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Public Health Continuum

Public Health 101: What it is
and why it matters

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: Antimicrobial resistance is a serious patient safety and public health issue. Although initially affecting ill people in hospitals, drug-resistant bacteria, such as multi-drug-resistant Staphylococcus aureus (MRSA), are infecting an increasing number of people in community-settings, outside hospitals, including healthy athletes and children. The resulting infections affect hundreds of thousands of Americans and cause tens of thousands of deaths each year. The infections are painful, difficult to treat, and cost many billions of dollars to the U.S. health care system annually.

"The last decade has seen the inexorable proliferation of a host of antibiotic resistant bacteria, or bad bugs, not just MRSA but other insidious players as well...For these bacteria, the pipeline of new antibiotics is verging on empty. 'What do you do when you're faced with an infection, with a very sick patient, and you get a lab report back and every single drug is listed as resistant?' asks Dr. Fred Tenover of the Centers for Disease Control and Prevention (CDC). 'This is a major blooming public health crisis.'" - July 18, 2008 Science magazine.

A CDC-supported study published in the Journal of the American Medical Association (October 17, 2007) estimated that MRSA infects more than 94,000 people and kills nearly 19,000 annually around the country- more deaths than those caused by emphysema, HIV/AIDS, Parkinson's disease and homicide. Infectious diseases and other physicians are concerned about MRSA infections, but they also are deeply concerned about resistant Escherichia coli (E. coli), Acinetobacter baumannii (afflicting soldiers returning from Iraq and Afghanistan), resistant Klebsiella species (spreading across the East Coast and into the Midwest), extensively drug-resistant tuberculosis (XDR-TB), Clostridium difficile, Pseudomonas aeruginosa, and Enterococcus faecium-new national surveillance data from CDC demonstrate that an incredible 80 percent of E. faecium associated with device-related healthcare-associated infections were resistant to vancomycin.

Clostridium difficile (C. diff.) is spawning infections in hospitals in the U.S. and abroad that can lead to severe diarrhea, ruptured colons, perforated bowels, kidney failure, blood poisoning and death. It is a common cause of antibiotic-associated diarrhea, accounting for 15-25% of all episodes. CDC estimates there are 500,000 cases of C. diff. infection annually in the U.S., contributing to between 15,000 and 30,000 deaths. Elderly hospitalized patients are at especially high risk and mortality in these patients may exceed 10%.

Physicians and other healthcare professionals are increasingly frustrated by the hurdles they face in caring for patients with life-threatening drug-resistant infections, and they are distraught about the toll it takes on their patients' lives and those of their families and friends. It is simply unacceptable to see children and adults die when society has the resources and the tools-but not the will-to reduce the impact of these diseases. We cannot stop the development of antibacterial resistance-bacteria will continue to mutate in response to antibacterial drug use. However, we can respond with new and effective strategies and interventions.

Outside of strengthening our diminishing antibacterial pipeline, what we need most are improved U.S. coordination and specific actions designed to better monitor, treat, and most importantly prevent the development and transmission of drug resistant microbes that threaten the health of all Americans and increase the cost of healthcare delivery.

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 never received funding, provides a blueprint for coordinated federal action, and has four major 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 (CA-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. In 2006, CDC released "Management of Multidrug-Resistant Organisms in Healthcare Settings, 2006," intended to guide the implementation of appropriate strategies and practices to prevent the transmission of MRSA, Vancomycin-resistant enterococci (VRE), and other multidrug-resistant organisms.

An important objective of all of these activities is to prevent drug resistance from developing in communities and in healthcare settings, and also to encourage drug-susceptibility testing and better use of proficiency testing and training programs in clinical laboratories. Although progress is being made, much more needs to be done to prevent, control and limit the impact of antimicrobial resistance including greater clinician and public education and the adoption of policies to promote careful antimicrobial use in healthcare facilities. There also is strong need for greater and coordinated national surveillance for antimicrobial resistance; monitoring patterns of antimicrobial use nationwide; monitoring antimicrobial use in livestock; strengthened applied research, and importantly, strategies and incentives to encourage development of new antimicrobial agents.

