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OCR for page 7
2. Objectives Process and Structure
More than 150 witnesses focused their testimony on
issues related to the process of setting objectives and
to the nature of the objectives themselves. Their
testimony, often based on experience in developing
and implementing objectives at the state level, gave
suggestions about the scope of the objectives, their
organization and format, and the need to address
special subpopulations. Many testifiers also addressed
the need to set priorities among the objectives and
suggested ways to do so.
Some of this testimony is relevant to developing
national objectives, and the ideas have already been
incorporated into the structure of the Year 2000
Health Objectives. The ideas in this chapter also are
relevant to implementation of the national objectives.
This material may, however, be most relevant for state
and local governments or other organizations that are
developing their own objectives, and for the future
development of national objectives.
NATURE OF THE OBJECTIVES
Those who testified at the hearings and in writing had
much to say about the nature of the Year 2000
Health Objectives. Their comments, for instance,
addressed the need to go beyond narrow definitions of
health and to include the social conditions that
underlie health problems. Others addressed the basic
framework for the objectives and suggested alternative
frameworks for health promotion and disease preven-
tion.
Need to Address Social CondItlons
Those who addressed the issue of social conditions
agreed that national objectives focusing exclusively on
health matters are In danger of missing the underlying
causes of illness.
"As broad as these objectives are and will be,"
writes Jule Sugarman, Secretary of the Washington
State Department of Social and Health Services, "they
are not broad enough to assure the preservation of
health. The World Health Organization is asking its
member nations to consider in its health policies the
impact on health of education, housing, business,
agriculture and the other sectors of society. We in
this nation need to give more public attention to
these intersectoral impacts on health." (~337) In a
similar vein, the American Public Health Association
suggests that "many health problems could be amelio-
rated by improved social conditions, including employ-
ment, housing, nutrition, and greater access to health
care. (#198)
Members of the Society for Prospective Medicine
propose that the objectives address and emphasize
social issues, as well as medical/technical issues, as the
means to attain national health goals. (#374)
Bernard Turnock, Director of the Illinois Department
of Public Health, suggests that interventions be
designed around models "that allow for a broad
definition of health and consider such issues as
transportation, ability to pay for services, and hous-
ing.~ (~215)
Peter Pulrang of the Washington State Bureau of
Parent and Child Health illustrates this point more
specifically. The 1990 Objectives, he [eels, are a
"one-step-at-a-time" process that is presently effective,
but not enough to bring about necessary behavior
changes, especially by the year 2000. Better pregnancy
outcomes result not just from education, but also
from emotional, economic, and environmental security,
and from availability and access tO appropriate
medical care and support services. (~354)
Concepts of Health Promotion and Disease
Prevention
Some testimony addressed the basic question of how
health promotion and disease prevention activities are
conceptualized and the implications for developing a
structure for the objectives. Suggestions ranged from
developing a more systematic and elemental approach
that looks at each health problem and its causes, tO
developing a more holistic approach that targets basic
underlying causes and requires multifactorial interven-
tions. Another point of agreement was that the ob-
jectives should be more positive and should focus on
health-enhancing factors rather than on diseases and
disorders.
William Lassek, Regional Health Administrator for
Public Health Service Region III in Philadelphia, calls
for ha significant change in the organization of the
objectives to bring them in line with accepted prin-
ciples of public health epidemiology, i.e., beginning
Objectives Process and Structure 7
OCR for page 8
with a negative health outcome, determining its risk
factors, and designing an intervention to reduce the
risk factors." Lassek proposes the following:
· Define new goals by age group for reducing
mortality.
· For each age group, enumerate and track the
leading causes of death by race and sex.
· Within each age group, set separate goals for
Whites and non-Whites, and track the rates sepa-
rately.
· For each cause of death within each age group,
enumerate the major risk factors.
· Set objectives for interventions known to reduce
risk factors.
