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Public Health Continuum

Public Health 101: The leading Challenges
for the U.S. in the Coming Decade

EXAMPLES OF HOW THE PUBLIC HEALTH CONTINUUM WORKS TO KEEP AMERICANS HEALTHY

The following case examples show how federal public health agencies work together as part of a continuum to improve health outcomes for a number of diseases and conditions:

• Antimicrobial Resistance
• Arthritis
• Diabetes
• Genetic Disorders
• Health Disparities
• Heart Disease
• HIV/AIDS
• Infant Mortality
• Infectious Diseases/Immunization
• Mental Health
• Neural Tube Defects
• Obesity
• Oral Health
• Stroke
• Substance Use Diosders
• Sudden Infant Death Syndrome (SIDS)

Antimicrobial Resistance: Overuse of antibiotics contributes to the emergence of microorganisms that are resistant to the first-line antimicrobials commonly used for treating patients with infectious diseases such as pneumococcal pneumonia, streptococcal pharnygitis, salmonellosis, and tuberculosis. According to the Institute of Medicine (IOM), the cost of resistant diseases is significant: the U.S. health care system spends an estimated $4-5 billion annually on the treatment of hospital acquired infections such as staphylococcus ("staph"). Costs are expected to rise given increasing rates of resistance and the number of cases each year. The IOM reports that over 55 percent of Staphylococcus aureus isolates were resistant to the antibiotic, methicillin, in 2002. The Centers for Disease Control and Prevention (CDC) estimates that as many as 80,000 hospital patients are infected with methicillin-resistant S. aureus each year. Several government agencies, including the Food and Drug Administration (FDA) the National Institutes of Health (NIH) and the United States Department of Agriculture (USDA), joined the CDC in 2001 to address this growing threat by releasing the Public Health Action Plan to Combat Antimicrobial Resistance. The plan, which provides a blueprint for coordinated federal action, has four components: surveillance, prevention and control, research, and product development. In 2003, the CDC announced a new extramural applied research grant program to fund research on the characterization of strains of community-associated methicillin-resistant Staphylococcus aureus (MRSA). The goal of the research program is to prevent and control the emergence and spread of antimicrobial resistance in the United States. CDC also launched its "Get Smart" campaign in 2003 which provides information to physicians and patients regarding the appropriate uses of antibiotics. An important objective is to prevent drug resistance from developing in health care settings and also to improve clinical laboratories by encouraging drug-susceptibility testing and better use of proficiency testing and training programs.

A combined effort can successfully address antimicrobial resistance as the following example illustrates:

In early 1997, a rapid increase in vancomycin-resistant enterococci (VRE), a highly resistant, often life-threatening, organism that is transmitted in health-care settings, was reported in the tri-state Siouxland region surrounding Sioux City, Iowa. The Siouxland district health department, consisting of local physicians, infection control practitioners, and public health officials formed a task force. The VRE task force formulated several interventions, including performing screening cultures on admitted patients, implementing strict infection control policies based on CDC guidelines, and educating health care workers about the epidemiology of VRE and prudent use of antibiotics, especially vancomycin. This strategy was effective. Over a two year period, the overall prevalence of VRE at all the healthcare facilities decreased from 2.5 to 0.5 percent. There was an elimination of VRE from all the hospitals and a significant reduction in VRE at the long-term care facilities. The key to success was the partnership between public health and clinical medicine so that when surveillance data indicated an emerging problem, science-based prevention and control measures could be implemented rapidly to prevent the spread of a serious drug-resistant infection in this community.

Arthritis: Arthritis means swelling, pain and loss of motion in the joints of the body. There are more than 100 rheumatic diseases that cause this condition, which can sometimes be fatal, in both children and adults of all ages. One in three adults, or 70 million people in the United States, are affected by arthritis and other rheumatic conditions. Arthritis and other chronic joint problems are the leading cause of disability among adults in the U.S., costing more than $116.3 billion a year in medical costs and lost productivity. These numbers and related costs are expected to increase as the U.S. population ages.

The federal government is doing critical medical research into the causes, treatment and prevention of arthritis and rheumatic diseases at the National Institutes of Health (NIH) through the National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS) and the National Institute of Allergy and Infectious Diseases (NIAID). Health services research performed by the Agency for Healthcare Research and Quality (AHRQ) complements the arthritis research of the NIH by helping rheumatologists make choices about what treatments work best, for whom and when. The Centers for Disease Control and Prevention (CDC) helps improve the quality of life for those living with arthritis through the National Arthritis Action Plan, a public health program through which the CDC and Arthritis Foundation work with state health departments to develop or enhance programs to fight arthritis.