A combined effort can successfully address or prevent antimicrobial resistance as the following example illustrates.

The Colorado Department of Public Health and Environment was notified by a local health department of a cluster of MRSA infections among members of a Colorado fencing club and family contacts in February, 2003. Three confirmed and two probable cases were identified among this group, most were hospitalized and received antimicrobial therapy. Although none of the fencers with infections reported sharing clothing, masks, and sabres, such sharing was common among team members, according to a surveillance survey conducted of club members. In addition, fencers wear a sensor wire under their clothes to record when they have been touched by an opponent's sabre. Club members indicated that these wires were shared routinely and had no routine schedule for cleaning. Club members, coaches and administrators were instructed in MRSA transmission control including increased hand hygiene; showering with soap after every practice or tournament; covering cuts and abrasions with a bandage until healed; laundering personal items such as towels after each use; cleaning or laundering shared athletic equipment such as helmets and pads at least once a week, but ideally after each use; established routine cleaning for sensor wires; and consulting a health care provider for wounds that do not heal or appear infected. As a result of such transmission control practices, no further infections were reported. The key to success was the partnership between public health, the community and clinical medicine so that when surveillance data indicated an emerging problem, prevention and control measures could be implemented to stop and 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. The CDC is also supporting research and initiatives to improve postpartum follow up and promote behavioral health initiatives for women who experienced gestational diabetes, in order to reduce the development of type 2 diabetes for this population.

Epilepsy: Nearly three million Americans have epilepsy, a neurological condition that makes people susceptible to seizures. Ten percent of Americans will experience a seizure in their lifetime, and each year, more than 181,000 new cases of epilepsy are diagnosed for the first time. Epilepsy affects people of all ages, races, and ethnic backgrounds. The condition can develop at any age, but epilepsy most often occurs in early childhood or old age. Although advances in medical treatment have allowed some individuals with epilepsy to control their illness, more than 40 percent of people with epilepsy still have persistent seizures. For this reason, continued research on a cure is desperately needed at the National Institutes of Health (NIH), National Institute on Neurological Disorders and Stroke. The second conference on the Cure will be held in the spring of 2007 at the NIH with the purpose of discussing and acting upon the newest research data. While NIH continues to seek a cure, living well with the condition has been the focus at the Centers for Disease Control and Prevention (CDC). Following the first Living Well with Epilepsy conference in 1993, the CDC has developed the CDC Epilepsy Program designed to study the epidemiology of epilepsy and establish critical community-based programs that help to reduce the stigma often associated with epilepsy and to communicate factual information about epilepsy to vital community partners such as school nurses, teachers, first responders, families, caregivers and teens living with epilepsy.

Because epilepsy can be controlled for some through the use of medications called Antiepileptic Drugs (AEDs), the role of the Food and Drug Administration and the Centers for Medicare and Medicaid Services (CMS) are critical to ensuring that all persons with epilepsy have access to safe, affordable drugs and other treatment options.

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 completed 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, sex, ethnicity and geographic disparity 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, diagnosis, treatment, and subsequent morbidity and mortality rates 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. Minorities living in rural areas face the double burden of health risk factors based on rural residence and health disparities related to race, sex and ethnicity. 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. "HRSA also supports projects through the Rural Health Care Serves Outreach, Delta States Rural Development Network, and Network Development grant that are designed to expand access to, coordinate, and improve essential health care services in geographically underserved rural areas." Women with disabilities are another population experiencing disparities in health care. According to the 2005 Surgeon General's Call to Action, a major goal is that health care providers "have the knowledge and tools to screen, diagnose and treat the whole person with disability with dignity" Since 2003, the CDC has funded initiatives to improve access to healthcare for women with disabilities and to improve provider sensitivity and training.

Health Professions: The Title VII and VIII health professions and nursing education programs are the only federal programs designed to train providers in interdisciplinary settings to meet the needs of special and underserved populations, as well as increase minority representation in the health care workforce. The programs listed below collectively contribute to the development of a well-distributed, well-trained, diverse health care workforce.