· Treat major causes of morbidity in the same way
as major causes of death. (#126)
Professor Joseph Stokes of the Boston University
Medical Center suggests that the Year 2000 Health
Objectives be organized along the McKeown model of
health and disease determinants, the model used by
the Canadian Lalonde report." According to Stokes,
~McKeown classifies these determinants as: (1) bi-
ological factors mediated through genetic transmission;
(2) factors in the physical, biological and social
environment; and (3) health behaviors such as diet,
exercise, cigarette smoking, alcohol and other drug
use, sexual behavior, motor vehicle and other
accident-risk behavior and finally health
services-particularly preventive health services.
(~627)
Others emphasize the importance of crosscutting
problems and the need for multifactorial approaches.
The American Academy of Family Physicians notes
that the structure of the Year 2000 Health Objectives
is organized on a problem-specific basis rather than a
solution basis.
This is a substantial barrier to health care. In
the traditional approach to medical education,
the body is taken apart by various organ systems
and each studied In almost complete isolation
from the others. However, this is not how the
body works. There are no hearts without brains,
no lungs without arms and legs. The body is a
highly integrated system. So too it is with medi
cal problems. Within the practice of family med
icine, no disease is an island unto itself. Most
disease is multifactorial. So, too, the solutions
need to be multifactorial. (~072)
Frank Bright of the Ohio Department of Health
echoes the point.
8 Healthy People 2000: Citizens Chart the Course
Chronic diseases and conditions often have
multiple risk factors, may be multifactorial in
origin, often occur together, and may work
synergistically to contribute to poor health.
Chronic disease needs to be addressed in a
multi-part, integrative approach that considers
all of the various factors that contribute to the
problem. (~470)
Many testifiers feel that the objectives should focus
on positive states and health-enhancing factors.
According to Lynn Artz of the University of Alabama
at Birmingham, the 1990 Objectives are concerned
with disease prevention and focus on risk factors and
negative states. Positive states and health-enhancing
factors should also be identified, and objectives set to
achieve them. Artz gives the following examples:
"Increase the proportion of Americans who consume
optimal quantities of fresh fruits, vegetables and
whole grains; who are physically fit; who sleep eight
hours a night; who are satisfied with their interper-
sonal relationships; who feel good about themselves,
their health, and their lives." (#667J
Carol Foster of the Children's Hospital of Los
Angeles also feels that the overall orientation of the
objectives should be more positive. "The purpose of
each initiative should be to achieve some definite
state (such as a positive pregnancy outcome) rather
than to avoid a list of the possible negative out-
comes." (#536J The American Society of Allied
Health Professions suggests that quality of life state-
ments be incorporated in the objectives and that the
objectives not be limited to morbidity and mortality
statements. It further suggests that emphasis be
placed on the development and refinement of health
status indicators to measure life quality characteristics.
(#631)
Testifiers suggest that psychological, emotional, and
social problems be balanced with physical problems.
According to Michael Jarrett, Commissioner of the
South Carolina Department of Health and Environ-
mental Control, "Many objectives appear to be veIy
weak regarding the influence of psychosocial issues on
the health status of the nation. Greater attention
needs to be paid to these issues with objectives that
include intervention strategies." (#108)
FORMAT AND FOCUS OF THE OBJECTIVES
Many witnesses spoke about the focus and the
organization of the objectives. For example, accord-
ing to Mark Richards, Secretary of Health for the
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Commonwealth of Pennsylvania:
One of the problems in implementing the 1990
Objectives was that there were too many dif-
ferent and inconsistently stated objectives. This
can only dilute our effectiveness in implementing
programs to address these objectives. Therefore,
the Year 2000 Health Objectives should be
more focused and specific, and perhaps less
global than the 1990 Objectives. (~387J
On the other hand, numerous witnesses called for the
addition of new topic areas and new target audiences
which, when added together, would greatly increase
the number of objectives.
Others addressed the need for more complete and
accurate data, and for objectives that are grouped by
or targeted to subgroups in the population.