Continued federal investment will help provide breakthrough advances that have the potential to revolutionize our understanding of arthritis and rheumatic diseases, leading to more effective treatments, decreased costs and increased quality of life for patients suffering from these conditions.

Diabetes: As reported by the Department of Health and Human Services, diabetes illustrates how research at the National Institutes of Health (NIH), the Centers for Disease Control and Prevention (CDC), and the Agency for Healthcare Research and Quality (AHRQ) work together to address this costly disease: "Thirty-three percent of diabetics, over five million people, have gone undiagnosed. The incidence of diabetes is growing in the American population. Medical research alone will not cure this problem. ... NIH focuses on genetic causes for diabetes and researches possible new avenues for treatment. ... But we need CDC's efforts in identifying diabetics and persuading them to seek treatment. We also need AHRQ's research, which focuses on finding the most economic and least intrusive methods to screen individuals for diabetes. Without the essential research and prevention services of CDC and AHRQ we will never reduce the serious threat that diabetes poses to our society." New research has confirmed that Type 2 diabetes is linked to obesity and that many individuals at risk for developing Type 2 diabetes can prevent full onset of the disease by changing their diet and increasing physical activity. Studies show that a 5-7 percent loss in body weight can prevent or delay the disease. The American Diabetes Association reports that diabetes cost society $131.7 billion in 2002.

Genetic Disorders: The Human Genome Project (HGP), an international collaboration led by the NIH's National Human Genome Research Institute, produced a working draft of the human genome sequence - the entire set of genetic instructions encoded in human DNA - in 2001 and will complete the human genome sequence in the spring of 2003, - two years ahead of the original HGP schedule and at a cost less than the original estimated budget. NIH also produces consensus statements and technology assessment reports on topics related to genetic testing, including the development and assessment of newborn screening for sickle cell disease, genetic testing for cystic fibrosis, and screening for and management of phenylketonuria (PKU).

The Centers for Disease Control and Prevention (CDC) established the Office of Genetics and Disease Prevention to translate the findings of the Human Genome Project into disease and disability prevention and health promotion for those who inherit specific genotypes. Working with other public health agencies, state and local governments and the private sector, CDC will work to develop appropriate public health assessment, including adequate family history; evaluation of genetic testing; intervention development, implementation and evaluation - this is expected to involve medical, behavioral, and environmental aspects; and communication and information dissemination.

The Genetic Services Program in the Health Resources and Services Administration (HRSA) has supported the development of ways to manage conditions such as PKU, congenital hypothyroidism, and sickle cell anemia within the health care setting and within newborn screening programs. The Agency for Healthcare Research and Quality (AHRQ) supports the U.S. Preventive Services Task Force, which rigorously reviews evidence for the effectiveness of more than 100 interventions to prevent illness and conditions, including screening tests for genetically determined conditions such as PKU and Down Syndrome. All federal government genetic activities will be guided by the DHHS Secretary's Advisory Committee on Genetic Testing, which will provide advice about all aspects of the development and use of genetic tests, including the complex medical, ethical, legal, and social issues raised by genetic testing.

Health Disparities: Compelling evidence that race and ethnicity correlate with persistent, and often increasing, health disparities among U.S. populations demand national attention and therefore one of the two overarching goals of Health People 2010 is "to eliminate health disparities among different segments of the population." Despite significant progress in the overall health of the Nation, there are continuing disparities in burden of illness and death across a broad range of medical conditions experienced by African-Americans, Hispanics, American Indians and Alaska Natives, and Asian-Americans and Pacific Islanders, compared to the U.S. population as a whole. The demographic changes that are anticipated over the next decade magnify the importance of addressing disparities in health status. Racial and ethnic groups will increase in upcoming decades as a proportion of the total U.S. population; therefore, the future health of America as a whole will be influenced substantially by our success in improving the health of these populations.

Authorized by the Minority Health and Health Disparities Research and Education Act of 2000 (PL 106-525), the NIH's National Center on Minority Health and Health Disparities was instrumental in the development of NIH's first Comprehensive Strategic Research Plan and Budget, which will focus on research, research infrastructure, and community outreach. The Center has also implemented three core programs: loan repayment programs for health disparities research and for individuals from disadvantaged backgrounds, an endowment program to facilitate capacity building at institutions that have demonstrated commitment to educating and training researchers from minority and health disparity populations, and the Centers of Excellence in Partnerships for Community Outreach, Research on Health Disparities and Training (Project EXPORT), which awarded $19 million to 26 eligible entities to support health disparities research.

