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OCR for page 57
Appendix A
PUBLIC HEALTH ROUNDTABLE MEETING
Arnold and Mabel Beckman Center
Irvine, California
October 27, 1995
AGENDA
8:45-12:00 noon MORNING SESSION
Stuart Bond?'rant, M.D., cochair
8:45-9:00 a.m. Welcome and Introductions
9:00-10:OOa.m Goals oftheRoundtable: What do we want to
accomplish this year?
10:00-11:00 a.m. Overview of The Future of Public Health
Hugh Tilson, M.D., Dr.P.H., cochair
Edward Baker, M.D., Director, CDC Public Health
Practice Program Office
1 1:00-1 1:45 a.m. Future of Public Health: Survey of Health Departments
F. Douglas Scutchf eld, M.D., Visiting Scholar, Kaiser
Permanente
57
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58
1 1:45-12:00 noon
12:00-1 :00 p.m.
HEALTHY COMMUNITIES
Update on the APHA Session
Cynthia Abel, Program Officer
Lunch
1:00-5:30 p.m. AFTERNOON SESSION
Hugh Tilson, M.D., Dr.P.H., cochair
1:00-2:00 p.m. California Medi-Cal Managed Care Program
James G. Haughton, M.D., MP.H., Senior Health
Services Policy Advisor, Los Angeles County
Department of Health Services
Ingrid Lamirault, Director, Planning and Policy
Development
2:00~:00 p.m. Related Public Health Activities
Centers for Disease Control and Prevention
David Satcher, M.D., Director, CDC
Edward Baker, M.D., Director, CDC Public Practice
Program Office
Public Health Functions Project
Data/perfonnance measurement for population health
Roz Lasker, MD., New York Academy of Medicine
Expenditures, Workforce, Communications and
Community Planning
Kristine M. Gebbie, R.N., Dr.P.H., F.A.A.N., Columbia
University School of Nursing
Practice Guidelines
Edward Baker, M.D.
The Robert Wood Johnson Foundation
Public Health Infrastructure
Nancy Kaufman, R.N., M.S., Vice President, The Robert
Wood Johnson Foundation
The Kellogg Foundation
Thomas Bruce, M.D., Program Director
: Initiative on
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APPENDIX A
59
American Medical Association
James Allen, M.D., Director of Public Activities
Milbank Fund Project on Leadership in Public Health
Edward Baker, M.D.
IOM Committee on Using Performance Monitoring to
Improve Community Health
John Lumpkin, MD., M.P.H. (Committee Member)
The Linkages Council
Hugh Tilson, M.D., Dr.P.H.
Other Activities: Roundtable members are encouraged
to talk about activities not mentioned above.
4:00-5:30 p.m. General Discussion: Objectives ofthe Roundtable,
Topics for Future Meetings, and Dates for Future
Meetings
Stuart Bondurant, MD., cochair
Hugh Tilson, M.D., Dr.P.H., cochair
PARTICIPANTS
Cynthia Abel
Program Officer
Institute of Medicine
Washington, DC
James Allen, M.D., M.P.H.
Vice President, Group on Science
Technology and Public Health
American Medical Association
Chicago
Charles F. Bacon
Special Project Officer
Centers for Disease Control and
Prevention
Atlanta
Edward L. Baker, M.D.
Director, Public Health Practice
Program Office
Centers for Disease Control and
Prevention
Atlanta
Steve Boedigheimer, M.M.
Deputy Director, Division of Public
Health
Delaware Health and Social
Services
Dover
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60
Stuart Bondurant, M.D., cochair
Director, Center for Urban
Epidemiologic Studies
New York Academy of Medicine
New York City
E. Richard Brown, Ph.D.
Professor of Public Health
School of Public Health and
Director, Center for Health Policy
Research
University of California, Los
Angeles
Thomas A. Bruce, M.D.