Measurement Issues
The lack of accurate and timely data to measure
progress toward the objectives, especially for local
areas and minoring populations, and the lack of
outcome measures other than mortality have impor-
tant implications for the format of the objectives.
Those who testified on this issue suggested that data
availability and quality be addressed directly in for-
mulating the objectives and that attempts be made to
identify potential sources for filling gaps in the
information base.
According to Richards, for instance, a
major implementation problem with the 1990
Objectives was unavailability of related or prosy
data to measure the status of some objectives.
At the state level in Pennsylvania, we could
review only 50 out of 226 objectives; at local
levels, the problem of lack of data was even
worse.2 (#387)
Jarrett also stresses the importance of having measur-
able objectives and uniform or widely known data
sources and advocates the Centers for Disease Con-
trol's Behavioral Risk Factor Surveillance System or
something similar. (#108J
The Association for Vital Records and Health
Statistics (AVRHS) recommends the following:
· Objectives should be stated in quantitative terms
and should be measurable.
If data sources do not exist to measure an
objective, a mechanism for obtaining adequate data
should be indicated.
· Data used to measure objectives should be of
high quality.
· Local and state data needs should be addressed,
as well as national data needs.
· Data sources for measuring progress toward each
objective should be cited.
The AVRHS adds:
Since the Year 20Q0 Objectives will provide a
focus for many agencies working to improve the
health of all citizens and are expected to be
translated to state and local needs, many state
and local agencies also will adopt the same
objectives. Data systems should, where possible,
address the needs of state and local agencies as
well as those for the nation. (~527)
Robert Harmon, Director of the Missouri Depart-
ment of Health, says that "information systems have
to be built around the objectives to provide meaning-
fi`l information about progress in achieving them.
This will take an expenditure of resources." He adds,
"The resources needed for this task are critical to the
success of the entire objectives-setting process and
should not be short-changed." (~085) The National
Safety Council warns that requiring quantified objec-
tives means that some important problems may be
neglected. It suggests that a new format be developed
for health problems such as stress and age-related
disabilities, by using descriptive rather than quantita-
tive paradigms. fit is possible, for instance, to state
that situation B is better than situation A even
though we cannot assign any percentage or ratio to
this improvement. f#019J
Artz also is concerned that the objectives not be
limited to easily measured outcomes. The 1990
Objectives "emphasize problems resulting in death
over problems that cause relatively more morbidity
and disability." The objectives stressed problems that
can be measured easily such as homicide, suicide, and
infant mortality. Hence, there are no objectives for
sexual assault, nonfatal domestic violence, and so on.
(#667)
Oregon's experience with using objectives at the
state level suggests that the current availability of data
should not be a determinant of the nature of the
objectives. Perhaps the most useful result of our
project was the identification of data gaps," says
Michael Skeets of the Oregon Department of Human
Objectives Process and Structure 9
OCR for page 10
Resources. (~321)
Group Objectives by Population Subgroups
Many of the witnesses suggested that the national
objectives include special objectives grouped by and
targeted to various demographic, racial, ethnic, and
other subpopulations. Ibe potential groups suggested
include men and women, the old and young, racial
and ethnic minorities, the poor, the homeless, and
various kinds of workers. The basic rationale was
that separate "special population targets" are necessary
to identitr the groups most in need of intervention
and to target programs, especially programs designed
for their needs, to them.