  • Minority and Disadvantaged Health Professions:Increases minority representation in the health professions and includes the Centers of Excellence (COE), Health Careers Opportunity Program (HCOP), faculty loan repayment and fellowships and Scholarships for Disadvantaged Students (SDS).

  • Primary Care Medicine and Dentistry: Expands the primary care provider workforce; includes programs in general pediatrics, general internal medicine, family medicine, osteopathic medicine, dentistry and physician assistants. An article published in the Annals of Family Medicine in 2008 examined the association between physicians' attendance in training programs funded by Health Resources and Services Administration Title VII Section 747 Primary Care Training Grants and work in a Community Health Center (CHC) and participation in the National Health Service Corps (NHSC) Loan Repayment Program. It found continued federal support of Title VII training grant programs was consistent with efforts to increase participation in the NHSC and improve access to quality health care for underserved populations through expanded CHC capacity: physicians who attended Title VII-funded medical schools were over 30 percent more likely to practice in a community health center than those who attended a non-Title VII funded medical school.
  • Interdisciplinary, Community-Based Linkages: Supports community-based training of various health professions in rural and urban underserved areas: Area Health Education Centers (AHECs), Health Education and Training Centers (HETCs), geriatric health professions, Quentin N. Burdick Rural Training, allied health and other disciplines, and violence prevention.
  • Health Professions Workforce Information and Analysis:Supports the compilation and analysis of data on the nation's health workforce.
  • Public Health Workforce Development:Supports public health training, preventive medicine residencies, dental public health, and health administration programs.
  • Nursing Workforce Development:Provides a federal focus on the supply and distribution of qualified nurses; includes the following programs: advanced education nursing; workforce diversity; nursing faculty loan program; nurse education, practice and retention; comprehensive geriatric education; and loan repayment and scholarships.
  • Student Financial Assistance: Assists disadvantaged health professions students - primary care loan, health professions student loan, and loans for disadvantaged students.

For more than two decades, federally supported Title VII health professions programs have funded enrichment efforts, such as the Health Careers Opportunity Program (HCOP) and Centers of Excellence (COE), which prepare minority and disadvantaged students for medical school or other health professions training. A typical HCOP offers high school students laboratory research experiences and pre-college science enrichment courses, as well as mentoring, peer support, and advising. COEs nurture and mentor the students who participate in these programs to ensure that they enter the health professions workforce. To date, at least 500,000 aspiring health professionals, including more than 400,000 underrepresented minorities, have benefited from these two programs

The success of these programs has been widely acknowledged. A study published recently in the Journal of the American Medical Association (JAMA) found that HCOP participants were three times more likely to enter medical school than non-participants, and that two-thirds of those participants were underrepresented minorities. A recent survey conducted by the AAMC (Association of American Medical Colleges) found that without Title VII funds, 83 percent of HCOP and COE programs will shut down, opening large gaps in the fragile medical education pipeline.

Minority medical students are also more likely than non-minorities to plan to practice in an underserved area. More than half of black, Hispanic/Latino, and Native American physicians in the U.S. practice also in primary care specialties. Targeting these students in the pre-college pipeline through programs such as Title VII is a long-term investment in the future of our nation's health. Without programs such as Title VII that seek to reach out to all well-prepared aspiring doctors, our physician workforce will not reflect the nation's growing diversity.

Title VII and VIII programs also benefit community health centers (CHCs). A March 2006 study published in the Journal of the American Medical Association found that CHCs report high percentages of provider vacancies, including an insufficient supply of dentists, pharmacists, pediatricians, family physicians, and registered nurses. These shortages are especially pronounced among CHCs in rural areas and within the inner city. Because Title VII programs have a successful record of training providers who serve underserved areas, the study recommends increased support for the programs as its primary means of alleviating the shortages. Further, the publication serves as an important reminder that the success of CHCs is highly dependent upon a well-trained clinical staff to provide care.

During their 40-year existence, the Title VII and VIII programs have created a network of initiatives across the country that supports the training of many disciplines of health providers. These are the only federal programs designed to create infrastructures at our schools and in our communities that facilitate customized training designed to bring the latest emerging national priorities to the populations at large and meet the health care needs of special, underserved populations.

