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PUTTING OUR ACTS TOGETHER
Proceedings of a New England Regional Conference
October 16, 2001
NECON has a long history of bringing the public health community together around issues affecting the health and well-being of the New England population. An
earlier series of NECON conferences addressed health status disparities (Diminished Life Chances: Race, Poverty, and Health in New England, 1988); health information resources (Final
Report of NECON's Regional Health Data Task Force, 1990); and issues in maternal and child health (Healthy Beginnings for New England's Children, 1990).
The present series of conferences, co-sponsored with DHHS Region I, and reporting annually to the New England Governors' Conference, has focused on public health responsibilities of state
governments in an evolving health care environment.
Over time these conferences have consistently moved NECON to explore new ground: (1)
sharpening the focus on specific policy and action recommendations, (2) broadening the range of health issues under consideration, (3) creating a regional infrastructure for implementation,
and (4) expanding NECON's audience and constituency.
Sharpening the Focus. The transition from deliberating issues to designing solutions came
when NECON began establishing specialist working groups and task forces to work on specific public health problems. These working groups, composed of experts and advocates from the six
New England states, were charged with responsibility for: (1) defining a particular public health problem, such as prevention of cardiovascular disease, (2) assembling current information on
best preventive practice, (3) designing a specific course of policies and activities to address the problem, and (4) reporting back to the next annual meeting of NECON with their recommendations.
Broadening the Range. NECON has always been concerned with both categorical and systemic issues. Initial working groups devoted their efforts to improving prevention of specific
disease entities, e.g., heart disease, cancer, diabetes, HIV/AIDS; but also to crosscutting public health concerns, such as women's health, minority health, and opportunities for
collaboration between the public health community and managed care plans. More recently NECON has added working groups devoted to asthma, obesity, mental health, and insurance coverage for low-income working families.
Creating a Regional Infrastructure. From the start, NECON has reported findings and recommendations from these annual conferences to the New England Governors' Conference,
and an important outcome of this process has been a mandate from the Governors that NECON recommend a short list of priorities for their attention. At the same time, responding to a
persistent sense of the meeting that it should become more directly involved in implementation, i.e., should follow up on conference recommendations with steps to secure
appropriate action by the states, NECON has begun sponsoring a series of State Action Forums. The purpose of these forums has been to bring the NECON agenda to the state level
and to mobilize stakeholders and policy-makers in the states to advocate for implementation. State Action Forums have been held, to date, in Massachusetts, New Hampshire, and Rhode Island.
Expanding NECON's Audience. In the past year NECON has sought to expand its audience and constituencies by opening lines of communication to the New England Conference of State
Legislatures and the New England Congressional Delegation. The collaboration with academia, initiated through a policy partnership with the Heller School at Brandeis University, is now being
expanded through discussions with the Harvard School of Public Health for a parallel research partnership (see page 12).
New Focus on Communities
With NECON's focus on implementation has come an increasing awareness of the importance of
local communities as both sites and agents for change, i.e., if you want to make a difference you have to act where people live. Action by state governments and public health
bureaucracies has to be partnered by community stakeholders and leaderships.
Dr. Charles A. Welch, President-Elect of the Massachusetts Medical Society, opened the
conference by reminding his listeners that disparities in health status were associated with disparities in economic status. Poverty, he said, was clearly related to the social and
behavioral risk factors for poor health outcomes. If we were serious about prevention we would have to address not just health manifestations but also their root causes; and this would take
medicine and public health into new realms of endeavor, advocating for NECON recommendations with state legislators, leaders in the business community, the health
insurance and pharmaceutical industries, the media, the court system, and ultimately, with local communities.
He was followed by Dr. Randolph Wykoff, Deputy Assistant Secretary, Disease Prevention and
Health Promotion, US DHHS. The overarching goals of Healthy People 2010, he said, were to increase the quality and years of healthy life in the United States, and to eliminate disparities
in health status and access to health care. Looking at two key indicators of the nation's health, life expectancy and infant mortality, it was both shameful and totally unnecessary that
we should lag behind 24 other countries in the world and have such wide racial and ethnic disparities in health status. African-American males had a 12-year shorter life expectancy than
white females; African-Americans experienced roughly two and a half times the infant mortality rate of whites. Healthy People 2010 laid out 467 measurable health objectives to be achieved
over the next decade, and 10 leading indicators for priority action. Developing plans to achieve these objectives was the responsibility of federal and state governments, the business
community, and public health professionals. But to make these objectives a reality they had to be implemented at the community level, and that required that the communities, themselves, be partners in the effort.