In partnership with NIH and the Health Resources and Services Administration, the Agency for Healthcare Research and Quality supports nine "Excellence Centers to Eliminate Ethnic/Racial Disparities" (EXCEED), which have been awarded five-year grants bringing together teams of new and experienced investigators to analyze underlying causes and contributing factors for racial and ethnic disparities in health care and to identify and implement strategies for reducing and eliminating them. The Minority and Disadvantaged Health Professions training programs funded through the Health Resources and Services Administration are designed to increase minority representation in the health professions, which the Surgeon General has stated is linked to greater access for minorities to essential health care services.

Heart Disease: Heart disease, America's #1 killer, kills about 700,000 Americans each year. Nearly 23 million Americans live with the effects of heart disease, the leading cause of premature, permanent disability among American workers. Heart disease will cost this nation an estimated $239 billion in medical expenses and loss productivity in 2004.

Since 1948, the National Heart, Lung, and Blood Institute (NHLBI) at the National Institutes of Health has supported basic, clinical, and population-based research studies to identify characteristics that predispose individuals to heart disease. Results of NHLBI research, particularly from risk-factor intervention studies, form the basis for widespread public health efforts by the Institute, other Federal agencies, and nonprofit organizations. They provide the impetus for the development of new treatments and for the establishment of national programs to educate health professionals, patients, and the public about heart disease risk factors identification and modification. The NHLBI also develops national public education campaigns in partnership with other Federal and nonprofit organizations; the Heart Truth Campaign, for example, was founded by the NHLBI in collaboration with the Office on Women's Health in the U.S. Department of Health and Human Services, the American Heart Association, and WomenHeart: the National Coalition for Women with Heart Disease to raise awareness among women about heart disease, the leading cause of death for American women, and what they can do to prevent it. Given the racial and ethnic health disparities in heart disease deaths, the NHLBI funds a number of community-based heart health programs targeting African American, American Indian/Alaska Native, and Asian American/Pacific Islander populations; collaborators such as the Indian Health Service are essential for the success of these programs. The Centers for Disease Control and Prevention's (CDC's) Preventive Health and Health Services Block Grant also has transferred findings from NHLBI-supported programs into community settings. CDC, in partnership with State health departments, has begun developing an integrated State-based Heart Disease and Stroke Prevention Program.

Impact of funding cuts in FY 2006 on heart and stroke research and programs:

1) Heart disease, stroke and other cardiovascular diseases remain the No. 1 killer in every state. Yet, only 14 states receive funding from CDC's Heart Disease and Stroke Prevention Program to actually implement state-tailored programs to prevent and control these often deadly and disabling diseases. This lifesaving program is cut below its FY 2005 funding level, an appropriation forcing the 19 states with planning grants to shelve their hopes of being elevated from a planning phase, that is largely complete, to actual program implementation.

2) An estimated 94 percent of all cardiac arrests that occur out-of-the hospital are deadly. Immediate cardiopulmonary resuscitation (CPR) and early defibrillation-- an electrical shock to help restore a heart to its normal rhythm--using an automated external defibrillator (AED) can more than double a victim's chance of survival. For every minute that passes without defibrillation, a victim's chance of survival decreases by 7-10 percent. The Health Resources and Services Administration (HRSA) Rural and Community Access to Emergency Devices Program funding is cut by 83 percent, virtually eliminating this lifesaving program, which provides states with grants to train lay rescuers and first responders to use automated external defibrillators (AEDs) and purchase and place them in public areas where cardiac arrests are likely to occur. HRSA will likely be forced to terminate the rural component of this program that supports 47 state, and focus only on the community segment that funds four cities in three states. Placing AEDs in more public settings could save thousands of additional lives each year. Communities with aggressive AED placement plans have achieved survival rates as high as 40 percent.

3) The NIH faces its first funding cut in 35 years under the FY 2006 budget. Unfortunately, under this NIH budget, the National Institute of Neurological Disorders and Stroke will scale back implementation of its Stroke Progress Review Group report The report serves as a guide for a long-range strategic plan for stroke. For example, due to budget shortfalls, the NINDS has been forced to compress its Specialized Programs on Translational Research in Acute Stroke from the planned 10 extramural centers to five currently funded. SPOTRIAS researchers facilitate translation of basic research into patient care and evaluate and treat victims very rapidly after the onset of stroke symptoms. Similarly, due to budget shortfalls, the National Heart, Lung, and Blood Institute will likely be forced to limit its Heart Failure Clinical Research Network to study new approaches to diagnose, treat and manage heart failure patients.

