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27. Other Chronic Diseases and Disabling Conditions The category Chronic disease" encompasses a vast and diverse collection of conditions and disabilities. One definition, developed by the Association of State and Territorial Chronic Disease Program Directors and adopted by some states, follows. Chronic disease is an impairment or deviation from normal, having any of the following char- acteristics: is related to avoidable behavioral risk factors; is permanent; leaves residual dis- ability; is caused by irreversible pathological alterations; requires special training of the patient for rehabilitation; may require a long period of ~~ (~470J supervision, observation, or care. Many such conditions were covered in the testimony, each involving specific prevention interventions. However, considerable testimony was concerned with general issues applying to chronic and disabling conditions as a whole. As Matthew Liang of Harvard Medical School observes, "Although each disease has its unique biology, the impact each has on the patients' energy, psychological and physical function- ing, emotional state, and productivity is similarly pervasive and handicapping.n (#132) Patience Drake of the Michigan Department of Management and Budget and Robert Dolsen of the Statewide Health Coordinating Council emphasize that those with chronic diseases face special problems because the health care system is oriented toward acute disease and does not offer the necessary sys- tematic response to all people with chronic needs for health services. (#420) Liang says there is a need to recast current approaches to chronic disease. Only by doing this can his proposed year 2000 objective of reducing its impact be met. A fundamental change in the paradigm which drives health care delivery and organization is needed. We will have to switch our view from cure to care; from preoccupation with the disease to the illness that results from the disease; from preoccupation with impairments to function; and from concerning ourselves with 196 Healthy People 2000: Citizens Chart the Course death to life and the quality of existence with illness. (i'132J This chapter describes testimony from 52 witnesses about several chronic conditions and disabilities: diabetes, musculoskeletal conditions, hearing disorders, vision disorders, and developmental and chronic disabilities. Although chronic diseases strike people of all ages, witnesses stressed the particular toll they take on the elderly and the very young. Regardless of their age, however, all those disabled with chronic diseases deserve an opportunity to live full, productive lives, according to the American Foundation for the Blind: "It is not contradictory to pursue the objective of promoting the health and fitness of people with impairments, disabilities, and handicaps, along with the objective of reducing the incidence of impair- ments, disabilities, and handicaps." (#116) The two most common chronic disease killers- heart disease and cancer are discussed in Chapters 24 and 25. Many of the behavioral risk factors for chro- nic diseases are treated in Chapters 10 through 13. DIABETES Witnesses who addressed the topic of diabetes emphasized that it is a serious disease that should be included in the Year 2000 Health Objectives. Daniel Porte of the Seattle Veterans Administration Medical Center, representing the American Diabetes Associ- ation, provides some statistics. Diabetes is the sev- enth leading cause of death in the United States, with 130,000 deaths annually; it is the number one cause of new cases of adult blindness, responsible for 5,800 cases each year, many of which can be prevented. Further, it accounts for approximately one-fourth of new cases of end-stage renal disease in the United States. Diabetic nephropathy is the most common cause of renal failure in persons age 25-64 years, and 40-45 percent of nontraumatic leg or foot amputa- tions are due to diabetes. In addition, individuals with diabetes are two to four times more likely to self-report a previous heart condition or report a heart attack or stroke, Porte says.t (#699) Most of the diabetes in the population is called Type IT or

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"adult onset. This form of the disease, which offers the best opportunities for prevention, was the focus of most of the testimony. Weight control is the most commonly mentioned form of primary prevention. According to Porte and others, controlling body weight can delay the onset of Type II diabetes by 10-20 years.2 (#261; #699J However, much testimony about diabetes involves the importance of secondary and tertiary prevention- avoiding the complications of the disease. The Ameri- can Diabetes Association (ADA) recommends that the prevention program developed in 1987 by the Na- tional Diabetes Advisory Board (NDAB) be incor- porated into the Year 2000 Health Objectives. (#699J Reducing the incidence of diabetic complica- tions is one of its goals.3 (#457) Several witnesses say that patient compliance with doctor-prescribed regimens and regular monitoring are important means of controlling the course of the disease. (~626) According to Victor Hawthorne of the University of Michigan, there is new evidence that screening for microalbuminuria could prevent kidney complications. f~4104 In addition to preventing or delaying onset of the disease, measures such as treating diabetic retinopathy at an early stage and being more aggressive in testing hypertension in early diabetes nephropathy also can prevent diabetes morbidity. (#132) Other parts of the NDAB agenda call for improved training of health professionals on topics such as the importance of assiduous skin and foot care (~132J, as well as better patient and public education. Anne Esdale, representing the Michigan Society for Public Health Education, says that patient education about diabetes