Sheryl Ruzek of Temple University, for instance,
suggests that special objectives are required for
women. These would include sexual assault, problems
associated with female reproductive organs and
processes, and unnecessary medical interventions that
are frequently applied to women such as hysterec-
tomies, aggressive surgery for breast cancer, and
cesarean sections. They would employ strategies that
include providing health information; supporting
community development; and promoting regulatory,
legislative, and judicial measures. (#189J
Ronald Mazur of the University of Massachusetts
at Amherst suggests a "men's health" category, focus-
ing on violence and destructive behavior including
alcohol-related trauma. (#530)
Nancy Stevens of Kaiser Permanente suggests
organizing the objectives by "age group (infants,
children, adolescents, adults, older adults) or con-
stituent groups (schools, worksites, municipalities), as
well as diagnostic group. This type of presentation
would enable providers of care, service, or employ-
ment to identity the health issues that are pertinent
to specific populations, as well as diagnostic groups."
f#352) Members of the Society for Prospective
Medicine also feel that the objectives should be made
for age groups, especially the elderly and children.
(~3 74) Edward Wagner of the Group Health Coop-
erative of Puget Sound, for instance, found the 1990
Objectives useful for establishing health status goals
for older Americans, but complained that specific
1990 Objectives provided little guidance in identifying
specific interventions to reduce unnecessary disability
among the elderly. (~738) According to Jerrold
Michael of the University of Hawaii, representing the
Association of Schools of Public Health:
10 Hea/thyPeop/e 2000: Citizens Chart the Course
[We should not] leave the differentiation of the
needs of special groups as a postscript in docu-
ments that never catch up with the main body
of the report. We are all special in some way.
Our differences are what provides us with the
spirit and creativity of our pluralistic society.
These differences, in need, in aspiration, in
priority, in concern, require more than a single
approach. We are talking not only of groups in
high risk who need special attention-although
these needs must be a starting point for much
of our decision makin~but of the larger con-
cept that requires us to be obligated to pattern
health objectives to the needs, interests, realities,
and possibilities of specific contexts. Health for
all never is achieved with a standardized set of
outcomes. (#149)
Robert Bernstein, Commissioner of the Texas
I:)epartment of Health, agrees, and suggests that the
objectives Target special populations such as the
school-age population or a geographic area and ethnic
groups like the Mexican-American populations along
the U.S.-Mexico border. Attention in objective set-
ting and initiatives developed to address the needs of
these special populations will help focus attention and
comprehensive action on improving the health of the
high-risk and priority populations." f#020)
Many witnesses felt that reducing disparities in
health between economic and racial groups should be
an overriding goal for the year 2000. According to
John Waller of Wayne State University:
Lee recognition of vulnerability and documented
disparities in health status between White and
minority populations should be sufficient jus-
tification for establishing within each of the five
health status goals for age groups specific
improvements in the health status of Blacks and
other minorities to be achieved via targeted
health promotion, health protection, and preven-
tive service objectives that are culturally specific.
The excess death methodology as defined in the
Report of the Secreta~y's Task Force on Black and
Minority Health should be used as the quantita-
tive measure for tracking progress or the lack of
progress toward the achievement of these Black
and/or minority objectives.
Wailer argues for special objectives for each of the
OCR for page 11
six causes of death identified by the task force that
are the major contributors to the disparity in health
status: cancer, heart disease and stroke, homicide and
accidents, infant mortality, cirrhosis, and diabetes.3 In
addition, there should to be culturally specific health
promotion objectives for smoking, misuse of alcohol
and drugs, nutrition, physical fitness, and control of
stress and violence. (#314)
Other testifiers suggested separate objectives for
various racial and ethnic groups such as Blacks,
Hispanics, Native Americans, Asian and Pacific
Islanders, and Arabs. Still others felt that the objec-
tives should target socioeconomic status instead of
race, because this is the more "operative variable" in
tracking health status. (#374) Socioeconomic groups
could include the poor and the homeless, farm and
migrant workers, and people who live in rural areas.
Missing Objectives
A number of witnesses testified about problem areas
or approaches that were missing from the national
objectives, as currently formulated. Some, for in-
stance, addressed the infrastructure for health
promotion and disease prevention. Others offered
alternative approaches to health promotion and
disease prevention, and mentioned particular areas
that should be included in the objectives.