HIV/AIDS: According to the Centers for Disease Control and Prevention (CDC), by the end of 2003, 929,985 cases of AIDS have been reported in the United States, up from 886,575 in 2002, with a total of 524,060 deaths. The CDC also estimates that nearly one million people are living with HIV/AIDS in the U.S., one half of whom do not have access to medical care - including 250,000 individuals who are unaware of there HIV status. The CDC has also recently reported an increase in new incidences of HIV infection from 40,000 in 2000 to 42,000 new infections in 2001. In addition, the continuing emergence of drug resistant strains of HIV has lead to increases in the number of AIDS cases and an increase in the number of AIDS related deaths.

Attacking this disease must include a strong Federal commitment to funding HIV/AIDS care and treatment, research, and prevention programs that will enable public health agencies to implement the newest medical advances and risk reduction models, and to effectively target their efforts in order to best serve the diverse communities hit hardest by the AIDS epidemic.

The Federal response to HIV/AIDS is a multi-disciplinary approach that draws upon the best in research and practice from a number of different agencies within the Department of Health and Human Services. The National Institutes of Health (NIH) has been essential in research and development of drugs that are effective in treating HIV. Efforts continue at NIH to find a vaccine to prevent HIV infection, as well as to identify a microbicide that could prevent transmission of the virus. Prevention efforts are administered through the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). These efforts, which are in turn guided by the social and behavioral research findings of the NIH, are critical to reducing the spread of the disease. In addition, the Minority HIV/AIDS Initiative was created in 1998 to address the disproportionate effect HIV/AIDS is having on communities of color. HIV specific care and treatment programs are delivered through the Ryan White CARE Act (CARE Act), the largest discretionary source of care and treatment services for people living with HIV, which is administered by HRSA. The CARE Act provides essential medical care and treatment, as well as support services, for people living with HIV/AIDS. In particular, the CARE Act has been a much-needed source of funding for expensive life saving drugs for uninsured or underinsured HIV/AIDS patients under the AIDS Drug Assistance Program (ADAP).

Infant Mortality: Unique among all health outcomes, the death of an infant has always been viewed as a sentinel event that serves as a measure of a community's overall social and economic well-being, and of the organization of its local health and human services. The US infant mortality rate increased from a rate of 6.8 infant deaths per 1,000 live births in 2001 to a rate of 7.0 per 1,000 births in 2002, the first year since 1958 that the rate has not declined or remained unchanged. However, there was continued decrease in late-term fetal deaths defined as 28 or more weeks of gestation. The CDC attributes the rise in infant mortality to an increase in neonatal infant deaths (infants less than 28 days old), particularly infants who died within the first week of life. Three causes of death accounted for most of the increase in infant mortality: congenital anomalies, disorders related to short gestation and low birth weight, and maternal complications of pregnancy. Racial and ethnic disparities in infant mortality persist. According to the CDC, the rate for black infants was 14.3 infant deaths per 1,000 live births, more than double the rate for white infants. The non-Hispanic white population infant mortality rate increased from 5.7 to 5.9 between 2001 and 2002. Because of inconsistencies in the reporting of some race groups and Hispanic origin on birth and death certificates, infant mortality rates for these groups are likely to be underestimated. Many agencies throughout the federal public health service contribute to the national goal of reducing infant mortality to 4.5 deaths per 1,000 live births, or lower, by year 2010. Rates prior to 2002 declined due to many factors addressed across the U.S. Public Health Service, including decreased maternal tobacco use, fewer SIDS cases, decreased perinatal HIV transmission, and the prevention of birth defects and alcohol syndrome. Examples of this are:

Annually, four million children will need to be immunized against 12 preventable diseases before the age of two. That equals 11,000 babies a day. And, nearly 25 percent of those children at age two have not received all of the recommended vaccine doses.

Each year, thousands die of vaccine preventable diseases or their complications. For example, 36,000 Americans die from influenza and its complications with 114,000 hospitalized and between 6,000-7,000 Americans die from pneumococcal infections. Moreover, both influenza and pneumococcal immunization rates are significantly lower for African American and Hispanic adults than for white adults.

Mental Health: The President's New Freedom Commission on Mental Health, the first such commission in over 25 years, found that the public mental health system is fragmented and inadequate, and in dire need of transformation. As the nation transitioned from institutionalized care to community-based care over the last few decades, the chronic underfunding of mental health services to be delivered in the community is primarily responsible for this disjointed, disconnected public mental health system.