reduces hospitalization and health care costs. t#o61' Alan Altschuler, an ADA spokesperson, notes that primary care doctors should be taught to use the most modern techniques for detection and treatment of diabetes. (#457) Several witnesses call special attention to the increased problem of diabetes among Hispanics and Blacks and the importance of making special efforts to reach these groups. (#457; #491; #496; #567) This issue is discussed in more detail in Chapter 6. MUSCULOSKELETAL CONDITIONS Witnesses who addressed musculoskeletal conditions focused their remarks on three particular preventable health problems: osteoporosis, osteoarthritis, and gout. Osteoporosis Osteoporosis is a reduction in bone mass that leads to easily fractured, fragile bones. The condition is most common in postmenopausal women, but indivi- duals who take medications such as corticosteroids that alter bone mass are also at increased risk. Witnesses characterized osteoporosis as a common and costly condition. Figures cited from the 1984 and 1987 consensus development conferences of the National Institutes of Health and the Food and Drug Administration indicate that 24 million Americans have osteoporotic fractures. Even more have serious bone mass reductions (osteopenia) that are likely to result in fractures in the future. The annual cost for acute hospital care alone approaches $10 billion. Hip fractures cause most of the mortality and morbidity. Other common sites include the spine, wrist, and penis. The fracture rates, mortality, and cost are expected to double by the year 2000, according to testimony from Paul Miller of the University of Colorado Health Sciences Center.4 (#367J Witnesses reported that primary reductions In bone mass (i.e., reductions not associated with another condition or medication) are a result of aging and de- creased estrogen levels due to menopause. Genetic disposition also plays a role: women with small frames, Caucasians, and Asians are more susceptible to the condition. (#367) Prevention can play a critical role in reducing the morbidity and mortality from osteoporosis, witnesses agreed. Maria Greenwald, representing the National Osteoporosis Foundation (NOF), identifies several measures required to reduce osteoporotic fractures: build greater bone density when young; prevent bone loss that begins in the middle years; rebuild bone density among the elderly; and prevent falls. (#281) Although studies suggest that attaining peak bone mass is highly dependent on calcium intake and activity during adolescence and the twenties, when bone mass reaches its peak. (#367) Although reach- ing teens with information about preventing oste- oporosis is not easy, it is vitally important, according to Charles Chestnut of NOF: "It is obviously ex- tremely difficult for young women aged 15 to be con- cerned about a disease that may occur 40 years later; however, it has been noted that osteoporosis may be a pediatric disease, and that the ultimate prophylaxis for osteoporosis may exist in the teenage female." (#332J Several witnesses propose objectives aimed at increasing exercise and calcium intake. These include Other Chronic Diseases and Disabling Conditions 197

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expanding public and professional education about the importance of bone mass and ways to prevent oste- oporosis. Other witnesses set specific targets for calcium intake or exercise levels. Dietitians Barbara Bruemmer and Darlene Fontana of the Pacific Medi- cal Center in Seattle, for example, suggest that vir- tually all contacts with health professionals for girls age 8 to 20 assess calcium intake and that health curriculum textbooks provide information on the link between calcium and osteoporosis. (~030) For older individuals, preventive strategies are aimed at increasing bone mass or reducing further deterioration. The NOF calls for increasing the num- ber of postmenopausal women on estrogen replace- ment therapy (ERT) by the year 2000. According to testifiers, this is one of the few interventions known to reduce hip fractures. They also note that because of side effects, the appropriateness of ERT must be determined on an individual basis. Ho testifiers report positive results in studies using drugs to increase bone density. However, it is still unclear whether these increases will lead to a reduction in fractures. (#281; #367) Several witnesses note the potential value of monitoring bone mass to identify quantitatively those at risk for osteoporosis. New radiological tests can detect a 2-3 percent bone loss, according to Miller; used properly-not as a mass screening technique these tests can assist physicians in determining wheth- er ERT is appropriate for postmenopausal women. As an objective for the year 2000, Miller and others recommend educating health professionals and the public about the indications for bone mass measure- ment and favorable third-party reimbursement for the procedure. (~214; #332; #367) As with many topic areas, success in reaching the proposed objectives will depend on effective public and professional education, witnesses agreed. Other needs identified include additional research into the cause and prevention of osteoporosis; better preva- lence and incidence figures about spinal osteoporosis; improved techniques for detecting bone mass loss; and better coordination among government, private, pro- fessional, and public groups involved in the field. Arthritis According to testimony, arthritis afflicts more than 37 million Americans and exacts an enormous toll in lost workdays and reduction in the quality of life.5 (#373) 198 Healthy People 2000: Citizens Chart the Course Wayne Tsuji of the Washington State Arthritis Foundation emphasizes primary prevention approaches to osteoarthritis. He notes that risk factors for the condition include advancing age, obesity, injuries, adverse workplace environment, and hip dysplasia