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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

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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

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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

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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

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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

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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