Top 10 Priorities for Prevention

ISSUE REPORT Ourfor a Vision Healthier A H E A LT H I E R A M E R I C A : 10 Top Priorities for Prevention MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. Ourfor a Vision Healthier A HEALTHIER AMERICA: 10 A Top Priorities for Prevention merica spends more than $2 trillion annually on health care, more than any other nation. Yet tens of millions of Americans still suffer every day from preventable illness and chronic disease. Additionally, the skyrocketing costs of health insurance threaten to bankrupt American businesses and weaken our economy. Some companies have already begun sending jobs to other countries where health care costs are lower, and this trend is likely to continue unless the health of the nation improves and costs are contained. Several factors contribute to the health care crisis. One of the most important is our health care system’s focus on caring for people after they have become sick or harmed. It’s time for the country to change course. Solutions to the problem must begin with stopping illness or harm before they occur. Prevention must drive America’s health strategy. TFAH IS A NON-PROFIT, NON-PARTISAN ORGANIZATION DEDICATED TO SAVING LIVES BY PROTECTING THE HEALTH OF EVERY COMMUNITY AND WORKING TO MAKE DISEASE PREVENTION A NATIONAL PRIORITY. TRUST FOR AMERICA’S HEALTH (TFAH) HAS IDENTIFIED 10 TOP COMPONENTS OF AN EFFECTIVE NATIONAL PREVENTION STRATEGY: I Promoting Disease Prevention I Combating the Obesity Epidemic I Preventing Tobacco Use and Exposure I Preventing and Controlling Infectious Diseases I Preparing for Potential Health Emergencies and Bioterrorism Attacks I Recognizing the Relationship Between Health and U.S. Economic Competitiveness I Safeguarding the Nation’s Food Supply I Planning for Changing Health Care Needs of Seniors I Improving the Health of Low-Income and Minority Communities I Reducing Environmental Threats PLUS A CROSS-CUTTING RECOMMENDATION FOR: I Holding Government Accountable for Protecting the Health of Americans FIND OUT MORE AT www.healthyamericans.org OR CONTACT TRUST FOR AMERICA’S HEALTH DIRECTOR OF GOVERNMENT RELATIONS RICHARD HAMBURG, RHAMBURG@TFAH.ORG OR 202-223-9870 X 18 A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Promoting Disease Prevention WHY ARE CHRONIC DISEASES A THREAT TO OUR NATION’S HEALTH? Preventable Diseases Are Pervasive: I More than half of all Americans live with one or more chronic disease, including heart disease, stroke, diabetes, and cancer.2 I Seven out of 10 deaths in the U.S. are due to chronic diseases.3 Prevention Efforts Could Greatly Reduce Disease Rates: I According to the U.S. Centers for Disease Control and Prevention (CDC), the majority of chronic diseases could be prevented through lifestyle and environmental changes. For instance: L Reducing adult smoking rates by one percent could result in more than 30,000 fewer heart attacks, 16,000 fewer strokes, and savings of over $1.5 billion over five years.4 L If one-tenth of Americans began a regular walking program, $5.6 billion could be saved in the treatment of heart disease.5 I Routine childhood vaccinations prevent more than 14 million cases of disease annually.6 Prevention Efforts Also Lower Health Care Spending: I Of the more than $1.7 trillion in health care spent nationally every year, less than 4 cents out of every dollar is spent on prevention and public health, even though studies show that disease prevention is one of the most effective ways to reduce health care spending.7, 8 I Between 1990 and 1998, the California Tobacco Control Program saved more than $3 billion in smoking-caused health costs.9 I Routine childhood vaccinations result in $50 billion saved annually in direct and indirect costs.10 “THE U.S. HAS THE HIGHEST RATE OF PREVENTABLE DEATHS AMONG 19 INDUSTRIALIZED NATIONS.” I -- Health Affairs MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO REDUCE PREVENTABLE DISEASES? I Implement a National Prevention Strategy. The federal government should develop and implement a National Prevention Strategy focusing on ways to lower disease rates that is a shared responsibility, involving every federal government agency, defines clear roles and responsibilities for states and localities, and engages private industry and community groups. Developing and implementing policies aimed at reducing obesity and tobacco use should be key objectives of the strategy. I Expand Preventive Care Benefits. Federal, state, and local governments must enhance Medicare and Medicaid programs and work with private employers and insurers to make certain that all Americans have access to preventive health care. I Increase Preventive Services and Public Education Campaigns in Communities. Proven prevention measures, such as immunizations and cancer screenings and public information campaigns to encourage healthy eating, increased physical activity, and tobacco cessation, should be funded and carried out in communities across the nation. Special emphasis should be placed on developing culturally competent communication campaigns that use respected and trusted messengers and appropriate channels for highrisk communities. I Promote Healthy Communities. Every segment of society has a role to play in prevention, including families, health care providers, schools, businesses, and communities. Federal, state, and local governments should take a leadership role in engaging all of these sectors to find ways to make communities healthier and make it easier for people to make healthy choices. I Expand Disease Prevention Research. More resources must be devoted to researching ways to prevent and reduce disease, including ways to encourage people to make healthy lifestyle choices, such as avoiding smoking and participating in more physical activity. Currently, the federal government spends 94 percent of health dollars on diagnosis and treatment of disease, and only 6 percent of health dollars on researching causes and preventing disease. ENDNOTES 1 E. Nolte and C. Martin McKee. “Measuring the Health of Nations: Updating an Earlier Analysis.” Health Affairs, 27, no. 1 (2008): 58-71. 2 R. DeVol and A. Bedroussian, et al. An Unhealthy America: The Economic Burden of Chronic Disease. Santa Monica, CA: Milken Institute, October 2007. http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801020&cat=ResRep. (accessed October 10, 2007). 3 U.S. Centers for Disease Control and Prevention. The Burden of Chronic Diseases and Their Risk Factors: National and State Perspectives 2004. Atlanta: GA: U.S. Department of Health and Human Services, 2004. http://0-www.cdc.gov.mill1.sjlibrary.org:80/nccdphp/ burdenbook2004. (accessed May 7, 2007). 4 J.M. Lightwood and S.A. Glantz. “Short-Term Economic and Health Benefits of Smoking Cessation -Myocardial Infarction and Stroke,” Circulation 96 (1997): 1089-1096. 5 B. Bulwar. “Sedentary Lifestyles, Physical Activity, and Cardiovascular Disease: From Research to Practice.” Critical Pathways in Cardiology 3, no. 4 (December 2004): 184-193. 6 U.S. Centers for Disease Control and Prevention. Program in Brief: Section 317 Immunization Grant Program. Atlanta, GA: U.S. Department of Health and Human Services, February 2007. 7 J. M. Lambrew. A Wellness Trust to Prioritize Disease Prevention. Washington, D.C.: Brookings Institution, April 2007. http://www.brookings.edu/papers/2007/ ~/media/Files/rc/papers/2007/04useconomics_lambrew/04useconomics_lambrew.pdf (accessed January 11, 2008). 8 Prevention Institute and The California Endowment with the Urban Institute. “Reducing Health Care Costs Through Prevention: Working Document.” August 2007. http://www.preventioninstitute.org/documents/HE_HealthCareReformPolicyDraft_091507.pdf (accessed January 28, 2008). 9 California Department of Health Services. “Economic and Health Effects of a State Cigarette Excise Tax Increase in California.” California Department of Health Services, Tobacco Control Section, May 26, 2006. http://www.calhealth.org/public/press/ Article%5C103%5CTax%20Impact%20Exec%20Sum mary.pdf (accessed January 11, 2008). 10 R. DeVol and A. Bedroussian, et al. An Unhealthy America: The Economic Burden of Chronic Disease. Santa Monica, CA: Milken Institute, October 2007. http://www.milkeninstitute.org/publications/publications.taf?function=detail&ID=38801020&cat=ResRep. (accessed October 10, 2007). A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Combating the Obesity Epidemic WHY IS THE OBESITY EPIDEMIC A THREAT TO OUR NATION’S HEALTH? A Growing Problem: I Two-thirds of Americans are obese or overweight.2 I Rates of adult obesity now exceed 20 percent in 47 states and D.C and 25 percent in 19 states. In 1991, rates did not exceed 20 percent in a single state.3 I Approximately 25 million U.S. children are obese or overweight. Rates of childhood obesity have more than tripled since 1980.4 Health Consequences: I Obesity and physical inactivity are risk factors in more than 20 chronic diseases, including type 2 diabetes, heart disease, and some forms of cancer.5 L More than 20 million American adults have type 2 diabetes, and 54 million more are pre-diabetic.6 Two million adolescents have pre-diabetes.7 L More than 75 percent of hypertension cases can be attributed to obesity.8 L Approximately 20 percent of cancer in women and 15 percent of cancer in men can be attributed to obesity.9 L Obesity increases a child’s risk for a range of health problems and negatively impacts mental health and school performance.10, 11 High Costs: I Obesity-related health care costs approximately $117 billion annually.12 Alarming Trends: I Twenty-two percent of American adults report that they do not engage in any physical activity.13 L Only 54 percent of high school students had a physical education class at least once a week, and only 33 percent of high school