Preventive strategies should be directed toward reducing these risk factors, where possible. Ts~ji proposes a prevention agenda that emphasizes weight control, ergonomic measures in the workplace, preven- tion and appropriate treatment of athletic injuries, and early diagnosis of children with hip dysplasia. (#339) Other witnesses also address some of these factors. According to Liang, congenital hip dislocation in newborns is a preventable cause of osteoarthritis, but screening for the condition is lapsing. He urges better education of pediatricians and medical students about its importance. (~132J The Arthritis Founda- tion emphasizes the importance of weight reduction for prevention of osteoarthritis of the knee. (~134) The importance of secondary prevention also is underscored in testimony. Debra Lappin, a represen- tative of the National Arthritis Foundation, says that it could make "an astounding difference" in preventing complications such as deformity and limitations in mobility. Lappin says that drug treatment, physical and occupational therapy, and physical medicine (e.g., joint replacement) are the most effective ways of controlling the disease, but that these techniques are not reaching all who could benefit from them. (#373) Liang notes that patients with polyarthritis, particularly those with rheumatoid arthritis and children with arthritis, are not being treated with agents that could lead to remission or better control of the disease. He says patients are not being referred for appropriate physical or occupational therapy and are being overtreated with steroids. (~132,) Michael Condit, also representing the Arthritis Foundation, makes a compelling case for the tragedy associated with rheumatoid arthritis, which often strikes younger people. Of moderately severe or mildly severe patients, about half are not able to work anymore. It is not so much that they cannot do any work, as they find themselves in the unfortunate position of falling in the cracks of our systems. They are too disabled to work, but not disabled enough to have some help. (~685J

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Gout Testimony about gout also emphasizes the inadequate dissemination of effective interventions. Although gout is called "one of the few forms of arthritis that is almost completely controllable," it still causes con- siderable morbidity. The Arthritis Foundation says that "no effective primary preventive measures exist" for gout, making the application of secondary mea- sures to reduce disability "an attractive alternative." Overall, the prevalence of gout based on doctor diag- noses is 1 million cases, but self-reports are double that, according to the foundation.6 Fully 80 percent of those suffering from gout are men; the first attack usually occurs between ages 40 and 50. (~134) Ac- cording to Liang, many patients are being misdiag- nosed and put on potentially dangerous drugs because synovial fluid analysis-the diagnostic tool-is not being interpreted correctly by laboratories. (~132) Lappin notes that low-income and minority groups are not receiving available treatment and says that an objec- tive for the year 2000 should be to increase access to available treatment. She says that disability from gout among Blacks is three times that in Whites. (~3 73) HEARING DISORDERS About 22 million people in the United States suffer from a hearing impairment.7 (#396) Although sever- al of the 1990 Objectives, particularly those involving prenatal care and newborn screening, could have an impact on reducing hearing disorders, none of them specifically targeted the prevention of hearing loss. Several witnesses propose such objectives for the year 2000. Testimony highlights the point that risk factors for hearing loss are known and largely preventable, but interventions must begin early in life. (#361J Much of the testimony falls into two general categories: (1) prenatal care and screening newborns and children, and (2) reduction in damage-causing noise. Many witnesses emphasize the importance of new- born screening. Marion Downs of the University of Colorado Health Sciences Center proposes that by the year 2000, 80 percent of all newborns be screened for hearing disorders by electrophysiological screening. In 1986, only 5 percent of newborns were screened, she says, and only at major hospitals in larger cities.8 (#361) Shirley Sparks of Western Michigan Univer- si~, representing the American Speech-Language- Hearing Association, calls for screening of high-risk infants. (#396) Witnesses agree about the importance of proper diagnosis and treatment of otitis media in children as a means of preventing hearing loss. Glenna Jojola- Ellison of the All Indian Pueblo Council calls for a 50 percent reduction in the incidence of diagnosed otitis media by the year 2000. Her strategy for reducing the incidence and severity of the condition includes improved prenatal care, development of high- risk registries, encouragement of breast-feeding or discouragement of bottle propping, isolation of sick children in day-care/group baby-sitting environments, and eliminating exposure to cigarette smoke. She and others also emphasize the importance of public edu- cation about the dangers and signs of early ear disease. (#113) Hearing loss in young children is especially dangerous because it can interfere with language development. Jojola-Ellison emphasizes the importance of addressing problems related to hearing loss, such as learning disabilities. falls) Downs suggests as a target for the year 2000 that 80 percent of primary care physicians screen all children age 1 to 3 for language delays from recurrent otitis media. Professional medical organizations should provide training materials for physicians and develop ways to make the screening cost-effective and routine. (#361J Sparks emphasizes the need to educate care givers about conditions that put language