and adults), they are likely to be among the first to recognize an event and respond.  Therefore, we promote coordinated planning and implementation of emergency procedures for medical epidemics and disasters.  

•	Health Services:  The predominant funding of school health services through education budgets need to be reexamined.  School nurses are vital extensions of the public health system.  Therefore, we promote maintaining critical health services in school such as:

?	Vision, hearing, lead, and dental screenings 
?	Immunizations
?	Risk assessments for obesity, mental health, and substance abuse
?	Health and emergency plans for chronic conditions – asthma, seizures, diabetes, and anaphylaxis
	
We recommend investigation of funding models that combine health and education funding streams and will assist in reducing health disparities and increase access to health care.

Anonymous on 5/30/2008 12:10:00 AM
On the critical importance of effective EARLY CHILDHOOD EDUCATION . . . .  The data are in, are explicitly clear, and are reinforced every year.  Investment in early childhood education is much like our investment in immunizations: specifically, the return on every dollar is multiplied many times over.  I believe that my community is typical of a national pattern wherein the children whose families can afford early enhancements are probably the children least in need of it because they are already gifted with involved parents who appreciate the value of education and already provide it in many ways.  My worry is that the children who need enhancements the most --- impoverished, or broken homes, or single parents, or families lacking in education themselves, or children "warehoused"  in indifferent daycare centers --- will miss that life-shaping early education unless more public support is provided.  Ranked on the great spectrum of public expenditures, early child education is a bargain and has an incredibly high rate of return.