students had daily physical education.14 L More than 35 percent of high school students watch 3 or more hours of TV and more than 20 percent of high school students played video or computer games or used a computer for non-school activities for 3 or more hours on an average school day.15 I Consumption of added sugar in the average diet has increased 22 percent since the 1980s.16 I Spending in fast food restaurants has grown more than 18 times (from $6 billion to $110 billion) in the past 30 years.17 “DESPITE STEADY PROGRESS OVER MOST OF THE PAST CENTURY TOWARD ENSURING THE HEALTH OF OUR COUNTRY’S CHILDREN, WE BEGIN THE 21ST CENTURY WITH A STARTLING -- AN EPIDEMIC OF CHILDHOOD OBESITY. THIS EPIDEMIC IS SETBACK OCCURRING IN BOYS AND GIRLS IN ALL 50 STATES, IN YOUNGER CHILDREN AS WELL AS ADOLESCENTS, ACROSS ALL SOCIOECONOMIC STRATA, AND AMONG ALL ETHNIC GROUPS...”I -- INSTITUTE OF MEDICINE’S PREVENTING CHILDHOOD OBESITY: HEALTH IN THE BALANCE MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO COMBAT THE EPIDEMIC? I Implement a National Strategy to Combat Obesity. The federal government should develop and implement a national strategy that is a shared responsibility, involving every federal government agency, define clear roles and responsibilities for states and localities, and engage private industry and community groups. I Improve Nutrition and Promote Physical Activity in Schools. School meal programs should concentrate on setting high nutritional standards for foods served in schools, instead of focusing on minimum nutrition standards. The USDA should immediately require schools to meet or exceed the 2005 Dietary Guidelines for Americans, and implement the Institute of Medicine’s nutrition standards for foods sold à la carte in schools by vending machines or other competitive marketers. Since physical activity has been shown to improve health as well as academic performance, schools must also increase the amount of time kids spend in physical education classes and work to ensure that students spend time engaging in moderate-to-vigorous physical activity before school, between classes and after the school day school ends. I Encourage Every Employer to Offer a Workplace Wellness Program. Federal, state, and local governments must work with private employers and insurers to make certain that every working American has access to a workplace wellness program and preventive care benefits. I Make Healthy Choices Easy Choices: Creating Opportunities for Exercise and Healthy Eating. Americans must be given the tools they need to engage in more physical activity, since even small amounts of activity can lead to major health improvements. Children should be given the opportunity to be more physically active throughout the day, both in and out of school. The communities we live in should allow greater opportunities for activity, including places for safe and affordable public recreation and increased availability of sidewalks. Americans must also be given the tools to take responsibility for their eating habits, including nutritional recommendations and information and access to supermarkets and affordable healthy foods. I Invest in Research. What are the most effective school-based, community-based and family-based prevention strategies? What are the factors that put children most at-risk of obesity? What is the real cost of childhood obesity to the economy? We need to invest in research to answer these and other questions to find real, science-based solutions that will work in the long-term. http://www.obesity.org/subs/fastfacts/Health_Effects.s html (accessed June 6, 2005). 9 U.S. Centers for Disease Control and Prevention. “Obesity in the News: Helping Clear the Confusion.” Power Point Presentation, May 25, 2005. 10 W.H. Dietz. “Health Consequences of Obesity in Youth: Childhood Predictors of Adult Disease.” Pediatrics 101, no. 3 (1998): 518-525. 11 A. Datar and R. Strum. “Childhood Overweight and Elementary School Outcomes.” International Journal of Obesity 30, (2006): 1449-1460. 12 U.S. Department of Health and Human Services. Prevention Makes Common “Cents”. Washington, D.C.: U.S. Department of Health and Human Services, 2003. 13 U.S. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System Survey Data. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006. 14 U.S. Centers for Disease Control and Prevention, “Youth Risk Behavior Surveillance -- United States 2005,” MMWR Surveillance Summaries 55, no. SS05 (2006):1-108. 15 Ibid. 16 Ibid. 17 E. Schlosser. Fast Food Nation: The Dark Side of the AllAmerican Meal. New York, NY: Houghton Mifflin Books, 2001. ENDNOTES 1 Institute of Medicine. Preventing Childhood Obesity: Health in the Balance. Washington, D.C.: National Academies Press, 2005. 2 National Center on Vital Statistics. Health, United States. Atlanta, GA: U.S. Centers for Disease Control and Prevention, 2003. 3 Trust for America’s Health. F as in Fat: How Obesity Policies Are Failing in America. Washington, D.C.: Trust for America’s Health, 2007. 4 National Center for Health Statistics. Press Release: Obesity Still a Major Problem. Atlanta, GA: U.S. Centers for Disease Control and Prevention, April 14, 2006. . 5 Office of the Surgeon General. The Surgeon General’s Call to Action to Prevent and Decrease Overweight and Obesity. Rockville, MD: U.S. Department of Health and Human Services, Public Health Service, Office of the Surgeon General, 2001. 6 C.C. Cowie, et al. “Prevalence of Diabetes and Imparted Fasting Glucose in Adults in the U.S. Population: NHANES 1999-2002.” Diabetes Care 29 (2006): 1263-8. 7 American Diabetes Association. “Total Prevalence of Diabetes & Pre-diabetes.” American Diabetes Association. http://diabetes.org/diabetesstatistics/prevalence.jsp (accessed July 10 2007). 8 American Obesity Association. “Health Affects of Obesity.” American Obesity Association. A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Preventing Tobacco Use and Exposure WHY IS TOBACCO USE A THREAT TO OUR NATION’S HEALTH? A Lingering Problem: I Worldwide, tobacco use causes nearly 5 million deaths per year.2 I Tobacco use is the leading preventable cause of death in the U.S. Every year, smoking and secondhand smoke kill about 440,000 people in the U.S. by causing lung cancer, emphysema, heart disease and other illnesses.3 I Exposure to second-hand smoke is responsible for approximately 38,000 of these deaths each year.4 I Nearly 21 percent of U.S. adults still smoke, as do 23 percent of U.S. high school students.5 While significant reductions were achieved in the late 1990’s and early 2000’s, progress has stalled in recent years. Health Consequences: I Smoking harms nearly every organ of the body; causing many diseases and reducing the health of smokers in general.6 I Cancer is the second leading cause of death in the U.S.; more than 80 percent of lung cancer deaths and about 20 percent of all cancer deaths are caused by tobacco.7 I Smoking causes cancers of the bladder, oral cavity, pharynx, larynx, esophagus, cervix, kidney, lung, pancreas, and stomach, and causes acute myeloid leukemia.8 I Smoking causes coronary heart disease, the leading cause of death in the United States.9 Smoking triples the risk of dying from heart disease among middle-aged men and women.10 I Cigarette smoking causes 80-90 percent of deaths from chronic obstructive lung disease.11 High Costs: I Tobacco use costs the U.S. almost $100 billion annually in health care bills, imposing a hidden tax on every individual, family and business. Productivity losses from premature death total another $97 billion.12 I People exposed to secondhand smoke run up an average $10 billion annually in health care costs.13 Alarming Trends: I Every day in America, 4,000 kids try their first cigarette. Another 1,000 kids become daily smokers and one-third of them will die prematurely as a result.14 I Progress in reducing smoking has stalled among both youth and adults. In 2006, 20.8 percent of adults smoked cigarettes, about the same as the 20.9 percent in 2004 and 2005. Among high school students, smoking increased from 21.9 percent in 2003 to 23 percent in 2005. This increase followed a 40 percent decline in high school smoking between 1997, when rates peaked at 36.4 percent, and 2003.15 I Tobacco company marketing expenditures have skyrocketed since the 1998 state tobacco settlement. From 1998 to 2005, tobacco marketing expenditures nearly doubled from $6.9 billion to $13.4 billion, according to the Federal Trade Commission’s most recent report on tobacco marketing.16 I Most states still fail to fund tobacco prevention programs at levels recommended by the CDC. In FY 2008, states will spend less than 3 percent of the $24.9 billion available to them from tobacco excise taxes and the 1998 Master Settlement Agreement (MSA) with the tobacco companies on tobacco prevention and cessation programs. Investing only 15 percent of these funds would allow every state tobacco control program to be funded at the level recommended by the U.S. Centers for Disease Control and Prevention (CDC).17 “IT IS TROUBLING NEWS FOR AMERICA’S HEALTH THAT PROGRESS HAS STALLED IN REDUCING TOBACCO USE, THE NATION’S NUMBER ONE PREVENTABLE CAUSE OF DEATH. IT IS ALSO INEXCUSABLE THAT ELECTED LEADERS HAVE NOT DONE MORE GIVEN THE OVERWHELMING SCIENTIFIC EVIDENCE OF WHAT WORKS TO REDUCE TOBACCO USE AMONG BOTH CHILDREN AND ADULTS.”1 -- WILLIAM V. CORR, EXECUTIVE DIRECTOR, CAMPAIGN FOR TOBACCO-FREE KIDS MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO STAMP OUT SMOKING? I Regulate Tobacco Products. Congress should enact long-standing legislation to grant the U.S. Food and Drug Administration (FDA) regulatory authority over tobacco products. FDA should have the authority to crack down on tobacco marketing and sales to children, stop tobacco companies from misleading consumers and require changes in tobacco products to make them less harmful and less addictive. Currently, FDA regulates food, drugs, cosmetics, and even dog food but does not regulate the products that kill more than 400,000 Americans every year. I Expand Proven Tobacco Control Measures. State and local leaders should implement proven measures to reduce tobacco use and protect everyone from the harms of secondhand smoke. These include tobacco taxes, comprehensive laws to make all workplaces and public places smoke-free, full funding of tobacco prevention and cessation programs, and access to proven smoking cessation methods (e.g., counseling, FDA approved medications) for all tobacco users. I Reduce Global Tobacco Use and Exposure. Nations around the world should ratify and implement the new international tobacco control treaty, the Framework Convention on Tobacco Control, in order to reduce tobacco use and save lives. I Fund Tobacco Prevention Initiatives. Congress and the President should increase the amount the CDC receives in federal government funding for tobacco prevention. 