|
Items in cart [1] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 196
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
OCR for page 197
"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
OCR for page 198
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
OCR for page 199
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
OCR for page 200
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.
OCR for page 201
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
OCR for page 202
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
OCR for page 203
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
Representative terms from entire chapter:
bone mass