Program Director
W.K. Kellogg Foundation
Battle Creek, MI
Kristine M. Gebbie, R.N., Dr.P.H.,
F.A.A.N.
Assistant Professor of Nursing
Columbia University School of
Nursing
New York City
Margaret A. Hamburg, M.D.
(By conference call)
Health Commissioner
New York City Department of
Health
New York City
James G. Haughton, M.D., M.P.H.
Senior Health Services Policy
Advisor
County of Los Angeles
Department of Health Services
Los Angeles
HEALTHY COMMUNITIES
Nancy Kaufman, R.N., M.S.
Vice President
The Robert Wood Johnson
Foundation
Princeton, NJ
Ingrid Lamirault
Director, Planning and Policy
Development
County of Los Angeles
Department of Health Services
Los Angeles
Roz Lasker, M.D.
Director, Division of Public Health
New York Academy of Medicine
New York City
John Lumpkin, M.D., M.P.H.
Director
Illinois Department of Public
Health
Springfield
Charles Mahan, M.D.
Dean, College of Public Health
University of South Florida
College of Public Health
Kathy Newman, R.N., M.P.H.
Director, Barron County Public
Health Nursing Service
Barron, WI
Robert Pestronk, M.P.H.
Health Officer
Genesee County Health
Department
Flint, MI
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APPENDIX A
David Satcher, M.D., Ph.D.
Director
Centers for Disease Control and
Prevention
Atlanta
F. Douglas Scutchfield, M.D.
Visiting Scholar
Kaiser Permanente
Oakland, CA
Michael A. Stoto, Ph.D.
Director, Division of Health
Promotion and Disease Prevention
Institute of Medicine
Washington, DC
Donna D. Thompson
Division Assistant
Institute of Medicine
Washington, DC
61
Hugh H. Tilson, M.D., Dr.P.H.,
cochair
Vice President and Worldwide
Director
Epidemiology Surveillance and
Policy Research
Glaxo Wellcome Company
Research Triangle Park, NC
Robert B. Wallace, M.D.
Head, Department of Preventive
Medicine and Environmental
Health
University of Iowa
Martin Wasserman, M.D., J.D.
Secretary
Health and Mental Hygiene
Department
State of Maryland
Baltimore
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HEALTHY COMMUNITIES
National Academy of Sciences
INSTITUTE OF MEDICINE
PUBLIC HEALTH ROUNDTABLE
APHA Session
San Diego, California
October31, 1995
SUMMARY MINUTES
Introduction Hugh Tilson, M.D., Dr. P.H.
Dr. Tilson introduced himself and outlined the format of the session and noted
that speakers were selected from a variety of public health organizations and
invited to prepare a short presentation in advance. Individuals who were asked
to speak have reputations as visionaries who have the ability to look forward,
but who are also aware of the realities of working in the public health field.
Presentations
Lead Abatement
· Lloyd Novick, M.D., SUNY School of Public Health, Linkages Council
Chair
Problems faced by different sectors of public health are similar, but standardized
approaches to solving those problems are lacking. The Linkages Council is
involved in evaluating the utility of public health guidelines in public health
practice. However, there are difficulties associated with the development of
standardized guidelines. For instance, differences between communities in
terms of population and resources make it questionable whether the same
guideline could provide optimal guidance to all communities. The Kellogg
Foundation provided the Linkages Council with a grant to examine the
usefulness of public health guidelines. Expert panels comprised of public health
practitioners from state and local health departments, as well as the public health
and clinical sectors, were convened to look at different areas of public health
and review all relevant literature. One panel is looking at the usefulness of
testing children for lead poisoning. A guideline would need to recommend
whether all children in a community should be tested or whether limited
resources should be focused on testing only low-income children, who are more
likely to be exposed. The Linkages Council is presently working with the
Public Health Service and the CDC with the intent of selecting two important
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APPENDIX A
63
public health topics and developing guidelines for them. The Public Health
Service is also in the process of convening its own task force to examine the
feasibility of guidelines.