42(1993): 645-648. http://www.cdc.gov/mmwr/PDF/ wk/mm4233.pdf (accessed February 15, 2008) 10 Ibid. 11 Office of the Surgeon General. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2 004/index.htm#full (accessed February 15, 2008) 12 U.S. Centers for Disease Control and Prevention. Sustaining State Programs for Tobacco Control: Data Highlights 2006. http://www.cdc.gov/tobacco/data_ statistics/state_data_highlights/2006/index.htm (accessed February 15, 2008). And, U.S. Centers for Disease Control and Prevention. “Annual SmokingAttributable Mortality, Years of Potential Life Lost and Economic Costs -- United States, 1997-2001.” Morbidity and Mortality Weekly Report 54 (2005): 625-628. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm5425al.htm (accessed February 15, 2008). 13 D.F. Behan, et al. Economic Effects of Environmental Tobacco Smoke Report. Schaumburg, IL: Society of Actuaries, 2005. http://www.soa.org/files/pdf/ETSReportFinal Draft(Final%203).pdf (accessed February 15, 2008). 14 Substance Abuse and Mental Health Services Administration. Results from the 2006 National Survey on Drug Use and Health: National Findings. Rockville, MD: U.S. Department of Health and Human Services, 2007. http://www.oas.samhsa.gov/nsduh/2k6nsduh/ 2k6Results.cfm (accessed February 15, 2008) 15 National Health Interview Survey. National Youth Risk Behavior Survey, 1997, 2003 and 2005. 16 U.S. Federal Trade Commission. Cigarette Report for 2004 and 2005. Washington, DC: U.S. Federal Trade Commission, 2007. http://www.ftc.gov/reports/ tobacco/2007cigarette2004-2005.pdf (accessed February 15, 2008). And U.S. Federal Trade Commission. Smokeless Tobacco Report for the Years 2004 and 2005. Washington, DC: U.S. Federal Trade Commission, 2007. http://www.ftc.gov/reports/ tobacco/0205smokeless0623105.pdf (accessed February 15, 2008). 17 Campaign for Tobacco Free Kids. A Broken Promise to Our Children: The 1998 State Tobacco Settlement Nine Years Later. Washington, D.C.: Campaign for Tobacco Free Kids; 2007. http://tobaccofreekids.org/reports/settlements/2007/fullreport.pdf. (accessed February 15, 2008). Centers for Disease Control and Prevention (CDC), Best Practices for Comprehensive Tobacco Control Programs, Atlanta, GA: U.S. Department of Health and Human Services (HHS), October 2007. ENDNOTES 1 Campaign for Tobacco Free Kids. “Press Release: CDC Reports Adult Smoking Declines Have Stalled; Elected Officials Should Step Up Fight Against Tobacco.” Washington, D.C.: Campaign for Tobacco Free Kids, November 8, 2007. http://www.tobaccofreekids.org/ Script/DisplayPressRelease.php3?Display=1042 (accessed February 19, 2008). 2 World Health Organization. The World Health Report 2002: Reducing Risks, Promoting Healthy Life. Geneva: World Health Organization, 2002. http://www.who.int/whr/2002/en/index.html. (accessed February 15, 2008). 3 U.S. Centers for Disease Control and Prevention. “Annual Smoking Attributable Mortality, Years of Potential Life Lost, and Productivity Losses -- United States, 1997-2001.” Morbidity and Mortality Weekly Report 54 (2005): 625-628. http://www.cdc.gov/mmwr/preview/mmwrhtml/ mm5425a1.htm (accessed February 15, 2008). 4 California EPA, Proposed Identification of Environmental Tobacco Smoke as a Toxic Air Contaminant, June 24, 2005, http://repositories.cdlib.org/tc/surveys/CALEPA2005C /. See also, CDC, “Factsheet: Secondhand Smoke,” September 2006, http://www.cdc.gov/tobacco/data_statistics/Factsheets/SecondhandSmoke.htm 5 National Center for Health Statistics, 2006 National Health Interview Survey. 2005 National Youth Risk Behavior Survey. 6 Office of the Surgeon General. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2 004/index.htm#full (accessed February 15, 2008). 7 American Cancer Society. Cancer Facts & Figures, 2008. http://www.cancer.org/downloads/STT/ 2008CAFFfinalsecured.pdf (accessed February 22, 2008). J. Mackay, et al. The Cancer Atlas. Atlanta, GA.: American Cancer Society, 2006. 8 Office of the Surgeon General. The Health Consequences of Smoking: A Report of the Surgeon General. Washington, D.C.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2004. http://www.cdc.gov/tobacco/data_statistics/sgr/sgr_2 004/index.htm#full (accessed February 15, 2008). 9 U.S. Centers for Disease Control and Prevention. “Cigarette smoking-attributable mortality and years of life lost -United States, 1990.” Morbidity and Mortality Weekly Report A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Preventing and Controlling Pandemic Flu and Other Infectious Diseases WHY ARE INFECTIOUS DISEASES A THREAT TO OUR NATION’S HEALTH? Infectious Diseases Are Spreading: I Thirty-nine new infectious diseases have been identified over the past 40 years, including HIV/AIDS, Ebola, and Severe Acute Respiratory Syndrome (SARS).2 I Older infectious diseases, including malaria and tuberculosis, have mutated and developed increased drug resistance, making them harder to treat.3 I Airlines now carry more than 2 billion passengers a year, making it possible for any diseases they may have to pass from one country to another in a matter of hours.4 I The regular seasonal flu kills 36,000 Americans and hospitalizes 200,000 yearly.5 I More than one million Americans are living with HIV/AIDS, with an estimated 40,000 new cases each year.6 I An estimated 4.1 million Americans have been infected with the hepatitis C virus (HCV), of whom 3.2 million are chronically infected.7 Pandemic Flu Poses A Particularly Ominous Threat: I A severe pandemic flu outbreak could result in 90 million Americans becoming sick, 2.2 million deaths, and the second worst U.S. economic recession since World War II.8 I Since 2003, there have been more than 352 humans infected with H5N1, the avian flu virus that scientists fear could become the next pandemic for humans (As of January 2008). Of the 348 humans infected, 219, or 62 percent, have died worldwide.9 I Children and teens are particularly vulnerable -- nearly 46 percent of H5N1 “bird” flu deaths have been individuals between the ages of 0-19.10 Measures for Preventing and Controlling Infectious Disease Are Antiquated and Inadequate: I The Institute of Medicine (IOM), Government Accountability Office (GAO), and U.S. Centers for Disease Control and Prevention (CDC) have found America’s public health system to be fundamentally unprepared to respond to major modern health threats.11,12,13 I The federal and state governments have failed to provide public evaluation of preparedness and pandemic planning on a state-by-state basis, limiting the ability to gauge progress and identify vulnerabilities. “I WOULD LIKE TO EMPHASIZE THAT ALTHOUGH WE CANNOT BE CERTAIN EXACTLY WHEN THE NEXT INFLUENZA PANDEMIC WILL OCCUR, WE CAN BE VIRTUALLY CERTAIN THAT ONE WILL OCCUR AND THAT THE RESULTING MORBIDITY, MORTALITY, AND ECONOMIC DISRUPTION WOULD PRESENT EXTRAORDINARY CHALLENGES TO PUBLIC HEALTH AUTHORITIES AROUND THE WORLD.”I WHAT CAN BE DONE TO BETTER PREVENT AND CONTROL INFECTIOUS DISEASES? I Increase and Better Coordinate FederalState-Local Government and Private Planning and Preparedness. The government should take the lead on preventing disease, and all jurisdictions should work together to create policies that follow best infection-control practices with the federal government providing strong leadership. Government at all levels should work to engage the private health care system and communities in their plans and efforts. Sufficient resources must be devoted to preparing for possible disease threats and the government should be transparent about their actions and held accountable for protecting the public. — DR. ANTHONY S. FAUCI, DIRECTOR, NATIONAL INSTITUTE OF ALLERGY AND INFECTIOUS DISEASES, NATIONAL INSTITUTES OF HEALTH, DEPARTMENT OF HEALTH AND HUMAN SERVICES MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. I Prepare for Mass Emergencies. During mass emergencies, measures must be put in place to care for a potential surge of patients, including creating alternative care sites and recruiting additional health care personnel. An emergency health care benefit and improved sick leave policies should be enacted to allow the uninsured, underinsured, and people without adequate sick leave to receive care and take time off during major infectious disease emergencies like a pandemic flu outbreak. I Emphasize Prevention, Care, and Treatment for Chronic Viral Diseases, Including HIV/AIDS and Hepatitis. Addressing the HIV/AIDS epidemic, hepatitis, and other chronic viral diseases must include increased funding for treatment and care, as well investing in proven prevention methods, including clean needle and needle exchange programs and other science-based behavioral prevention. I Enhance Research and Development