In his landmark 1999 report on mental health, the U.S. Surgeon General reported that during a given year 20 percent of the population experiences a mental disorder. For about five percent of the population, the mental disorder is a severe and persistent mental illness, such as schizophrenia, bipolar disorder, or major depression. It is estimated that 20 percent, or 13.7 million, American children have a diagnosable mental or emotional disorder, and approximately five to nine percent of these youth have a serious emotional disorder (SED). Tragically, mental illness plays a major role in the 30,000 lives that are lost to suicide, and the over 650,000 attempted suicides every year.

In the vast majority of cases, mental disorders today can be treated successfully through an array of specific interventions. Our extensive knowledge of mental illness owes much to the rich research literature supported over the years by the National Institutes of Mental Health. Despite treatment effectiveness, however, nearly 67 percent of adults and 80 percent of children who need mental health services do not receive treatment. (Mental Health: A Report of the Surgeon General, 1999) The reasons for this treatment gap include: (1) the historical stigma surrounding mental illness and treatment; (2) financial barriers, including discriminatory provisions in both private and public health insurance plans that limit access to mental health treatment. The Substance Abuse and Mental Health Services Administration (SAMHSA) plays a critical role in improving the availability and quality of prevention and treatment services for mental disorders and substance use disorders in the community. Increased research is critical to better treatment and prevention, including research targeted to specific populations such as children.

Many behavioral factors are now known to increase individual's risk for disease, physical disability, and early death, such as physical inactivity, obesity, anxiety, traits of anger or hostility, and depression. Behavioral research 1) determines how attributes of habit, personality, and social environment contribute to the development and course of disease, and 2) establishes practical behavioral strategies to reduce disease risk and to assist in preventing, improving, and managing illness.

Neural Tube Defects: The National Institutes of Health has furthered our knowledge of the benefits of adequate folic acid intake in the diets of women of childbearing age to prevent neural tube defects -- spina bifida and anencephaly. We now know that if all American women consumed 400 mcg of the B vitamin folic acid each day, 50-70 percent of all cases of spina bifida and anencephaly would be prevented, saving about $245 million per year. As a result of this research, four years ago the Food and Drug Administration required fortification of certain basic foods with B vitamin folic acid. However, out of concern for potential negative side effects for certain elderly consumers that are currently being investigated, the FDA opted to require somewhat lower levels of Vitamin B folic acid in foods than the Public Health Service has determined are enough to prevent neural tube defects. In order to ensure that women of child bearing age consume enough Vitamin B folic acid through foods or vitamin supplements, the Centers for Disease Control has been conducting a national public awareness and education effort. As a result of the combined efforts of fortification and increased educational outreach efforts, CDC reports that the rates of neural tube defects have decreased 19 percent since 1996. This means approximately 800 more babies are born healthy in the United States each year.

Obesity: From 1987 to 2000, overweight and obesity increased dramatically among U.S. adults, and now obesity has reached epidemic proportions. Nearly 59 million adults are obese, and the percentage of young people who are overweight has more than doubled in the last 20 years. Fifteen percent of Americans aged 6-19 years are overweight. The effects are catastrophic: poor diet and physical inactivity lead to 300,000 deaths each year - second only to tobacco use - and costs an annual $117 billion. People who are overweight or obese increase their risk for cardiovascular diseases, diabetes, high blood pressure, arthritis-related disabilities, and some cancers. The Secretary's new initiative, Steps to a Healthier US, as well as on-going activities within CDC and HRSA, represent cross-agency efforts within the U.S. Public Health Service to address this underlying factor in the development of many serious chronic diseases.

Oral Health: Oral health is essential to general health and well-being and can be achieved. However, a number of barriers hinder the ability of some Americans from attaining optimal oral health. Oral diseases are progressive and cumulative and become more complex over time. Advances in oral health depend on biomedical research aimed at understanding the causes and pathological processes of diseases. This can lead to interventions that will improve prevention, diagnosis, and treatment.

Federal policymakers have played a significant role in addressing oral health disparities, and a declining dental health workforce through the commitment and support of Congress several federal programs act as a major catalyst for dental institutions to provide access to primary oral heath care to underserved populations, fund training programs, expand prevention services, and increase loan repayment and scholarship programs. Examples include: The National Institute of Dental and Craniofacial Research (NIDCR) has brought focus to the research needs of oral health and contributed to the knowledge base of dental education. The Health Resources and Services Administration (HRSA) Title VII health professions general dentistry and pediatric dentistry residency training programs train residents to provide dental care to patients requiring specialized or complex care, such as developmentally disabled individuals, the elderly, high-risk medical patients, and patients with infectious diseases. The Centers for Disease Control and Prevention's (CDC) Oral Health Program supports state and community-based programs and communicates with the public to prevent oral disease and reduce disparities in oral health.