· Thomas Schlenker, M.D., Salt Lake City-County Health Department
Recent research has determined that low-level lead exposure can be harmful to
young children and has helped to redefine childhood lead poisoning as a
medical and social issue. In 1988 the CDC established a lead poisoning section
to focus on issues related to childhood lead poisoning. Organizations such as
the Alliance to End Childhood Lead Poisoning and the National Center for
Lead-Safe Housing are collaborating with the CDC to define and combat the
issue on a national level. However, some clinicians who treat young children
never see lead poisoning in their patients, while others think they see it
everywhere. There is also ongoing debate over whether the CDC's current
danger level for lead exposure in young children of 10 ,ug/dcl is accurate. While
the lead problem is well-defined nationally, Dr. Schlenker feels that the problem
needs to be solved on a local level. It is the responsibility of local health
departments to convince the medical community that lead poisoning is a
problem that must be addressed. To achieve a greater awareness of lead issues,
health departments need to collaborate with each other, the medical community,
government agencies, and others, such as the construction and housing
industries. Local health departments also need to collect data on blood lead
levels in the populations they serve. In communities where blood lead levels
have been monitored, the resulting data have been a sufficient basis for the
development of lead-related programs.
STDs: Prevention and Control
· Ellen Gursky, M.D., Department of Health, Trenton NJ
In New Jersey, the rates of syphilis and gonorrhea have decreased in recent
years while the rate of HIV infection has leveled off. However, these trends are
disproportionately distributed, in that rates remain very high in urban minority
adolescent populations. Twenty-five percent of the patients in New Jersey STD
clinics are adolescents. These facts illustrate the need for ongoing surveillance
of STD morbidity. STD surveillance and prevention is handled mainly by state
and local health departments, many of which receive state funding. As
increasing numbers of patients are absorbed into managed care organizations
and Medicaid managed care, surveillance of STDs and assurance of prevention
activities, historically a key role of health departments, may become more
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HEALTHY COMMUNITIES
challenged. In, addition, appropriate and timely treatment of STDs and
epidemiologic follow-up may become compromised outside a public health
system. On a national level, the surveillance of STDs and development of
effective prevention programs will require the assurances of interconnected and
standardized electronic information systems between managed care and public
health systems.
· Kathleen E. Toomey, M.D., M.P.H., Georgia Department of Human
Resources
STD control programs in Georgia had remained stagnant over the past 50 years,
until recently. Under the old system, Georgia had one of the highest rates of
gonorrhea infection in the nation. The lack of standardization in reporting and
poor data management under the old system made interpretation of gonorrhea
data difficult. Improved communication both within different departments in
the health department and among the health department, the medical
community, and the local community, along with better data management, is
essential for control of STDs. Better monitoring of infection rates for STDs
could be used as a tool to focus resources. For example, 75% of the syphilis
cases in Georgia are found in 25 counties, and prevention and control programs
for STDs could be concentrated in those counties. The majority of women who
delivered infants with congenital syphilis actually had received prenatal care and
had been tested for syphilis. These women remained untreated because results
of positive serologic tests for syphilis were not appropriately communicated
among the various agencies providing care. State and local public health
agencies need to play a more active role in the coordination and communication
among all health care providers to successfully reduce this and other preventable
STD complications.
· Josh Lipsman, M.D., Alexandria Health Department
Dr. Lipsman outlined the services of the Alexandria, Virginia, Health
Department. In Virginia, the local health department is a field office of the state
health department, funded both by the city and the state. Services include
family planning, administration of the WIC program, STD services and clinics,
and full health clinics. The STD clinics are held three times a week on a walk-
in basis. They are staffed by a different physician from the local community in
rotation. To date in 1995, there have been approximately 2,000 visits to STD
clinics in the Alexandria area. STD specialists interview each priority STD and
HIV case and report each case to the state health department. If an individual
from the Alexandria area is diagnosed with an STD in another part of Virginia,
it is reported to the Alexandria health department, which takes responsibility for
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APPENDIX A
65
following the case. While Virginia's system for tracking and treating STD cases
works well, it could be made more cost effective. Some of the tasks performed
by physicians in the clinics could be reassigned. Nurses could be trained to
collect specimens. Patients could be treated with a single-dose chlamydia
treatment, which is more expensive than the standard treatment, but also more
effective. Many patients also seek primary care services from the STD clinics.