Keith Hartgrove and Dr. N. Burgess Record provided insights into how things looked from the community level. Mr. Hartgrove spoke of his experience as a patient in an urban environment,
one of five African-American men scheduled for heart surgery and the only one to survive. He attributed that survival to the skill of his surgeon and to the community of health
professionals, as well as friends, neighbors, and colleagues who gathered around him to provide essential support during his recovery and rehabilitation. He contrasted this with the absence of
a sense of community on the street, especially for an African-American in a racist society. How oppressive that racism is was brought home to him in the wake of September 11th, when
suddenly "Black people weren't so scary any more" as society focused its racial attitudes on another group in the population. Americans needed to end race as a basis for division and
come together as true communities.
Dr. Record described a different kind of transition that was needed from the perspective of
rural America. He has been practicing in Franklin County, Maine, which has had significantly reduced tobacco use and hospitalizations for cardiovascular disease. He attributed this
success to two kinds of partnerships: (1) among health professionals, with a heavy reliance on clinical and public health nurses, and (2) between the hospital and its surrounding
communities. Of particular importance was the change in the institutional roles where the traditional model of a hospital as a place to which the seriously ill traveled for acute care was
replaced by a model in which the hospital partnered with community providers and volunteers to bring preventive health services to well residents of the community, in their own home towns.
These presentations set the stage for a plenary session in the afternoon, during which Judith Kurland, President of Hunt Alternatives, moderated a discussion with Tom Wolff, Ph.D., Sharon
L. Rosen, Ph.D., and members of the audience, on ways of building social capital and civic infrastructure to promote health in the community, i.e., to enhance local resources and
capabilities which communities could use to solve their own problems.
Major advances in health in the past century, Ms. Kurland observed, resulted primarily from
public health interventions, e.g., environmental protection; improved nutrition, sanitation, food and water protection; and broad-based immunization programs. Recently there has been an
emphasis on behavioral health, that is, lifestyle choices which could be made by individuals to achieve longer, healthier lives. But this should not be allowed to obscure the fact that
individuals needed to be empowered to make appropriate lifestyle choices by favorable conditions in the community. The community context was crucial. We know, for example, that
if we want to encourage the elderly to become more physically active we have to create communities that are safe to walk in.
Dr. Wolff, director of the Community Partners Program, described the Healthy Communities
movement, which is designed to help local communities organize and mobilize their resources to define problems and devise workable solutions. The Healthy Communities movement is a
value-driven process, he said, in which the key elements are commitment to: (1) policy-making by those who are directly affected by policy choices, (2) inclusion of all sectors of the
community, (3) promotion of active citizenship and political empowerment among local residents, and (4) building on community strengths and resources. Key elements in the
community mobilization process included: (1) establishing a community organization, (2) identifying and training local leaders, (3) making mini-grants to groups with particular interests
to help them participate in the process, and (4) identifying and tapping community resources.
The idea at the heart of social capital theory, said Dr. Rosen, President and CEO of Pentagoet,
is that social networks have productive value, and that building social networks creates powerful community resources for social change. This new resource can be an effective
instrument for dealing with specific community problems, but it also creates a new vibrancy in community life overall, built on mutual trust and ongoing communication. The important thing,
she said, is that people should talk with each other, on a basis where the contribution of each participant has equal weight because each is a member of the community.
During the discussion part of the program it was agreed that categorical funding of programs and projects, by government and philanthropic agencies, tended to impose the funder's view of
problems and solutions on communities, and created tensions between what the funders wanted and what the communities needed. On the other hand, it was recognized that the
funders had mandates to fulfill. The answer was for the funders to be more flexible in their approach, relinquishing the initiative to communities in regard to the deliberative process, while
retaining requirements for accountability and evaluation.
Mr. Yaffe asked how these insights could be integrated with NECON's ongoing mission. Two recommendations emerged from the discussion. NECON should:
- Help communities access and use the data they need.
- Advocate for community needs and the community mobilization process.
The Public Health Response to Bioterrorism
The luncheon speaker was Dr. Patricia A. Nolan, Director, Rhode Island Department of Health. We had all been affected by the events of September 11th, she said, and the subsequent
anthrax attacks had made the issue of bioterrorism a present reality. It was important to recognize that preventing bioterrorism was a law enforcement issue, but responding to
bioterrorism required coordinated action by public health, medical care, and other emergency services. State health departments had a clear leadership role in planning for, and responding to, bioterrorist acts.