Joel Nitzkin, Director of the Monroe County
Health Department in New York and representing the
National Association of County Health Officials,
points out that certain process and infrastructure
issues must be addressed within a state or locality
before that state or locality can effectively pursue
implementation of the Year 2000 Health Objectives.
He specifically suggests that an entire new section
entitled "Prevention Process and Infrastructure" be
added to the objectives document to provide guidance
relative to assignment of responsibility for review of
the national objectives, development of a local
response, establishment and monitoring of needed
surveillance systems, and a variety of other political,
administrative, and technical issues. (#523)
lithe American Academy of Family Physicians feels
that a new major category should be developed for
"Systems/Programs Supporting Disease Prevention and
Health Promotion." This would include (1) develop-
ment of insurance or other payment systems that pay
for scientifically supported disease prevention and
health promotion in the doctor's office and outpatient
settings; (2) development and adoption of office-based
systems for health risk assessment and longitudinal
tracking for both screening examinations and health
behaviors; (3) development of disease prevention and
health promotion curricula within medical schools and
residences on an equal par with other medical educa-
tion topics; and (4) funding of research to determine
appropriate assessments and interventions, as well as
their frequencies and effectiveness. (#072)
Douglas Mack, Director of the Kent County
Michigan Health Department, makes a similar sugges-
tion.
The Year 2000 Health Objectives should provide
a category called "Administration and Support
Services," with attendant measurable objectives
that will provide for responsible management
and design for the delivery of the more sophisti-
cated health service delivery objectives. Without
a steady improvement in the basic administrative
infrastructure, the service delivery objectives run
the risk of inefficient development and unequal
distribution to the nation's general population.
(~137)
The American Society of Allied Health Professions
asks for Objectives to increase coverage of preventive
health care services of proven efficiency and cost
effectiveness." (~631)
According to Jarrett:
The 1990 Objectives appear to be scant in
taking into consideration the roles and impor-
tance of the family in determining and influenc-
ing health status. This was particularly evident
in objectives dealing with stress, violence, sub-
stance abuse, and handicapped children. Grea-
ter attention should be paid to this area with
objectives to support, maintain, and develop the
strength of the family unit. (#108)
Carol Foster of the Children's Hospital of Los
Angeles suggests that a new objective category be
established, called Family Support, to include family
violence, genetic services, nutritional services, and
services to children including day care, school health,
and early intervention. (~536) Foster also suggests
that all substance abuse issues be incorporated into
one category and that all of the health promotion
activities plus family support be in a single category
entitled "Maintaining Health and Quality of Life
Through Health Promotion." (#536)
James Woodrum, President of the Wellness and
Prevention Program in Houston, suggests that the
Objectives Process and Structure 11
OCR for page 12
objectives include a new category on the "improve-
ment of social health" to reflect the concerns of
Sugarman and others summarized earlier. Woodrum
defines social health as efforts To effect health
promotion and disease prevention through the ap-
plication of positive individual, group, and community
social factors." (#22 7J
Other witnesses mentioned specific areas they
thought were missing from the 1990 Objectives.
Some of these will be addressed in the Year 2000
Health Objectives. The missing areas include adoles-
cent health (#125), aging (#125; #215; #629),
chronic diseases (~125; #215), mental health (~215),
AIDS fitly), iatrogenic injury fatly), smokeless
tobacco (#2153, food-borne diseases (#125), back
problems (#019), asbestos (#215), day care (#006;
#303), and access to health care (~33 79.
PRIORITY SETTING
A number of witnesses suggested that there be fewer
objectives than there were for 1990 or that priorities
be set among them. Some testified that priorities are
required to focus efforts, allocate resources, and
reduce disparities in the burden of illness. Others
proposed specific analytical models or processes for
setting priorities.
Need for Priorities Among the Objectives
Support for setting priorities comes from both the
public and the private sector. Harmon, for instance,
draws on his experience in using state objectives.