development at risk. (~396) Testimony on hearing loss also emphasizes noise reduction. Witnesses cite several sources of poten- tially dangerous noise. According to one witness, musicians suffer hearing loss and research is needed into ways to control noise damage. (~152) Sally Lusk of the University of Michigan says that 14 million workers are exposed to hazardous noise,9 and because the noise is not always controllable, protec- tive devices are needed. However, she describes the difficulty in convincing workers to use these devices and urges research into ways to achieve better com- pliance. (~424) Others speak of controlling community noise from sources as diverse as rock music and rifles. Michael Marge of Syracuse University proposes that by the year 2000, 80 percent of states and their communities have ordinances prohibiting hazardous noise levels. (#433) Downs suggests that by the year 2000, 50 percent of the population should be able to identify noxious noise that may endanger their hearing and should possess or know how to obtain adequate ear protection for unavoidable harmful noise levels. (#361) Other Chronic Diseases and Disabling Conditions 199

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In addition to prevention of hearing loss, some testifiers call for reducing secondary disability from hearing loss that has been sustained. Sparks says that by the year 2000, disability from communication di- sorders among the elderly should be reduced by in- aeasing the use of assistive devices and other support measures. She suggests as an objective that there be no increase in the incidence of communication disor- ders, despite the projected increase in the number of elderly. (#396) VISION DISORDERS Vision impairments are a common problem in the United States. According to testifiers, more than 11.4 million Americans are visually impaired, and about 500,000 are legally blind. More than 100 million Americans wear corrective lenses.~ (#758) Testi- fiers link vision impairment to a large number of problems, including unintentional injury, poor school performance, reduced work productivity, and decreased alertness or independence among the elderly because of sensory deprivation. (#213) Good vision also is related to the safe operation of motor vehicles, and Robert Kleinstein of the University of Alabama at Birmingham recommends that by the year 2000, all drivers be tested for vision when renewing their dri- ver's licenses. (#720) Testimony from the American Public Health Asso- ciation (APHA) Vision Care Section identifies several areas for increased public awareness, including the importance of early detection and treatment of eye problems and the role of environmental factors, such as posture, nutrition, and luminance, in vision prob- lems. About one out of every 20 Americans has low vision. Many are unable to read ordinary print or watch television, even with correctional glasses or contact lenses. Low vision problems range from legal blindness to any vision impair- ment that, even with conventional glasses, prevents participating in or enjoying a desired visual activity. The APHA notes that individuals with low vision should be alerted that they probably can be helped. (~758) According to John Tumblin of the American Optometric Association (AOA), most people with low vision can achieve vision improvement with pro- fessional help. (~213) Several witnesses emphasize the importance of 200 Healthy People 2000: Citizens Chart the Course regular eye exams for everyone from preschoolers to older people. Robert Reinecke of the American Aca- demy of Ophthalmology emphasizes that traditional school vision-testing programs are not enough. "Un- fortunately, these exams usually are done for children over six years of age, thus missing the children at the time that they are most susceptible to treatment of the visual loss. (#455) He and others call for vision screening in schools and preschools to reach the very young. (#455; #720) To increase the number of eye exams among the elderly, the AOA proposes that routine vision services be available under Medicare Part B for all older pa- tients, especially those who are in institutions or homebound. (~455) In an effort to help the disad- vantaged elderly gain access to quality eye care, the American Academy of Ophthalmology has a toll-free number through which those 65 and older can be as- signed to a nearby volunteer ophthalmologist who will either accept insurance or give them free care, if needed, and who will provide follow-up. (#068; #455) The APHA says that by the year 2000, employers should be fully informed about the importance of establishing an occupational vision program. (#198} The AOA proposes on-thejob vision assessment and calls for a 50 percent reduction in eye injuries in industry from 1990 levels. It also emphasizes the need of eye protection for athletes and those regularly exposed to ultraviolet radiation. (#213) Saunders Hupp of the University of South Ala- bama discusses the ocular complications of diabetes: diabetes is the leading cause of new blindness among adults age 20 to 74, but it can be prevented with early intervention. Hupp calls for a 60 percent reduction in the incidence of legal blindness due to diabetes by the year 2000; this can be achieved if all segments of the population receive eye exams early enough to detect problems when they are treatable. Hupp notes that large numbers of diabetics-especially indigent people-are not receiving regular eye exams and says that physicians should be educated about new eye treatments for diabetes patients. (~265) DEVELOPMENTAL AND CHRONIC DISABILITIES Although disabilities originate from a variety of sources and at various times, testimony often focused on problems common to all disabled people. One issue raised several times is lack of access to health services, especially preventive services, which is discussed in detail in Chapters 7 and 8.