These patients are referred elsewhere. More community involvement and
education regarding STD programs is essential. The overall trend in Alexandria
and in Virginia has been toward a decrease in STDs over the past four years.
The decrease in STDs may be attributable to education programs in the state and
tracking of STDs by local health departments.
Family Violence
· Elizabeth McLoughlin, So.D., San Francisco General Hospital
To date, family violence issues have been addressed for the most part not by the
traditional public health system, but by the women's movement, shelters, and
grassroots efforts. It has been determined that Healthy People 2000 objectives
related to family violence (reduction of physical abuse to 27/10,000 couples and
reduction in the number of battered women to less than 10%) are not being met.
It is difficult to develop statistics on family violence since the system for
collecting incidence data on spousal abuse and violence against women is not
very effective. Much abuse still goes unreported to anyone outside the family.
In order to define the problem it is necessary to collect data on the incidence of
family violence and establish some baseline statistics. To this end, the CDC
recently established a task force to develop strategies for surveillance of family
violence. The public health sector needs to get more involved in family
violence issues in general. In the past, the public health sector has assisted
women's organizations and others who have taken the lead in combating family
violence, but public health should now take a leadership role. Some strategies
for reducing family violence include educating judges about family violence;
working with immigrant women, who traditionally have had a significant
problem with spousal abuse; and working to change societal norms so that
family abuse becomes unacceptable.
· Alex Kelter, M.D., California Department of Health Services
Definitions of family violence differ from agency to agency and state to state.
In California, data on family violence is collected separately from data on other
forms of violence. One obstacle to collecting data on family violence is the
public perception that reporting of family violence has little benefit and may
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HEALTHY COMMUNITIES
incur high risk. As with other public health issues, health departments need to
form partnerships with the community, other agencies and the medical
community. The increase in managed care organizations is creating new
challenges for health departments. Health departments need to think of
incentives to get managed care organizations to report public health problems,
such as domestic violence. Dr. Kelter suggested that health departments take
the lead in violence prevention in their communities. However, better
surveillance and research into family violence issues is needed to understand the
depth of the problem. For example, it is not known if women who use shelters
to escape abusive spouses have better outcomes than those who do not.
Domestic violence prevention programs also need to be focused on men, not just
women.
· Desmond Runyan, M.D., University of North Carolina
Several years ago there was considerable focus on child abuse issues in the
public health field. In recent years, however, the focus has shifted from child
abuse to family violence. Efforts to assess the extent of the child abuse problem
in the United States have been hampered by a lack of uniformity in data
collection among different states, leading to difficulty in pooling data, and the
lack of a uniformly accepted definition of child abuse. Legislation recently
approved by the House of Representatives would have eradicated the National
Center for Child Abuse and Neglect and sent the money to the states instead.
This action by the House further impedes collection of data on child abuse as it
will take some time for the states to set up programs. In response to concerns
over child abuse, North Carolina initiated the North Carolina Child Abuse
Evaluation Program. This program enlists community physicians and provides
them with continuing education related to the identification and prevention of
child abuse. The State of North Carolina pays for all education and exams for
participating physicians. Most physicians who participate are dedicated to the
program and have formed a network in the state. However, the educational
programs focus mainly on physical abuse; as a result, physicians still lack know-
ledge about the sexual abuse of children.
Representative terms from entire chapter:
health departments