When looking this far ahead, it helps to focus
on priorities. Establishing a strategic vision or
mission for the future not only helps to Claris
desired achievements, it also helps eliminate
those issues that may be veer important but are
not central to an agency's overall purpose. The
nation should select priorities based on what is
achievable by the year 2000, what represents a
marked improvement over the status quo, what
falls within the national public health mission,
and what can be impacted directly or indirectly
by a positive endorsement from the federal
government. The collection of objectives for the
nation should be limited to those objectives that
are most important to the achievement of
improved health status by the year 2000.
(#085)
12 Healthy People 2000: Citizens Chart the Course
Based on his experience In Texas, Bernstein says:
It is essential that priority should be given to
directing resources where there is disparity
between state or local morbidity or mortality
rates so that interventions can be directed
toward underserved or high-risk populations.
This could be accomplished by utilizing the
objectives as criteria in requests for funding
proposals released at both the state and federal
levels, as well as more closely tying block grant
funds to the Year 2000 Health Objectives.
(~020)
According to Turnock:
Having clearly visible and repeatedly articulated
priorities and broadly defining these priorities
into categories is critically important. It allows
all potential participants to better understand
their roles in addressing a collective health
problem and selves to catalyze inclusion and
participation over exclusion and avoidance. It
focuses our efforts on the health outcomes and
on the persons affected or potentially affected by
the problem, rather than on the health care
delivery system as so many of our past and
current so-called health priorities have done. It
establishes a focal point for integration and
systemization of diverse efforts-including some
even outside the traditional notion of health
strategies-and provides a rallying point for
seeking and securing new and expanded resour-
ces. (~91SJ
Some representatives of the private sector feel the
same way, for example, Charles Arnold who
represents the Health Insurance Association of
America.
Regrettably, we cannot afford to specitr all
objectives, no matter how desirable they may be.
If critical objectives are to be attained, more
attention must be given to policy issues such as
setting priorities, associated expenditures, mana-
gerial efficiencies, research to support the objec-
tives, and collaboration at federal-state and
public-private levels. (#440)
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IUlodels for Setting Priorities
Although a number of analytical and process models
were proposed for determining priorities among the
objectives, they all shared two factors: a concern for
the burden of illness that might be alleviated, and a
consideration of the possibilities (theoretical and
practical) for carrying out the intervention and mak-
ing it succeed.
Beverly Long, for instance, representing the
National Mental Health Association, calls for a
process to set national priorities, which takes into
account the burden of illness (she notes the need to
develop a method to assess this) and defines a role
for all disciplines, public and private agencies, profes-
sional and volunteer groups. Recognizing the "dis-
taste for saying that one sorrow is worse than anoth-
er," she nevertheless calls for scientifically derived
facts to help make difficult decisions. (#270)
A number of witnesses gave concrete suggestions
about models and criteria for setting priorities.
Alfred Haynes of the Charles R. Drew Postgraduate
Medical School suggests that the number of objectives
be drastically reduced.
My own experience in health planning in the
United States and abroad convinces me that it
is impossible to mobilize a nation around 226
objectives. If we want to make things happen,
if we want to change the course of events by
design rather than by chance, then we must
sharpen the focus on items of highest priority,
use the best available knowledge, and allocate
appropriate resources to obtain the desired
results.
Haynes suggests three criteria for setting priorities:
1. The condition or risk factor involved must be
one of high priority to the nation or to a large
segment of the population, based on the current or
potential burden of illness and death.
2. The objective must be linked to a scientifically
proven method of achieving it.
3. Resources must be available and identified to
implement the objective by using a scientifically
proven method. (#276)
Paul Entmacher of the Business Roundtable
recommends the development of a "guiding conceptual
framework" to bind disparate objectives together
toward a common goal of improving the public's
health.