Oral Health disparities exist across population groups at all ages. Over one third of the U.S. population (100 million people) has no access to community water fluoridation. Over 108 million children and adults lack dental insurance, which is over 2.5 times the number who lack medical insurance. The nation's total bill for dental services was estimated by the Department of Health and Human Services' Centers for Medicare and Medicaid Services to be $70.1 billion in 2002; this figure underestimates the true cost because it does not take into account the indirect expenses of oral health problems, nor the cost of services by other health care providers.

Despite Federal assistance and advances in oral health, profound disparities remain and there is still much work to be done. Unfortunately, the cuts in FY 2006 to the Health Professions Training program at the Health Resources and Services Administration, and the cuts in NIH research and prevention activities makes closing the gap in health disparities harder. The impact of Hurricane Katrina on Gulf Coast states' efforts to further research, prevention and deliver dental care services has presented further significant challenges.

Katrina Threatens Dental Research and Patient Treatment at Louisiana State University

Researchers at the Louisiana State University (LSU) School of Dentistry were developing new biomaterials to make cavity fillings more effective and possibly save money for millions of dental patients. However, Hurricane Katrina's devastation has put potential medical breakthroughs like these on hold. LSU Spokesman Charles Zewe said years of "wrecked and postponed" health science research leaves hundreds of millions of dollars in research funding hanging in the balance.

The School of Dentistry, which receives over four million dollars in research grants, was flooded with both structural damage and water damage primarily on ground floors. Some LSU researchers stayed behind despite the mandatory evacuation in an attempt to save ongoing research materials and years of research data. However, when the levee broke and conditions worsened much of the research facility was destroyed.

LSU dental research provides state of the art studies on the effectiveness of dental treatments that could lead to advancements in technologies and improved efficiencies in oral health care delivery. This research is not necessarily lost. The LSU System plans to rebuild its southeastern Louisiana branches and continue research at these facilities. However the magnitude of recovery of that research capability depends on federal funding, not just in emergency relief, but for the National Institutes of Health (NIH) which funds the bulk of the School of Dentistry's research efforts. NIH funding is required to restore and resume ongoing and future research projects; however, in 2006 the NIH budget was cut for the first time in 36 years. The impact of these funding cuts could be potentially devastating to vital LSU research.

The LSU School of Dentistry is also a major provider of dental care across the state, but care in the southeastern region has been disrupted by Katrina's devastation. "We will be identifying different clinics across the state for the purpose of patient care," said Dr. Eric Hovland, Dean of the School of Dentistry. "Patient treatment by dental students will continue, but exactly how is still unknown."

Complications in dental care caused by the emergency magnify the need for the patient care mission of the Dental School. Many residents that have remained in the area are older and in need of denture replacement or denture repairs in order to eat. Dental clinics in the area don't have the resources so elderly patients are often referred to dental schools. Also, many of the poor New Orleans residents who have stayed behind had rampant dental disease and now have abscesses and need emergency care. Major disparities in patient care already existed. Care for these patients may be further strained by cuts made in federal programs that train dental residents to care for patients with specialized or complex conditions, such as developmentally disabled individuals, the elderly, and patients with infectious disease. The Health Resources and Services Administration (HRSA) Title VII Health Professions programs received drastic cuts in the FY 2006 budget cycle despite these pressing needs. The need to enhance our capacity to provide oral health services to all our citizens has never been greater.

Impact of Hurricane Katrina on Dental Health Programs in Mississippi

On September 3 during the height of disaster response, 270,000 evacuees were living in registered shelters, with 13,673 evacuees staying in shelters in Mississippi. Over 509,000 Mississippians have registered for federal disaster assistance through FEMA and 29,486 mobile living units have been placed to house 79,612 people. By November 30, about 2,046 people remained in 18 Mississippi shelters, which do not include people living in makeshift shelters and motels throughout Mississippi. By January 2006, 1,168 Katrina victims remained in living quarters on a cruise liner, the Carnival Holiday, on the Gulf Coast.

All 14 of the hospitals in the lower 6 counties of the state were damaged. Immediately after the storm, approximately 25 self-dispatched medical teams and clinics responded to the affected areas and provided free medical care. Additionally, federal medical assets were deployed in support of the response phase including dental care.