of Vaccines and Public Health Technologies. Basic technology and tools of public health must be modernized to adequately protect the American people. This includes research and development of vaccines and new technologies; and improved chemical laboratory testing capabilities. I Increase Childhood and Adult Vaccinations. Vaccines prevent disease in the people who receive them and protect those who come into contact with unvaccinated individuals. Vaccines help prevent infectious diseases and save lives. Vaccines are responsible for the control of many infectious diseases that were once common in this country, including polio, measles, and mumps.14 I Modernize Disease Surveillance Systems. Every health department and health agency should be part of a 21st century surveillance system that meets national standards and is interoperable between jurisdictions and agencies to ensure rapid information sharing. Plans should ensure adequate laboratory surveillance of influenza and other infectious diseases, as well as testing for pathogens such as E.Coli, Methicillin-resistant Staphylococcus Aureus (MRSA), and extensively drug resistant Tuberculosis (XDR-TB). The U.S. should take the lead on improving global disease surveillance. I Replenish and Augment the Strategic National Stockpile (SNS). The government should ensure the SNS contains enough vaccines, antiviral medications, and supplies to respond to public health crises, and states must be better prepared to distribute and administer needed medications to the public. I Clarify Existing State and Federal Roles in Setting Quarantine and Isolation Policies. The federal government, in coordination with the states, must establish clear legal authority and emergency measures to effectively contain the spread of disease. 8 Trust for America’s Health. Pandemic Fu and the Potential for U.S. Economic Recession: A State-by-State Analysis. Washington, D.C.: Trust for America’s Health, 2007. 9 World Health Organization. “Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO,” Updated January 3, 2008, http://www.who.int/csr/disease/avian_influenza/country/cases_table_2008_01_03/en/index.html (accessed January 9, 2008). 10 Trust for America’s Health and the American Academy of Pediatrics. Pandemic Influenza: Warning, Children AtRisk. Washington, D.C.: TFAH, October 2007. 11 Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press for the Institute of Medicine, 2003. 12 U.S. Government Accountability Office. HHS Bioterrorism Preparedness Programs: States Reported Progress But Fell Short of Program Goals in 2002. Washington, D.C., Government Accountability Office, 2004. 13 U.S. Centers for Disease Control and Prevention. Public Health Infrastructure -- A Status Report. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2001. 14 U.S. Centers for Disease Control and Prevention. “The Importance of Childhood Immunizations.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2006. http://www.cdc.gov/vaccines/vac-gen/ importance.htm (accessed January 23, 2008) ENDNOTES 1 A.S. Fauci. The Role of NIH Biomedical Research in Pandemic Influenza Preparedness. Testimony Before the House Committee on Appropriations Subcommittee on Labor, HHS, and Education, United States House of Representatives. Washington, D.C.: U.S. Department of Health and Human Services, National Institutes of Health, 2005. (accessed May 18, 2005). 2 World Health Organization. News Release: International Spread of Disease Threatens Public Health Security. Geneva: WHO, August 23, 2007. 3 Ibid. 4 Ibid. 5 U.S. Centers for Disease Control and Prevention. “Key Facts about Seasonal Influenza (Flu).” U.S. Department of Health and Human Services. http://www.cdc.gov/flu/keyfacts.htm (accessed October 12, 2007). 6 U.S. Centers for Disease Control and Prevention. “A Glance at the HIV/AIDS Epidemic.” U.S. Department of Health and Human Services. http://www.cdc.gov/ hiv/resources/factsheets/At-A-Glance.htm (accessed January 28, 2008). 7 U.S. Centers for Disease Control and Prevention. “Hepatitis C Fact Sheet.” U.S. Department of Health and Human Services. http://www.cdc.gov/ncidod/ diseases/hepatitis/c/cfact.pdf (accessed January 28, 2008). A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Preparing for Potential Health Emergencies and Bioterrorism Attacks WHY ARE HEALTH EMERGENCIES AND BIOTERRORISM A THREAT TO OUR NATION’S HEALTH? The Nation Remains Inadequately Prepared: I Despite a federal investment of more than $6 billion to improve public health emergency preparedness after September 11, 2001, analyses find critical areas of the nation’s emergency preparedness effort still require attention.2 L The federal government has yet to establish clear performance measures and data collection methods to assess the effectiveness of the investments. I Only 10 labs in the U.S. are equipped to test for mustard agents, nerve agents, and other toxic chemicals that could be used in a chemical terrorist attack. I Ten states do not have adequate plans to distribute emergency vaccines, antidotes, and medical supplies from the Strategic National Stockpile.3 I Twenty-one states do not have statutes that allow for adequate liability protection for healthcare volunteers during emergencies.4 I Seven states have not purchased any portion of their federally-subsidized or unsubsidized antivirals to use during a pandemic flu.5 I The Homeland Security Presidential Directive 21 identifies mass casualty care as a key priority, however, federal government funding for hospital surge capacity development is only $100,000 per year per hospital, far from the level needed to adequately prepare.6 I Some $230 million has been spent on BioSense, the nation’s early-event detection system, however it still “lacks realtime capability and has issued a stream of false alarms that would be comical were the stakes not so high.”7 The Impact of Health Emergencies Can Take Enormous Human and Financial Tolls: I The September 11, 2001 tragedies resulted in the loss of approximately 3,000 lives and an estimated $80 billion in direct costs.8, 9 I An anthrax attack in New York City could lead to $90 billion in workers’ compensation losses, 3 times more than the entire $30 billion workers’ compensation industry, according to a study by a major financial institution.10 I According to a U.S. Centers for Disease Control and Prevention (CDC) study, if public health officials identify an anthrax attack on a city of 100,000 persons, and distribute antibiotics to the exposed persons within 24 hours, the number of lost lives could be roughly 5,000 and economic losses will reach $128 million. But, if it were to take public health officials 6 days to identify the attack, an estimated 33,000 people could die, and economic losses could reach $26.2 billion.11 I In 2003, Severe Acute Respiratory Syndrome (SARS) infected more than 8,000 people and left 774 dead.12 Its reach demonstrates the tremendous speed in which disease can spread. The economic losses, due to lives lost, quarantines, and lost tourism dollars, are estimated to be $30 billion to $50 billion.13 “THE ASSUMPTION THAT CONVENTIONAL PUBLIC HEALTH AND MEDICAL SYSTEMS CAN FUNCTION EFFECTIVELY IN CATASTROPHIC HEALTH EVENTS HAS, HOWEVER, PROVED TO BE INCORRECT IN REAL-WORLD SITUATIONS. THEREFORE, IT IS NECESSARY TO TRANSFORM THE NATIONAL APPROACH TO HEALTH CARE IN THE CONTEXT OF A CATASTROPHIC HEALTH EVENT IN ORDER TO ENABLE U.S. PUBLIC HEALTH AND MEDICAL SYSTEMS TO RESPOND EFFECTIVELY TO A BROAD RANGE OF INCIDENTS.”1 -- HOMELAND SECURITY PRESIDENTIAL DIRECTIVE/HSPD 21 MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. HOW CAN WE IMPROVE READINESS FOR HEALTH EMEGENCIES? I Clearly Designate Strong Federal Leadership. National plans should establish officials in charge of public health preparedness and specify how various departments are to collaborate in the event of a public health emergency. I Require Accountability and Conduct Meaningful Oversight. The federal Pandemic and All-Hazards Preparedness Act, was enacted to improve our emergency preparedness response capabilities. Many deadlines for benchmarks and deliverables, however, have not been met. The Administration must adhere to the deadlines in the legislation, and Congress must conduct ongoing oversight to ensure that progress is being made. I Bolster Surge Capacity and the Public Health Workforce. Public health emergency planning at the federal, state, and local levels must include preparations for mass emergencies, including surge capacity alternative care sites and recruiting and retaining a robust volunteer health care workforce. Congress should also address the public health workforce shortage crisis through legislation to recruit a new generation of professionals. I Modernize Technology and Equipment. Basic technology and tools of public health must be modernized to adequately protect the American people. This includes research and development of vaccines and new technologies; improved chemical laboratory testing capabilities; and, modernized surveillance systems to detect infectious disease outbreaks or a bioterrorist attack. I Partner with the Public. Preparedness plans need to consider the diverse needs of the U.S. population, in particular, vulnerable and ‘special needs’ populations. This includes designing culturally competent risk communication campaigns that use respected, trusted messengers to communicate the message. ENDNOTES 1 Homeland Security Council. Homeland Security Presidential Directive/HSPD 21: Public Health and Medical Preparedness. Washington, D.C.: The White House, 2007. 2 Trust for America’s Health. Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism. Washington, D.C.: TFAH, 2007. 3 Ibid. 4 Ibid. 5 Ibid. 6 E. Toner, et al. “Meeting Report: Hospital Preparedness for Pandemic Influenza.” Biosecurity and Bioterrorism 4, no 2. (2006): 1-11. 