Public health agencies had specific tools for responding to bioterrorism. These included:
- Surveillance and epidemiology, to identify and assess occurrence.
- A laboratory capacity for identifying biological agents used and to support diagnoses.
- A health alert capacity to inform community partners in the health system (hospitals, physicians, EMTs) and train them in appropriate response.
- Linkages with media to facilitate dissemination of appropriate, accurate public information.
All of these were coming into play today, from the work of the U.S. Centers for Disease Control, to the preparations being made by state and local health departments, to the
upgrading of skills of medical personnel in the community and information flow to media outlets.
There is an epidemic of obesity in the United States. The prevalence of obesity in children has
more than doubled since the 1960s; the prevalence in adults rose over 50% between 1991 and 1998.Recent research has shown that adverse health effects of obesity are far
wider than previously thought, including not only cardiovascular disease, diabetes, and other already identified conditions, but also many types of cancer. A second recent discovery is that
consistent annual weight gain during adulthood, even when an individual is not overweight, is associated with excess mortality.
The broad health promotion strategies successfully applied to other public health interventions, e.g., tobacco control, can and should be applied to obesity control as well. Characteristics of such programs include:
(1) interventions of adequate duration and intensity, (2) a slow, stage-by-stage approach, (3) legislative action to support control efforts, (4) an emphasis on public education, (5)
concerted advocacy, and (6) effective public, private, and community partnerships. Schools, families, employers, health care providers, public agencies, and community coalitions all have
important roles to play in making obesity control a success. The Task Force on Regional Prevention and Control of Obesity, a joint endeavor of NECON and the Harvard School of Public
Health, has recently received a $200,000 grant from Abbott Laboratories for regional planning and development of intervention strategies to promote proper nutrition and increase physical activity.
The Alliance for a Healthy New England is a regional association of state-based coalitions seeking a 50 cent increase in the tobacco tax in each New England state. The strategy of the
Alliance is to bring tobacco control advocates and advocates for increased health access into a partnership to lobby for the tax increase, with a significant portion of the anticipated
revenues allocated to Medicaid expansion and other health programs.
Opposition to the tax increase comes primarily from the tobacco industry and convenience
store owners who sell cigarettes. Intensive public education and lobbying are the major strategies being used to promote the tax.
The current economic downturn is reducing state revenue projections and increasing legislative interest in the tax as a revenue generating measure. However, the downturn may make it
difficult to secure allocation of these additional revenues to health programs as opposed to the general fund.
NECON's concern with mental health was addressed, in 2000, by the establishment of the Task Force on Mental Health Promotion, Mental Illness and Substance Abuse Prevention. The first report with recommendations
(The Time Is Now) of the Task Force was presented to the New England Governors' Conference in August 2001; and to the New England Conference of State Legislators in November 2001.
The mental health system is undergoing its most significant change since the move to deinstitutionalize patients in mental hospitals and expand resources for delivering ambulatory
mental health services in the community. This is a change, above all, in attitudes and expectations:
- Recognition that mental health is an integral part of overall human health. Or, in the words of the Surgeon General, "Mental health is fundamental to well-being."
- Acceptance of the fact that mental health can be actively promoted and mental illness can be prevented. The Institute of Medicine's 1999 report Reducing Risks for Mental Disorder
makes it clear that treatment of existing mental illness is not the only option open to society.
- The application of concepts of "emotional competency" to therapeutic interactions, including those with persons with severe and persistent mental illness, can strengthen
coping skills and mitigate emotional and behavioral problems in this population. Components of emotional competency include: (1) increasing self awareness, (2)
improving mood management, (3) strengthening motivation, (4) developing capacity for empathy, and (5) developing social skills.
- And finally, the events of September 11th have been a wake-up call to the mental health profession that they have a responsibility for promoting the emotional well being of the population at large.
State mental health agencies provide the leading edge in these efforts. Major tasks before them include:
- Disseminating information about this new approach as broadly as possible, and especially through education of health care providers, third-party payors, employers, and the general public.
- Establishing more effective collaboration between mental health agencies and other state agencies, e.g., health, welfare, children's and elder services, education, corrections, etc.
- Providing relevant orientation and training for mental health workers in both the public and private sectors.