Some of the dental health assets deployed include:

1. Two mobile dental units were deployed to Waveland and positioned next to the Carolina Med-1 portable hospital. The first was a volunteer organization called 'Smiles of Grace'. The van was staffed by private volunteer dentists and USPHS commissioned corp dentists. The second mobile dental van was deployed by the Sullivan-Schein Company and was called the 'TDOT' for Tomorrow's Dental Office Today. This van was also staffed by private volunteer dentists and USPHS Commissioned Corp dentists. All volunteer dentists were 'federalized' by the SERT. Free emergency dental services were provided from September 12 to October 29, 2005. Approximately 972 patients were seen.
2. Two mobile dental units were deployed to Gulfport and positioned next to the Nevada-1 medical unit. The first was provided by a private dentist in Georgia and the second was provided by the Virginia Dental Association. Both were staffed by 'federalized' volunteer dentists and USPHS Commissioned Corp dentists. Free emergency dental care was provided from September 21 to October 27, 2005 and approximately 290 patients were seen.
3. Dental units for DMORT (Disaster Mortuary Team) personnel with equipment providing training and technical assistance to local mortuary teams in support of assisting Mississippi with storm deaths.

Primary care in the affected area was served by 849 primary care physicians and 256 dentists. One-hundred forty-nine primary care providers in the affected area have practices that were damaged. Eighty-five dentists in the affected area have practices that were damaged, and forty-four dentists have lost their residence.

'Successes':

1. Emergency dental care was included in the federal response. The pre-existing need was great and a lack of access to pharmacies and emergency rooms made it necessary for government to assure access to basic emergency procedures. However, many Katrina victims reported losing their dentures during the storm, especially due to the fact that the Mississippi Gulf Coast is a large retirement area for the elderly. There was no program available to replace the missing dentures for these people.

1. nadequacies in the Stafford Act prevented FEMA from contracting with local displaced health providers to deliver emergency care, including displaced dentists, a readily available workforce, during the early relief efforts.
2. Lack of portable or mobile health units, that includes dental operatories, that be deployed early to provide temporary health clinics in areas with need.
3. Lack of temporary portable housing units for the health care workers that were deployed.
4. Needs and conditions at shelters were assessed for 47 shelters that were occupied and had personnel accessible for a brief phone interview. Directors stated that 23 percent of shelter residents were children; of those, close to half were reported to be infants, toddlers, or preschoolers (45% of all children). Twenty percent of shelter directors reported at least one child with special needs in residence. The single greatest unmet need reported by directors was oral health care, at 17 percent. In comparison, 9 percent of shelter directors reported children with unmet needs for health care and mental health care, and 4 percent reported a need for toiletries.
5. Coastal dentists are reporting a decrease in patient visits since December possibly due to the lack of employer purchased insurance coverage and the overwhelming expenses for Katrina victims (i.e purchasing a car to replace the one that was damaged or lost).
6. There remains only one safety net dental program on the Mississippi Coast - Coastal Family Community Health Center. Their Biloxi dental clinic was destroyed so they are using a two-chair temporary dental van provided by the Virginia Dental Association until January 31, 2006. It is unknown what will happen once the dental van leaves to replace this need. The other Coastal Family dental clinic is located in Gulfport.
   

Stroke: Stroke is America's No. 3 killer and a leading cause of permanent disability. Each year about 700,000 Americans suffer a stroke and more than 164,000 of them will die. Approximately 4.8 million Americans live with the consequences of stroke at an estimated cost of $54 billion in medical expenses and lost productivity in 2004. Recurrent stroke accounts for about one-third of all strokes. Clinical studies supported by the National Institutes of Health's (NIH's) National Institute of Neurological Disorders and Stroke (NINDS) have verified that treating those who have suffered a first-time ischemic (clot-caused) stroke with aspirin or other drugs that inhibit clotting reduces the number of recurrent strokes by 30 percent. Additional NINDS-sponsored research demonstrated that if the clot-busting drug Tissue Plasminogen Activator (tPA) is administered within three hours of the onset of ischemic (clot-caused) stroke symptoms, there is a 33 percent increase in the number of patients that are free of disability three months after their stroke. The findings were so convincing that the U.S. Food and Drug Administration (FDA) approved tPA in 1996 for the emergency treatment of ischemic stroke six months after the clinical trial results were published. The use of tPA has been approved for reimbursement to physicians and hospitals, making it available on a community-by-community, hospital-by-hospital and patient-by-patient basis. TPA is a salient example of the progression of the results of NIH research being approved by FDA and then the Centers for Medicare and Medicaid Services.