7 K. Eban. “Biosense or Biononsense? Years of Development and Hundreds of Millions of Dollars Later, What Has the CDC’s Syndromic Surveillance Program Accomplished?” The Scientist 21, no. 4 (April 2007): 32, http://www.the-scientist.com/2007/ 4/1/32/1 (accessed October 22, 2007). 8 Congressional Budget Office. “Cost Estimate: H.R. 4634: Terrorism Insurance Backstop Extension Act of 2004.” CBO, http://www.cbo.gov/ftpdoc.cfm?index= 6014&type=0&sequence=0 (accessed January 10, 2008). 9 H. Kunreuther and M.K. Erwann. Dealing with Extreme Events: New Challenges for Terrorism Risk Coverage in the U.S. Philadelphia, PA: University of Pennsylvania, Wharton School of Business, April 2004, http://grace.wharton.upenn.edu/risk/downloads/0409%20Howard%20and%20Erwann.pdf (accessed January 10, 2008). 10 Towers Perrin. Workers’ Compensation Terrorism Reinsurance Pool Feasibility Study. Stamford, CT: Towers Perrin, March 2004. 11 A.F. Kaufmann, et al. “The Economic Impact of a Bioterrorist Attack: Are Prevention and Postattack Intervention Programs Justifiable?” Journal of Emerging Infectious Diseases 3, no. 2 (April-June 1997): 83-94. 12 World Health Organization. “Summary of Probable SARS Cases with Onset of Illness from 1 November 2002 to 31 July 2003.” WHO. http://www.who.int/ csr/sars/country/table2004_04_21/en/ (accessed January 9, 2008). 13 Bio Economic Research Associates. “Thinking Ahead: Anticipating Early Impacts of an Avian Influenza Pandemic.” Bio-Era. http://www.bio-era.net/ research/add_research_18.html (accessed January 9, 2008). A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Recognizing the Relationship Between Health and U.S. Economic Competitiveness WHY IS POOR HEALTH A THREAT TO U.S. ECONOMIC COMPETITIVENESS? Health Care Costs Are Undermining Business Profits and Successes: I Poor health is putting the nation’s economic security in jeopardy. The skyrocketing costs of health care threaten to bankrupt American businesses, causing some companies to send jobs to other countries where costs are lower. I U.S. health care costs exceed $2 trillion annually, nearly 3 times more than in 1990, over 8 times more than in 1980.2 I More than one-quarter of health care costs are related to obesity, overweight, and physical inactivity due to associated health problems including heart disease, hypertension, diabetes, and some forms of cancer.3 L Health care costs of obese workers are up to 21 percent higher than nonobese workers.4 L More than one quarter of U.S. health care costs are related to physical inactivity, overweight, and obesity.5 L Obese and physically inactive workers also suffer from lower worker productivity, increased absenteeism, and higher workers’ compensation claims.6 L Obese employees, on average, submit twice as many workers compensation claims as normal weight employees, and these claims are far more expensive.7 I More than 20 percent of adult Americans currently smoke. Lifetime health care costs for individuals who smoke are $17,500 higher than for those who do not smoke.8 I Workplace injuries annually cost U.S. employers $46.8 billion — nearly $1 billion per week -- in direct costs (medical and lost wage payments). When indirect costs, such as overtime, training, lost productivity, are taken into account, costs to employers can climb to as much as $291.6 billion each year.9 Keeping People Healthier is Crucial to Keeping Health Costs Down: I Keeping the American workforce well helps American business remain competitive in the global economy, for example: L Caterpillar’s Healthy Balance Program will save $700 million by 2015.10 L MetLife estimates a 2.52 return on investment from its fitness program, which costs about $550,000 a year, a savings of about $1.38 million per year. The percentage of MetLife employees who were previously considered at high cardiovascular risk has dropped from about 35 percent of a 200 person random sample to less than 10 percent.11 L Motorola’s Wellness Program saves the company $3.93 for every $1 invested in wellness benefits.12 “IF WE CAN CREATE A HEALTH CARE PLAN THAT CONTAINS COSTS OR DRIVES THEM DOWN, THAT IMPROVES THE HEALTH OF THE EMPLOYEE AND EXTENDS THEIR LIFE, AND AVOIDS CATASTROPHIC ILLNESS AND DOESN’T COST THEM ANY MORE MONEY, WHY WOULD ANYONE QUARREL WITH THAT PLAN?”I -- SAFEWAY CEO, STEVEN BURD MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO IMPROVE THE HEALTH OF THE U.S. WORKFORCE? I Encourage Every Employer to Offer a Workplace Wellness Program. Federal, state, and local governments must work with private employers and insurers to ensure that every working American has access to a workplace wellness program and preventive care benefits. Preventive benefits should also be extended to employees’ families. I Promote Healthy Communities. Businesses should support measures to ensure the communities where their employees and their families live are healthy, through advocating for safe, affordable recreation spaces, sidewalks, bike paths, healthy school policies, access to affordable healthy foods, and other strong public health policies and services that help make healthy choices easy choices. I Improve Job Safety. Federal agencies, including the Occupational Safety and Health Administration (OSHA) and the National Institute for Occupational Safety and Health (NIOSH), should receive the funding they need to set and enforce workplace safety and health standards. I Support Smoke-Free Communities. Businesses should adopt create smokefree workplace policies and communities should support smoke-free laws and tobacco-taxes to encourage smoking cessation and reduce second-hand smoke. ENDNOTES 1 V. Colliver. “Preventive Health Plan May Prevent Cost Increases: Safeway Program Includes Hot Line, Lifestyle Advice.” San Francisco Chronicle, February 11, 2007. 2 KaiserEDU.org. “U.S. Health Care Costs: Background Brief.” Kaiser Family Foundation. http://www.kaiseredu.org/topics_im.asp?imID=1&parentID=61&id=358 (accessed January 10, 2008). 3 K. Thorpe, et al. “Trends: The Impact Of Obesity On Rising Medical Spending.” Health Affairs 4, (October 2004): 480-486. 4 E. Ostbye, et al. “Obesity and Workers’ Compensation: Results from the Duke Health and Safety Surveillance System.” Archives of Internal Medicine 167, no. 8, (2004):766-773. 5 L.H. Anderson, et al. “Health Care Charges Associated with Physical Inactivity, Overweight, and Obesity.” Preventing Chronic Disease 2, no. 4, (October 2005):1-12. 6 S. Klarenbach, et al. “Population-Based Analysis of Obesity and Workforce Participation.” Obesity 14, no. 5 (May 2006): 920-927. 7 Ibid. 8 Campaign for Tobacco Free Kids. “Fact Sheet: Lifetime Health Costs of Smokers vs. Former Smokers vs. Nonsmokers.” Campaign for Tobacco Free Kids. http://www.tobaccofreekids.org/research/factsheets/p df/0277.pdf (accessed January 10, 2008). 9 The Liberty Mutual Research Institute for Safety. “2006 Liberty Mutual Workplace Safety Index.” Liberty Mutual. http://www.wausau.com/omapps/Content Server?cid=1078452376750&pagename=wcmInter%2F Document%2FShowDoc&c=Document. (access January 28, 2008). 10 U.S. Department of Health and Human Services. Prevention Makes Common “Cents”. Washington, D.C.: U.S. Department of Health and Human Services, 2003. 11 Business Roundtable. Doing Well Through Wellness: 2006-07 Survey of Wellness Programs at Business Roundtable Member Companies. Washington, D.C.: Business Roundtable, 2007. http://www.businessroundtable.org/pdf/Health_Retirement/BR_Doing_ Well_through_Wellness_09192007.pdf (accessed October 9, 2007). 12 U.S. Department of Health and Human Services. Prevention Makes Common “Cents”. Washington, D.C.: U.S. Department of Health and Human Services, 2003. A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Safeguarding the Nation’s Food Supply WHY ARE FOODBORNE ILLNESSES A THREAT TO OUR NATION’S HEALTH? Major Cause of Sickness and Death: I Approximately 76 million cases of foodborne diseases occur in the U.S. each year, leading to an estimated 325,000 hospitalizations and 5,000 deaths.2 Virtually all of these illnesses could be prevented if the right measures are taken to improve the U.S. food safety system. I More than 200 known diseases are transmitted through food, many through improper food handling techniques.3 I One outbreak of E. coli contamination in spinach in 2006 caused more than 200 known illnesses and at least 3 deaths. Officials believe for every E. coli case reported, 20 go unreported.4, 5 Agriculture and Food Production Are Essential to the Economy: I Agriculture represents one-sixth of the Gross Domestic Product at more than $1 trillion a year and accounts for over $50 billion in exports annually, the largest positive contribution to the national trade balance.6 I Agriculture and the food sector employ one out of every 7 U.S. workers, more than any other single industry.7 I Over 13 percent of all jobs in metropolitan areas are tied to agriculture and the food sector.8 I Plant diseases alone currently cost the U.S. economy an estimated $33 billion a year.9 I If a significant outbreak of mad cow disease in the United States occurred, the Food and Drug Administration (FDA) estimates that there would be a loss of $15 billion, resulting from a 24 percent decline in domestic beef sales and an 80 percent decline in beef and live cattle exports.10 Slaughter and disposal costs of at-risk cattle could add up to an additional $12 billion.11 Outdated Regulation and Poor Coordination Leave U.S. Food Supply Vulnerable: I Studies from the National Academy of Sciences (NAS), the Institute of Medicine (IOM), and the U.S. Government Accountability Office (GAO) have all raised serious concerns about the system that is responsible for keeping the country’s food safe.12, 13, 14 I None of the agencies with the largest roles in food safety oversight has ultimate