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Another approach is to reduce secondary dis- abilities in disabled people. For example, several witnesses mention the problem of decubitus ulcers, both in the context of the disabled and in relation to the elderly and acute care hospital patients. (#087; #139; #5~; #639; #732~. In addition to these general goals for the disabled, several specific disabilities were discussed in testi- mony. Mental retardation received the most com- ments. However, the point also was made that the most common conditions often get the most attention whereas many other conditions~ften classified as "others-get short shrift from planners despite the extensive morbidity associated with them. (#420) Drake and Dolsen mention postpolio sequelae, lupus, myasthenia gravis, multiple sclerosis, chronic viral diseases, and other examples. (~420) Dementia and Alzheimer's disease also are identi- fied by witnesses as important chronic illnesses, especially in the elderly. According to a survey conducted by reviewer Robert Katzman, University of California, San Diego, the incidence of new cases of dementia in those age 80 in New York is as great or greater than that of myocardial infarction, and exceeds that of stroke. These conditions are not prevent- able, and individuals with them are likely to have additional disabilities, he notes. (~794) Mental Retardation Approximately 2-3 percent of babies born each year will be diagnosed at some point in their lives as mentally retarded.~3 (#048) Witnesses from orga- nizations representing the mentally retarded em- phasize that many of these cases are preventable. REFERENCES Mary De Riso of the American Association on Mental Retardation (AAMR) says that both psychoso- cial and biomedical prevention activities are necessary. Poverty; lack of economic opportunity; and inadequate jobs, nutrition, or housing all contribute to mental retardation and should be addressed, according to De Riso. On the biomedical side, the AAMR seeks increased support for immunization programs, prena- tal care, mandatogr lead screening, and other interven- tions aimed at reducing the incidence of mental retardation. f#O45J Several 1990 Objectives are aimed at preventing mental retardation, and Sharon Davis, representing the Association for Retarded Citizens of the United States, urges that these be updated and retained in the Year 2000 Health Objectives. She says that by the year 2000, the prevalence of mental retardation from known causes should be cut in half. (~048) Robert Guthrie of the State University of New York at Buffalo recalls President Nixon saying in 1971 that half of all mental retardation could be prevented with what was known then. This underscores the point he and other witnesses make that knowledge about how to prevent mental retardation has outfaced concerted efforts to achieve these gains. Guthrie notes in particular the need for leadership and coordination at both the national and the state levels. (#529) Several witnesses also emphasize the goal of caring for more of the mentally retarded through community health services rather than in institutions by the year 2000. (#012; #048) However, Milton Baker of the National Council on the Handicapped recognizes that "such a community direction toward integration requires a disciplined plan of action and cannot take place without multiple supports and built- in monitoring." (~012) 1. National Diabetes Data Group (Ed.): Diabetes in America. (NIH Publication No. 85-1468), August 1985 2. Ibid. 3. National Diabetes Advisory Board: The National Long Range Plan to Combat Diabetes, 1987 (NIH Publication No. 87-1587), 1987 4. NIH Conference proceedings: Consensus Conference: Osteoporosis. J Am Med Assoc 252:799, 1984 5. Lawrence RC, Hochberg MC, Kelsey JL, et al.: Workgroup report: Estimates of the prevalence of selected arthritic and musculoskeletal diseases in the United States. J Rheumatol 16~4~:427-441, 1989 6. Ibid. Other Chronic Diseases and Disabling Conditions 201