- Making mental health promotion and disease prevention an integral part of state mental health plans and programs.
The New England states have made significant progress in recent years toward addressing issues of unmet health needs of women. The NECON/DHHS working group has defined a series
of goals and strategies for guiding this effort. These include:
- Promoting primary prevention and a comprehensive approach to women's health across the lifespan, to replace the "body part" approach encouraged by categorical funding and programming.
- Identifying and focusing on critical health needs of women, particularly those of adolescents (aged 11-21) and elder women (aged 60 and over), largely overlooked up to
now due to the programmatic emphasis on maternal and child health in federal funding.
- Improving the collection, analysis, and sharing of data related to women's health, to guide planning, development, implementation, and evaluation of targeted women's health programs.
- Developing public, private, academic, and community collaboration and coalitions to carry forward this work.
A starting point has been the development of women's health indicators around which to gather and disseminate information on women's health status, identify unmet needs, and
measure progress in improving women's health over time.
For adolescent women these include measures of: (1) health insurance coverage and utilization
of preventive health services, (2) prevalence of physical, sexual, and dating violence, (3) use of alcohol, tobacco, and drugs, (4) prevalence of eating disorders, and (5) experience with unsafe sex.
For elder women these include measures of: (1) health insurance coverage and utilization of preventive health services, (2) rates of adult immunization, (3) prevalence of injuries from falls
requiring hospitalization, (4) prevalence of depression, and (5) occurrence of myocardial infarction.
In most states, at the present time, programs related to women's health are distributed over
various divisions and programs in state health departments, and in other agencies of state government. To develop a more concerted effort to improve women's health, the New England
states have been working to strengthen the infrastructure for responding to women's health needs, both in the public sector, and between the public and private sectors.
Three states (Massachusetts, Rhode Island, and Vermont) have created an Office of Women's Health as lead entity in this effort, but this is not the only approach. Some common elements to state capacity building include:
- Strenuous efforts to collect data from national, state, and community s ources, and develop indicator-based matrices identifying major unmet health needs and service gaps.
- Developing intra- and inter-departmental working groups to design collaborative women's health programs to fill service gaps.
- Developing statewide public, private, and community coalitions to address policy and program issues.
- Developing state reports on women's health and strategic plans for long-term efforts to meet ongoing health care needs of women.
- Holding statewide conferences to promote awareness of, and mobilize support for, women's health initiatives.
Recent epidemiological data indicate that incidence of HIV/AIDS in the population over age 50 is increasing, and that programs to prevent, diagnose, and treat HIV in this population need to
be increased and improved.
Several key issues need to be addressed:
- There is a general perception that older people do not engage in sexual activity, or participate in risk taking behaviors.
- There is a lack of HIV medical providers who are knowledgeable about care of older persons and a lack of geriatric providers who are knowledgeable about HIV. Most primary
care providers fail to recognize signs of HIV and are uncomfortable asking older persons about their sexual practices and drug use.
- Most public health HIV prevention programs target youth and younger adults and fail to reach aging populations.
Increased efforts are needed to increase public awareness of HIV and aging, to educate the medical profession, and to reach out to older populations at risk. The lead is being taken with
this effort by NAHOF, the National Association on HIV Over Fifty.
Disparities in Health Care
The federal report Healthy People 2010 has demonstrated beyond doubt the wide disparities in
health status and access to health care which exist in the United States, especially on the basis of race and ethnicity. These disparities are significant across New England, even in
states in northern New England that formerly had relatively homogeneous populations, due to a recent and continuing influx of foreign immigrants and migrants from other parts of the United
States, and recognition of unmet health needs of indigenous Native American populations. A particularly disturbing feature of these disparities is that minority groups in the population
often exhibit disproportionately high prevalence of adverse health conditions associated with socioeconomic determinants and personal risk behaviors.
A recent two-day meeting convened by the DHHS Office of Minority Health identified four goals for remedial action:
- To develop better data defining disparities in order to make more informed policy, target programs to specific areas of need, and monitor outcomes.
- To develop stronger and more active public/private partnerships to address disparities, and especially for the public sector to reach out to and involve non-governmental
stakeholders: providers, employers, academia, and private foundations.
- To improve the cultural competence of health care providers.
- And, in particular, to develop programs that focus on joint action with community based organizations and coalitions. The prerequisite for community mobilization is identification
and development of local leaders to organize and guide local action.