authority or responsibility, and no agency takes an integrated, holistic approach to ensuring food safety. L As one example: FDA regulates frozen cheese pizzas, but if the pizza is topped with cooked meat or poultry, it is regulated by USDA.15 Inspections at pizza production facilities must follow 2 sets of guidelines, one issued from FDA and one from USDA. USDA already inspects plants making pepperoni pizza every day, after it has already inspected the manufacture of the pepperoni on a daily basis and the slaughter of every animal used to make the pepperoni. I FDA is responsible for 80 percent of food safety oversight, but two-thirds of the food safety budget goes to USDA.16 CDC estimates that 85 percent of cases of illness reported for which there is a known food source were associated with FDA-regulated food products. I The FDA’s main food safety statutes date back to 1938 or earlier. “OUR FRAGMENTED FOOD SAFETY SYSTEM HAS RESULTED IN INCONSISTENT OVERSIGHT, INEFFECTIVE COORDINATION, AND INEFFICIENT USE OF RESOURCES. WITH 15 AGENCIES COLLECTIVELY ADMINISTERING AT LEAST 30 LAWS RELATED TO FOOD SAFETY, THE PATCHWORK NATURE OF THE FEDERAL FOOD SAFETY OVERSIGHT SYSTEM CALLS INTO QUESTION WHETHER THE FEDERAL GOVERNMENT CAN MORE EFFICIENTLY AND EFFECTIVELY PROTECT OUR NATION’S FOOD SUPPLY.”I -- 2007 REPORT BY GOVERNMENT ACCOUNTABILITY OFFICE LISTING FOOD SAFETY AS ONE OF THE FEDERAL GOVERNMENT’S “HIGH RISK” PROGRAMS MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. HOW CAN WE KEEP OUR FOOD SUPPLY SAFER? I Unify Government Food Safety Agencies. Legislation should be passed to bring existing food safety agencies together into a single, unified food safety agency to carry out a prevention-focused, integrated food safety strategy. I Develop a Prevention- and Risk-Based Strategy. Policies and resources should be reevaluated to set priorities based on understanding where the highest and most likely risks are in the food safety system, and then devoting resources to reduce and eliminate threats as much as possible, where inspections and other efforts are applied in ways most likely to contribute to disease reduction. I Improve Federal-State-Local Efforts. States should adopt the FDA’s Food Code that sets forth up-to-date, scientifically sound practices and enroll in the FDA’s Voluntary National Retail Food Regulatory Program for more uniform and accountable practices ENDNOTES 1 L. Shames. Federal Oversight of Food Safety: High-Risk Designation Can Bring Attention to Limitations in the Government’s Food Recall Programs. Testimony of Lisa Shames, Acting Director Natural Resources and Environment, Government Accountability Office before the Subcommittee on Oversight and Investigations, Committee on Energy and Commerce, House of Representatives. Washington, D.C.: U.S. Government Accountability Office, 2007. http://www.gao.gov/new.items/d07785t.pdf. 2 P.S. Mead, et al. “Food-Related Illness and Death in the United States.” Emerging Infectious Diseases 5, no. 5, (Sept-Oct 1999): 607-625. http://www.cdc.gov/ncidod/eid/vol5no5/mead.htm. 3 Ibid. 4 L. Sander. “Nebraska Woman’s Death Brings to 3 Those Attributed to Spinach.” New York Times, October 7, 2006. 5 A. Shin. “E. Coli Detected Near Spinach.” Washington Post, October 13, 2006. 6 H. Parker. Agricultural Bioterrorism: A Federal Strategy to Meet the Threat: McNair Paper 65. Washington, D.C.: National Defense University, 2002. 7 Ibid. 8 Ibid. 9 D. Pimentel, et al. “Environmental and Economic Costs Associated with Non-indigenous Species in the United States.” BioScience 50, no. 1, (2000):53-65. 10 Food and Agriculture Organization of the United Nations. The State of Food and Agriculture 2001. Rome, Italy: Food and Agriculture Organization of the United Nations, 2001. 11 Ibid. 12 National Academy of Sciences. Addressing Foodborne Threats to Health: Policies, Practices, and Global Coordination, Workshop Summary. Washington, D.C.: National Academy Press, 2006. 13 Committee to Ensure Safe Food from Production to Consumption, Institute of Medicine and National Research Council. Ensuring Safe Food: From Production to Consumption. Washington, D.C.: National Academy Press, 1998. 14 Government Accountability Office. Food Safety: USDA and FDA Need to Better Ensure Prompt and Complete Recalls of Potentially Unsafe Food. Washington, D.C.: U.S. Government Accountability Office, 2004. 15 Committee to Ensure Safe Food from Production to Consumption, Institute of Medicine and National Research Council. Ensuring Safe Food: From Production to Consumption. Washington, D.C.: National Academy Press, 1998. 16 M. Taylor. Improving Food Safety, Noontime Seminar at the George Washington University School of Public Health and Health Policy. Washington, D.C.: September 24, 2007. A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Managing the Changing Health Care Needs of Seniors WHY ARE THE CHRONIC DISEASES OF AGING A THREAT TO OUR NATION’S HEALTH? High Health Burden, High Financial Costs: I By 2030, 20 percent of the U.S. population -- 71 millions Americans -- will be 65 or older. Aging-related diseases are projected to increase the country’s health care costs by 25 percent during this time period.2 I 80 percent of America’s seniors (people 65 and older) live with at least one chronic disease that could lead to premature death or disability.3 Many Health Problems Could Be Prevented, Delayed, or Better Managed: I Many cases of chronic illnesses, particularly heart disease, stroke, diabetes, and some forms of cancer, could be avoided or delayed with healthy lifestyle practices, such as regular physical activity, healthy eating, and avoiding tobacco use, and through screenings for early detection of cancer and other diseases, according to U.S. Centers for Disease Control and Prevention (CDC).4 I There is growing evidence that Alzheimer’s can be prevented or delayed through health lifestyles, physical activity, and “exercising” the brain by reading and staying socially active. I Seniors with the flu are at higher risk for developing pneumonia as a complication, which can be lethal, particularly in older adults. Flu and pneumonia are currently the eighth leading cause of death in the United States. In 2004, over one million hospitalizations and 60,207 deaths were associated with people who died from pneumonia and there were over one million hospitalizations associated pneumonia.5, 6 I A recent study found that despite government recommendations, more than onethird of Americans aged 65 and over did not receive a flu shot.7 I Each year, between 360,000 and 480,000 older Americans sustain fall-related injuries, many of which could be prevented.8 “CHRONIC DISEASES EXACT A PARTICULARLY HEAVY HEALTH AND ECONOMIC BURDEN ON OLDER ADULTS DUE TO ASSOCIATED LONG-TERM ILLNESS, DIMINISHED QUALITY OF LIFE, AND GREATLY INCREASED HEALTH CARE COSTS. ALTHOUGH THE RISK OF DISEASE AND DISABILITY CLEARLY INCREASES WITH ADVANCING AGE, POOR HEALTH IS NOT AN INEVITABLE CONSEQUENCE OF AGING.”I -- U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. HOW CAN WE KEEP SENIORS HEALTHIER? I Promote Prevention. Health care providers and insurers, community organizations, employers, and government should provide seniors with increased information about the importance of lifestyle changes, such as those related to diet and exercise, and the importance of getting routine screenings and physicals for early diagnosis and treatment of medical conditions. Federal, state, and local governments should develop and implement a national strategy for promoting prevention activities. I Expand Prevention Benefits Covered by Medicare and Provide More Information to Seniors About Existing Prevention Benefits. Medicare should actively promote the range of prevention benefits provided, including preventive screenings for heart disease, diabetes, and a number of other chronic diseases, and vaccinations for flu and pneumonia. I Prioritize Vaccinating Seniors for Flu and Pneumonia. Government health departments should strive to achieve the national goals of vaccinating 90 percent or more of seniors for flu and pneumonia. I Increase Resources for Research. The federal government should increase funding for the National Institute on Aging, and research efforts at the National Institutes of Health that investigate causes and cures of aging-related chronic diseases, including neurological diseases such as Alzheimer’s and dementia. 5 A. M. Minino, et al. “Deaths: Preliminary Data for 2004.” National Vital Statistics Report 54, no. 19 (June 28, 2006). 6 C. J. DeFrances, et al. “2004 National Hospital Discharge Survey.” Advance Data from Vital and Health Statistics no. 371 (May 4, 2006). 7 U.S. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System, Prevalence Data, Nationwide (States and D.C.) - 2005 vs 2004, Immunization. Atlanta, GA: U.S. Department of Health and Human Services, 2006. (accessed October 30, 2006). 8 U.S. Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007. < http://www.cdc.gov/aging/pdf/saha_2007.pdf> ENDNOTES 1 U.S. Centers for Disease Control and Prevention. “Healthy Aging for Older Adults.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, http://www.cdc.gov/aging/ (accessed January 10, 2009). 