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7. National Center for Health Statistics: Vital and Health Statistics: Current Estimates from the National Health InteIview Survey, 1988. Series 10, No. 173 (DHEIS Publication No. [PHS] 89-1501), October, 1989 8. Swigart ET (Ed.~: Neonatal Hearing Screening. San Diego: College-Hill Press, 1986 9. Occupational Safety and Health Administration: Noise Control. A Guide for Workers and Employers. OSHA 3048, Washington, D.C.: U.S. Department of Labor, 1980 10. American Academy of Ophthalmology: Eye Care for the American People. San Francisco, 1987 11. National Diabetes Data Group: op. cit., reference 1 12. Katzman R. Aronson M, Fuld P. et al.: Development of cementing illnesses in an 80-year-old volunteer cohort. Ann Neurol 25~4~:317-324, 1989 13. Oliphant PS, Geiger-Parker B. Gundell GW: Programs for Preventing the Causes of Mental Retardation. Presented to the Governor's Council on the Prevention of Mental Retardation by the Association for Retarded Citizens, New Jersey. New Brunswick: New Jersey Governor's Council on the Prevention of Mental Retardation, 1985 TESTIFIERS CITED IN CHAPTER 27 012 Baker, Milton; Syracuse Developmental Services Office 030 Bruemmer, Barbara; Pacific Medical Center and Fontana, Darlene; University Hospital (Seattle) 045 De Riso, Mary; American Association on Mental Retardation 048 Davis, Sharon; Association for Retarded Citizens of the United States 061 Esdale, Anne; Michigan Chapter, Society for Public Health Education 068 Garber, Norma; American Association of Certified Allied Health Personnel in Ophthalmology 087 Haus, Therese; Columbia University 113 Jojola-Ellison, Glenna; The All Indian Pueblo Council (Albuquerque) 116 Kirchner, Corinne; American Foundation for the Blind 132 Liang, Matthew; Harvard University 134 Long, Mary; Arthritis Foundation 139 Maklebust, JoAnn; Harper Hospital (Detroit) 152 Monaghan, Susan; Hunter Bellevue School of Nursing 198 Sheps, Cecil; American Public Health Association 213 Tumblin, John; American Optometric Association 214 Turner, Suzanna; National Osteoporosis Foundation 261 Thomas, John and Neser, William; Mehar~y Medical College 265 Hupp, Saunders; University of South Alabama 281 Greenwald, Maria; Universitr of California, Los Angeles 332 Chestnut, III, Charles; University of Washington 339 Tsuji, Wayne; Washington State Arthritis Foundation 361 Downs, Marion; University of Colorado Health Sciences Center 367 Miller, Paul; University of Colorado Health Sciences Center 373 Lappin, Debra; National Arthritis Foundation 396 Sparks, Shirley; Western Michigan Universi~ 410 Hawthorne, Victor; University of Michigan 420 Drake, Patience; Michigan Department of Management and Budget and Dolsen, Robert; Statewide Health Coordinating Council 424 Lusk, Sally; University of Michigan 433 Marge, Michael; Syracuse University 202 Healthy People 2000: Citizens Chart the Course

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455 Reinecke, Robert; Wills Eye Hospital 457 Altschuler, Alan; Prudential-Bache Securities, Inc. 470 Bright, Frank; Ohio Department of Health 491 Haffner, Steven; University of Texas Health Science Center at San Antonio 496 Young, Eleanor; University of Texas Health Science Center at San Antonio 529 Guthrie, Robert; State University of New York at Buffalo 567 Diehl, Andrew and Stern, Michael; University of Texas Health Science Center at San Antonio 568 Brandon, Jeffrey; University of New Orleans 626 Hiss, Roland; University of Michigan 639 Parrino, Sandra; National Council on the Handicapped 685 Condit, J. Michael; Kelsey-Seybold Clinic 699 Porte, Jr., Daniel; Seattle Veterans Administration Medical Center 720 Kleinstein, Robert; University of Alabama at Birmingham 732 Hill, Nina; International Center for the Disabled 758 Whitener, John; American Public Health Association, Vision Care Section 794 Katzman, Robert; University of California, San Diego Other Chronic Diseases and Disabling Conditions 203