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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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62 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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64 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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66 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.