Since only a fraction of stroke patients arrive at a hospital in time to benefit from this treatment, the NINDS initiated a public education campaign, Know Stroke: Know the Signs, Act in Time to help people recognize the symptoms of stroke and obtain get medical help as soon as possible. As an extension of this campaign, NINDS has recently partnered with the Centers for Disease Control and Prevention to launch a new grassroots education program called Know Stroke in the Community. The program is designed to identify and enlist the aid of "Stroke Champions" who will educate communities about the signs and symptoms of stroke. Know Stroke in the Community focuses on reaching populations at high risk for stroke-African Americans, Hispanics and seniors, in communities that have the health care systems in place to treat them. NINDS staff just completed a pilot phase of the program in five cities-Houston, Richmond, Chicago, Birmingham and New Orleans. In less than six months, the program has identified 63 Stroke Champions, who have conducted more than 350 education events, and delivered stroke education messages and materials to more than 100,000 people. In FY 2005, NINDS will expand the Stroke Champions program to more cities and states. NINDS has also partnered with National Council of La Raza to develop materials for Hispanic audiences, who are at high risk for stroke.

Recent research -- including a 2004 study published in The Lancet -- has substantiated the benefits of acute stroke treatments. By improving the outcome for stroke victims through continued research and education efforts, health care costs will decrease as the the need for rehabilitative services and long-term care for stroke survivors is reduced.

Substance Use Disorders: Alcohol and Drug Abuse costs the United States over $346 billion each year and causes 116,000 fatalities annually. The body of science indicates that addiction is a brain disease for which we have effective evidence-based treatment that is built on the research findings of the National Institute of Drug Abuse (NIDA) and the National Institute of Alcohol Abuse and Alcoholism (NIAAA) within NIH and the Center for Substance Abuse Treatment (CSAT) within SAMHSA.

The public sector share of treatment expenditures has grown to 64 percent while private sector expenditures are in negative growth. Within the public sector, the Federal Government accounts for one-third of treatment expenditures which it provides through Medicare, the Federal Share of Medicaid, the Department of Defense, Department of Justice, the Department of Veterans Affairs and the Substance Abuse Prevention and Treatment Block Grant within SAMHSA. In any given year, recent national survey data indicates that 22 million people need treatment for alcoholism and/or drugs but only 3 million receive care.

The Substance Abuse Prevention and Treatment Block Grant is the single largest funding stream for treatment programs and the most important program that affords addicted individuals treatment. In Maryland, an untreated substance abuser on the street costs society an estimated $43,000 a year. An incarcerated substance abuser costs $39,600 a year. By contrast, eight months of residential treatment at a residential substance abuse treatment facility in Maryland costs only $17,280 and for the remaining four months of the year and beyond, the recovering addict is an employed taxpayer.

Treatment works. A NIDA study on a California in-prison treatment program showed that, for a 3-year return to custody rate, re-entering offenders with no treatment had a 75 percent return rate, but with in-prison treatment and aftercare the return rate dropped to 27 percent.

Closing the "treatment gap" should be a major public health priority. Another facet of closing the treatment gap is having a qualified and effective workforce. This training of current providers, the education of future practitioners, and appropriate continuing courses for addiction professionals can only serve to enhance the development of a competent, diverse workforce that is responsive to the client service needed for addictions treatment. Funding for FY 2007 should
reflect these priorities.

Substance abuse is often under treated in this nation and not on the same standard as primary health care. Approximately 50-80 percent of all child abuse and neglect cases substantiated by child protective services involve some degree of substance abuse by the child's parent. Often because of financing and attitudes, a person who goes through treatment is supposed to be "cured" and should need no additional attempts at recovery beyond one treatment event. Funding should recognize substance abuse as any other chronic illness. Substance abuse is often treated in isolation from the rest of our health care system. Remaining in treatment for an adequate period of time is critical for treatment effectiveness.

Sudden Infant Death Syndrome (SIDS): SIDS is the leading cause of death for infants under one year of age, however, deaths due to SIDS have fallen by more than 38 percent as a direct result of the research advances at the National Institutes of Health (NIH) working in partnership with other public health agencies and the private sector. Meta-analyses of SIDS studies revealed the role of sleeping position in infant deaths. NIH initiated the "Back to Sleep" campaign, a public education effort that encourages parents and other caregivers to place infants on their backs to sleep to reduce the risk of SIDS. However, despite the success of the Back to Sleep campaign, the SIDS rate in African-American communities is twice as high as in white communities. To reduce SIDS in African American infants and to eliminate this health disparity, the National Institute for Child Health and Human Development, in collaboration with HRSA's Maternal and Child Heath Bureau (MCHB) and other private sector organizations, partnered with the National Black Child Development Institute to develop a special Back To Sleep Campaign resource kit targeted to reduce SIDS and infant mortality in African American communities.

©2008 Coalition for Health Funding