The guiding framework could be based on
several aggregate measures of health of the
public. Candidates for objectives should be
evaluated on the extent to which they are a
source of preventable health loss and the extent
to which strategies exist that would be effective
in reducing preventable health loss. Since not
all desirable objectives may be affordable, the
Business Roundtable favors prioritization of the
categorical goals so that resource allocation can
be properly guided. The absolute and relative
expenses associated with attaining each objective
should be estimated. With those economic data
as guidance, planners could make reasonable
estimates of the national level of effort required.
The ends-means-resources planning model
implied here would permit an assessment of the
relative value of each objective in terms of
priority and cost, as well as the feasibility of
having the means to reach those ends. (#465J
Turnock says that "in determining priorities, it is
essential to focus on health outcomes and the health
of the public, with a special emphasis on the dis-
proportionate rates of excess deaths among minority
populations." (#215) He also stresses the need to
work with community organizations and local agencies
to establish realistic goals. HA comprehensive process
of selecting priorities, working with and through
community organizations and local agencies, and
setting incremental objectives specific to communities
is necessary to realize objectives and establish a
realistic and useful implementation process." (#215)
Objectives Process and Structure 13
OCR for page 14
REFERENCES
1. Lalonde M: A New Perspective on the Health of Canadians: A Working Document. Ottawa: Information
Canada, April 1974
2. Commonwealth of Pennsylvania, Department of Health: Pennsylvania Assessment: Health Objectives for the
Nation 1990, Mid-Decade Report. Harrisburg, Pa.: 1987
3. U.S. Department of Health and Human Selvices: Report of the Secretary's Task Force on Black and
Minority Health. Washington, D.C.: U.S. Government Printing Office, August 1985
TESTIFIERS CITED IN CHAPTER 2
006 Allensworth, Diane; American School Health Association
019 Benjamin, George; National Safebr Council
020 Bernstein, Robert; Texas Department of Health
072 Graham, Robert; American Academy of Family Physicians
085 Harmon, Robert; Missouri Department of Health
108 Jarrett, Michael; South Carolina Department of Health and Environmental Control
125 Larsen, Michael; Mississippi State Department of Health
126 Lassek, William; Department of Health and Human Services, Region III
137 Mack, Douglas; Kent County Health Department (Michigan)
149 Michael, Jerrold; University of Hawaii School of Public Health
189 Ruzek, Sheryl; Temple University
191 Salive, Marcel and Wolfe, Sidney; Public Citizen Health Research Group (Washington, D.C.)
198 Sheps, Cecil; American Public Health Association
215 Turnock, Bernard; Illinois Department of Public Health
227
270
276
Woodrum, James; Wellness and Prevention Program, inc. (Houston)
Long, Beverly; World Federation for Mental Health
Haynes, Alfred; Charles R. Drew Postgraduate Medical School
303 Grimord, Mary; Texas Woman's University
314 Waller, John; Wayne State University
321 Skeets, Michael; Oregon Department of Human Resources
337 Sugarman, Jule; Washington State Department of Social and Health SeIvices
352 Stevens, Nancy; Kaiser Permanente, Northwest Region
3S4 Pulrang, Peter; Washington State Bureau of Parent and Child Health
374 Society for Prospective Medicine
387 Richards, N. Mark; Pennsylvania Department of Health
440 Arnold, Charles; Metropolitan Life Insurance Company
465 Entmacher, Paul; Metropolitan Life Insurance Company
470 Bright, Frank; Ohio Department of Health
523 Nitzkin, Joel; Monroe County Health Department (New York)
527 Freedman, Mary Anne; Association for Vital Records and Health Statistics
530 Mazur, Ronald; University of Massachusetts at Amherst
536 Foster, Carol; Children's Hospital of Los Angeles
627 Stokes, III, Joseph; Boston University
629 Kinsman, Katherine; South Dakota Department of Health
631 Freeland, Thomas; American Society of Allied Health Professions
667 Artz, Lynn; University of Alabama at Birmingham
738 Wagner, Edward; Group Health Cooperative of Puget Sound
14 Healthy People 2000: Citizens Chart the Course
Representative terms from entire chapter:
health objectives