2 U.S. Centers for Disease Control and Prevention and The Merck Company Foundation. The State of Aging and Health in America 2007. Whitehouse Station, NJ: The Merck Company Foundation; 2007. http://www.cdc.gov/aging/pdf/saha_2007.pdf 3 Ibid. 4 U.S. Centers for Disease Control and Prevention. “Healthy Aging for Older Adults.” U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, http://www.cdc.gov/aging/ (accessed January 10, 2009). A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Improving the Health of Low-Income and Minority Communities WHY ARE HEALTH DISPARITIES A THREAT TO OUR NATION’S HEALTH? Racial and Ethnic Minorities Are More Likely to Have Less Access to Care: I Thirteen percent of white Americans are uninsured, however, that figure nearly doubles to 22 percent among AfricanAmericans, and nearly triples to 36 percent among Latinos.5 People with Lower-Incomes Have Fewer Opportunities to Make Healthy Choices: I There is limited access to nutritious, affordable foods in low-income areas. Low-income zip codes tend to have fewer and smaller grocery stores, and people in these areas often pay more for fresh fruits and vegetables when such foods are even available.6 The presence of supermarkets is related to lower rates of obesity, while higher rates of obesity are related to the presence of convenience stores.7 I Even before Hurricane Katrina, Gulf Coast populations - many of them lowincome, minorities - were among the most chronically ill in the nation. After the hurricane, one in five survivors with chronic illness reported a disruption in his/her treatment, which researchers attribute to the loss of healthcare facilities and personnel in the region, as well as unemployment and associated income loss among survivors.8 I The states with the highest rates of obesity in the nation are also the poorest; these states often have high rates of adults lacking health insurance. Obesity is a risk factor for more than 30 serious diseases. Eight of the states with the highest poverty, diabetes, and hypertension rates were also in the top 15 in the country for obesity.9 “OF ALL THE FORMS OF INEQUALITY, INJUSTICE IN HEALTH CARE IS THE MOST SHOCKING AND INHUMANE.” -- MARTIN LUTHER KING, JR. Low-Income and Minority Communities Systematically Have Less Access to Health Care, Higher Exposure to Health Threats, and Worse Health Outcomes: I Rates of death from heart disease were 29 percent higher among African-American adults than among white adults in 2000, and death rates from stroke were 40 percent higher.1 I African-American males are over twice as likely to die of prostate cancer.2 I Cervical cancer incidence rates in Vietnamese women have been found to be 5 times higher than the rate among white American women.3 I African-American, American Indian, and Puerto Rican infants have higher death rates than white infants. AfricanAmerican babies are two-and-a-half times as likely to die in infancy as white infants, a statistic that has remained unchanged for the past 2 decades.4 MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. HOW CAN WE ELIMINATE HEALTH DISPARITIES? I Create Strategies to Improve the Health of All Americans, Regardless of Race, Ethnicity, Income, or Where They Live. All Americans should have the opportunity to be as healthy as they can be. As a nation, we must invest in first understanding the systematic disparities that exist and the factors that contribute to these differences, including poverty, income, racism, and environmental factors like exposure to pollution and quality of housing. Resources must be devoted to implement community-driven approaches to address factors. I Engage Entire Communities in Addressing Disparities. Efforts to eliminate disparities in health must also include addressing the range of community factors that influence health, such as safe and affordable housing, safe streets and recreation spaces, and affordable and accessible nutritious foods. This will require taking a community-wide approach, involving federal, state, and local government, businesses, and community groups. I Partner with a Diverse Range of Community Members in Developing and Implementing Health Strategies. Federal, state, and local governments must engage communities in efforts to address both ongoing and emergency health threats. The views, concerns, and needs of community stakeholders, such as volunteer organizations, religious organizations, and schools and universities must be taken into account when developing strategies if they are to be successful. Established proven programs, such as REACH (Racial and Ethnic Approaches to Community Health) should be fully-funded and expanded. I Communicate Effectively with Different Community Groups. Federal, state and local officials must design culturally competent communication campaigns that use respected, trusted, and culturally competent messengers to communicate the message and appropriate channels for reach target audiences. I Prioritize Community Resiliency in Health Emergency Preparedness Planning. Federal, state, and local government officials must work with communities and make a concerted effort to address the needs of low-income and minority communities during health emergencies. Public health training should be targeted to include disaster scenarios in at-risk populations’ neighborhoods. For example, planning for how emergency responders would react to an event in a neighborhood of primarily Spanish-speaking residents. I Promote Health Services, Including Preventive Care Services, in Underserved Communities. Policies must address the ongoing gaps in services to low-income and underserved minority communities. Inadequate preventive care means problems are often left untreated until they become higher-cost emergency care or serious chronic care issues. ENDNOTES 1 Office of Minority Health and Health Disparities. “Disease Burden & Risk Factors.” U.S. Centers for Disease Control and Prevention. http://www.cdc.gov/ omhd/AMH/dbrf.htm (accessed October 11, 2007). 2 National Medical Association and Pfizer, Inc. Racial Differences in Cancer: A Comparison of Black and White Adults in the Unites States. New York, NY: Pfizer, Inc. and National Medical Association, 2005. http://www.pfizer.com/files/products/Racial_Differences_in_Cancer.p df (accessed January 10, 2008). 3 B.A. Miller, et al. Racial/Ethnic Patterns of Cancer in the United States 1988-1992: NIH Pub. No. 96-4104. Bethesda, MD: National Cancer Institute, 1996. 4 Office of Minority Health. “Highlights in Minority Health: April 2004.” U.S. Centers for Disease Control and Prevention. http://www.cdc.gov/omh/Highlights/ 2004/HApr04.htm. (accessed October 11, 2007). 5 Kaiser Family Foundation. “Uninsured Rates for the Nonelderly by Race/Ethnicity, States (2004-2005), U.S. (2005).” Washington, D.C.: Kaiser Family Foundation, State Health Facts. http://statehealthfacts.org/comparebar.jsp?ind=143&cat=3 (accessed October 10, 2007). 6 Trust for America’s Health. F as in Fat: How Obesity Policies are Failing in America 2006. Washington, D.C.: TFAH, 2006. http://healthyamericans.org/reports/ obesity2006. 7 K. Morland, et al. “Supermarkets, Other Food Stores and Obesity: The Atherosclerosis Risk in Communities Study.” American Journal of Preventive Medicine 30, no. 4, (2006): 333-339. 8 The Hurricane Katrina Community Advisory Group. “Hurricane Katrina’s Impact on the Care of Survivors with Chronic Medical Conditions.” Journal of General Internal Medicine 22, (2007): 1225-1230. 9 Trust for American’s Health. F as in Fat: How Obesity Policies are Failing in America 2007. Washington, D.C.: TFAH, 2007. http://www.healthyamericans.org/ reports/obesity2007. A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Reducing Environmental Threats WHY ARE ENVIRONMENTAL THREATS HARMFUL TO THE NATION’S HEALTH? The Health Impact of Environmental Hazards is Well Documented: I The National Academy of Sciences estimates that 25 percent of developmental diseases, such as cerebral palsy, autism, and mental retardation, are caused by environmental factors acting alone or together with genetic risk factors.2 I The World Health Organization estimates that 13 million deaths annually are due to preventable environmental causes.3 I Global warming is expected to lead to more extreme weather events ranging from intense heat and drought to more severe storms and flooding, which have the potential to negatively affect health.4 I Researchers are also exploring concerns that diseases such as multiple sclerosis, Parkinson’s disease, and Alzheimer’s disease may be linked to exposure to environmental hazards. I Childhood asthma has more than doubled over the last 2 decades, with outdoor and indoor air quality considered to be major contributing factors.5 I Illnesses stemming from air pollution cost between $14 billion and $55 billion annually.6 Investigating Connections Between the Environment and Health Yields Life-Saving Discoveries: I Tracking the impact of environmental factors has led to greater understanding of the connections between: L Folic acid and the reduction of neural tube birth defects; L Tobacco and cancer; L Childhood exposure to lead and development of mental retardation and loss of motor skills; and L Early cancer screenings and better treatment outcomes. “WHEN WE IMPROVE THE HEALTH OF AN ENVIRONMENT, WHETHER THAT ENVIRONMENT IS A COMMUNITY OR A WORKPLACE, WE IMPROVE THE HEALTH OF THE PEOPLE WHO LIVE OR WORK IN THAT ENVIRONMENT.”I -- JULIE GERBERDING, DIRECTOR, U.S. CENTERS FOR DISEASE CONTROL AND PREVENTION (CDC) MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO REDUCE ENVIRONMENTAL HEALTH HAZARDS? I Improve Coordination Among Agencies. Health departments at the federal, state, and local levels should work with environmental agencies to undertake initiatives to reduce known health threats from food, water, and air, and educate the public about ways to avoid potential risks. I Establish a Nationwide Health Tracking Network. Congress should provide full funding for the U.S. Centers for Disease Control and Prevention’s (CDC) environmental public health tracking program. The CDC should be provided with the mandate and resources to establish a centralized, nationwide health tracking center, and each state should get funding to fully conduct health tracking activities, including tracking animal diseases; chronic diseases such as cancer and asthma; events related to bioterrorism; and environmental risks. I Fund Research on Global WarmingRelated Health Effects. Congress should provide funding to CDC to track data on environmental conditions, disease risks, and disease occurrence related to climate change. CDC should use this data to inform communities about the healthrelated risks of climate change and means to reduce them. I Increase Funding for Research into the Impact of Chemical Exposures on Human Health. CDC has conducted limited research on how chemicals ranging from pesticides to personal care products impact health. CDC and state health departments need greatly increased resources for “biomonitoring” (analysis of blood, urine, and tissues to measure chemical exposure in humans) to gain more understanding of how different chemicals and levels of exposures to chemicals affect health. I Prioritize Childhood Lead Poisoning Prevention. While great progress has been made nationally in reducing childhood lead poisoning through efforts to remove older paint from homes and to reduce lead gasoline emissions, serious problems remain. In many cities, lead is present in the water at unacceptable levels, while lead paint is still found in older, substandard housing in many lowerincome urban areas. ENDNOTES 1 U.S. Centers for Disease Control and Prevention. “News Release: Four Communities to Pilot New Federal Environmental Health Partnership.” Atlanta, GA: U.S. Centers for Disease Control and Prevention, July 18, 2007. http://www.cdc.gov/nceh/pressroom/ 2007/Four_Pilots.htm (accessed January 10, 2008). 2 National Research Council. Scientific Frontiers in Developmental Toxicology and Risk Assessment Washington, D.C.: National Academies Press, 2000. 3 World Health Organization. Preventing Disease Through Healthy Environments: Towards an Estimate of the Environmental Burden of Disease. Geneva: World Health Organization, June 2006. 4 U.S. Centers for Disease Control and Prevention. “CDC Policy on Climate Change and Public Health.” U.S. Department of Health and Human Services. http://www.cdc.gov/nceh/climatechange/ (accessed January 28, 2008). 5 U.S. Environmental Protection Agency. “America’s Children and the Environment.” U.S. Environmental Protection Agency. http://www.epa.gov/envirohealth/ children/highlights/index.htm (accessed May 11, 2007). 6 B. Ostro and L. Chestnut. “Assessing the Health Benefits of Reducing Particulate Matter Air Pollution in the United States.” Environmental Research 76, no. 2 (1998): 94-106. A H E A LT H I E R A M E R I C A : 10 TOP PRIORITIES FOR PREVENTION Holding Government Accountable for Protecting the Health of Americans WHY IS THE LACK OF ACCOUNTABILITY A THREAT TO OUR NATION’S HEALTH? Evaluations Question Abilities of Public Health System, Yet No Basic Standards Exist for Public Health Departments: I A series of assessments by the Institute of Medicine (IOM), Government Accountability Office (GAO), U.S. Centers for Disease Control and Prevention (CDC), and independent research organizations conclude that the public health system is unprepared to meet the challenges of today’s modern health threats.1, 2, 3, 4, 5 I There are currently no basic standards, performance measures, or accreditation programs for the more than 3,000 federal, state, and local public health agencies across the country. L The IOM “called on the public health community to consider how accreditation ultimately could prompt improvements in the nation’s health.”6 L In 2006, a model voluntary national accreditation program by the Association of State and Territorial Health Officials and the National Association of County and City Health Officials recommended the development of accreditation standards to promote quality improvement and accountability for public health, including performance measures.7 Limited Information Makes It Difficult to Set Policies or Measure the Effectiveness of Public Health Programs: I No independent source analyzes the impact of public health spending or systematically evaluates how spending is impacting the health of Americans.8 L Disease rates and public health spending vary dramatically from state-to-state, but there is no mechanism in place to determine the reasons for the differences. L For example, rates of asthma among adults range from a low of 10.5 percent in South Dakota to a high of 15.4 percent in Oregon, and adult obesity rates range from a low of 16.9 percent in Colorado to a high of 29.5 percent in Mississippi, but there is no evaluation into why these differences exist.9 L Federal public health funding for CDC grants for states ranges from a per capita low of $13.89 in Indiana to a per capita high of $77.24 in Alaska.10 L Each state reports its budget for public health in a different way. Based on an analysis that tries to compare budgets in a standardized way, the median state spending on public health is $31 per person, with a range of $3.73 per person in Nevada to $127.69 per person in Hawaii.11 I According to the Journal of Public Health Management and Practice, “Knowledge of the sources and uses of public health funding remains scarce. Evidence is not readily available on efficient models for resource allocations, and metrics to measure funding outcomes have not yet been identified.”12 “AMERICANS DESERVE AND SHOULD EXPECT BASIC HEALTH PROTECTIONS -- AND THEY ALSO DESERVE TO KNOW WHAT THE GOVERNMENT IS DOING TO KEEP THEM HEALTHY AND SAFE. RIGHT NOW, THERE IS NO SYSTEMATIC APPROACH FOR ENSURING A MINIMUM LEVEL OF HEALTH SERVICES OR THAT MONEY SPENT ON PUBLIC HEALTH PROGRAMS IS BEING USED IN THE MOST EFFECTIVE WAY TO REDUCE AND PREVENT DISEASE AND INJURY.” -- LOWELL WEICKER, FORMER THREE-TERM U.S. SENATOR AND GOVERNOR OF CONNECTICUT, AND BOARD PRESIDENT OF TRUST FOR AMERICA’S HEALTH MARCH 2008 PREVENTING EPIDEMICS. PROTECTING PEOPLE. WHAT CAN BE DONE TO INCREASE ACCOUNTABILITY? I Make Information About the Health of Americans and Spending to Improve Health Easily Accessible to the Public. Federal, state, and local health agencies should be required to collect and make health data easily accessible and understandable to the public at a community level. States should follow the lead of Wisconsin’s Department of Health & Family Services, which annually publishes health and demographic information about each county in the state.13 I Designate Leaders Who Are Responsible to the Public. Clear, strong leadership at the federal, state, and local must be defined so Americans know who to hold accountable for improving the health of their communities. These leaders should be given the authority to bring together resources from across government agencies that have an impact on health and engage businesses and community groups. I Require Collection of Consistent and Detailed Data and Budget Reporting Practices. Consistent and comparable information is needed to better understand the health of Americans and to measure the effectiveness of public health programs. Budget transparency would allow the public to monitor how much is being spent at the state and local levels on public health and to measure the effectiveness of these programs. Improved transparency would also allow the public and government to compare spending levels and program outcomes to determine best practices for the best prices. I Institute Federal, State, and Local Accountability Measures. The public health community must adopt accountability and quality improvement measures, including performance and accreditation standards, based on delivery of services and health improvement outcomes. Reallife and table-top exercises should be used to help gauge health emergency preparedness. Measures should take into account the influence of other factors on health beyond those the public health community can control, such as healthcare systems and urban planning. Performance data must be collected and made publicly available on a regular basis. 7 Robert Wood Johnson Foundation. Press Release: Public Health Leaders Recommend Voluntary National Accreditation Program. Washington, D.C.: RWJF, September 21, 2006. http://www.rwjf.org/newsroom/newsreleasesdetail.jsp?id=1-433. 8 Trust for America’s Health. Shortchanging America’s Health 2006: A State-By-State Look at How Federal Public Health Dollars Are Spent. Washington, D.C.: Trust for America’s Health, June 2006. 9 Trust for America’s Health. “Your State’s Health.” Trust for America’s Health. http://healthyamericans.org/ state/. (accessed January 11, 2007). 10 Ibid. 11 Ibid. 12 P.A. Honore and B.W. Amy. “Public Health Finance: Fundamental Theories, Concepts, and Definitions.” Journal of Public Health Management and Practice 13, no. 2 (March-April 2007): 89-92. 13 Department of Health and Family Services. “Public Health Profiles.” State of Wisconsin. http://dhfs.wisconsin.gov/localdata/pubhlthprofiles.htm (accessed January 28, 2008). ENDNOTES 1 Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press for the Institute of Medicine, 2003. 2 U.S. Government Accountability Office. HHS Bioterrorism Preparedness Programs: States Reported Progress But Fell Short of Program Goals in 2002. Washington D.C.: Government Accountability Office, February 2004. 3 U.S. Centers for Disease Control and Prevention. Public Health Infrastructure --A Status Report. Atlanta, GA: U.S. Department of Health and Human Services, 2001. 4 Trust for America’s Health. Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism -2007. Washington, D.C.: Trust for America’s Health, 2007. 5 C. Nelson, et al. “Assessing Public Health Emergency Preparedness: Concepts, Tools, and Challenges.” Annual Review of Public Health 28, (April 2006): 1-18. 6 Institute of Medicine. The Future of the Public’s Health in the 21st Century. Washington, D.C.: National Academies Press for the Institute of Medicine, 2003. Ourfor a Vision Healthier 1730 M Street, NW, Suite 900 Washington, DC 20036 (t) 202-223-9870 (f) 202-223-9871