Heart Disease: Heart disease, America's No, 1 killer, kills nearly 630,000 people in the United States each year. About 26 million people in the United States live with the effects of heart disease. Heart disease will cost this nation an estimated $287 billion in medical expenses and loss productivity in 2008.

Since 1948, the National Institutes of Health's National Heart, Lung, and Blood Institute (NHLBI) 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, ethnic and gender 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 and its new Division for Heart Disease and Stroke Prevention and the Health Resources and Services Administration (HRSA) have transferred findings from NHLBI-supported programs into community settings. CDC, in partnership with State health departments, is developing integrated State-based Heart Disease and Stroke Prevention and WISEWOMAN programs. However, budget cuts has forced HRSA to drastically scale back its Rural and Community Access to Emergency Devices Program designed to save more lives of victims of sudden cardiac arrest, particularly in rural areas.

Impact of insufficient FY 2008 funding 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.

2) Heart disease, stroke and other cardiovascular diseases kill more females than males. While successful, CDC's Well-Integrated Screening and Evaluation for Women Across the Nation (WISEWOMAN) programs exist in only 20 states. During FY 2008, the Department of Health and Human Services instituted a national competition, requiring funded states to re-compete for support and allowing all states to compete for resources. CDC approved applications of 10 states, but could not fund them due to insufficient federal resources for this program. WISEWOMAN screens uninsured, under-insured and low-income women ages 40 to 64 for heart disease and stroke risk and provides those with abnormal results with counseling, education, referral and follow-up. Since January 2000, WISEWOMAN has screened more than 70,000 women, finding 3 out of 4 with at least one risk factor for heart disease and stroke and has provided more than 170,000 lifestyle intervention sessions.

3) 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. Health Resources and Services Administration's (HRSA) Rural and Community Access to Emergency Devices Program provides states with grants to train lay rescuers and first responders to use AEDs and purchase and place them in public areas where cardiac arrests are likely to occur. Funding cuts for this program has forced HRSA to reduce the rural component of this program that served 47 states to an initiative that supports only 15 states. Placing AEDs in more public settings could save thousands of additional lives each year. Communities with comprehensive AED programs, including training of anticipated rescuers, have achieved survival rates of 40 percent or higher, compared to10% in many other locations.

4) When adjusted for medical research inflation, funding for heart disease, stroke and other cardiovascular disease research is 15 percent lower in FY 2008 than in FY 2003. The loss of purchasing power over the past few years has reduced the ability of the National Heart, Lung, and Blood Institute (NHLBI) to fund meritorious investigator-initiated research and necessitated cutbacks in Institute-initiated programs. Continued budget limitations are expected to limit the pace at which the new NHLBI strategic plan can be implemented. The plan, which provides a guide for the Institute's research and training programs over the next 5 to 10 years, presents broad strategies that the NHLBI will employ to facilitate the conduct of research; enhance interdisciplinary work; speed early-stage translation of basic discoveries; ensure cross-fertilization of basic, clinical, and epidemiologic discoveries, and maximize the resultant public health benefit of the information created.

HIV/AIDS: In 2008, the Centers for Disease Control and Prevention (CDC) released revised estimates for both HIV incidence and prevalence, revealing that the HIV/AIDS epidemic remains a severe and worsening public health crisis in the United States. CDC estimates that in 2006 56,300 new HIV infections occurred in the United States. The new incidence number is 40% higher than previous estimates. At the end of 2006 an estimated 1.1 million adults and adolescents were living with HIV in the United States. Of those living with HIV in the United States, 21% are unaware of their infection and over half did not have access to medical care.

The HIV epidemic continues to have a glaring disproportionate impact in racial and ethnic communities. The impact of HIV is greater among African Americans than any other racial or ethnic group, with rates that are 7 times higher than that of whites and almost 3 times higher than that of Latinos. African Americans represented 46% of those estimated to be living with HIV, but account for only 12% of the total US population. Hispanics and Latinos, which comprise 15% of the US population, represent 19% of the current epidemic.

Our federal response to this public health challenge has been a collaborative and multi-disciplinary approach across agencies within the Department of Health and Human Services. Research conducted at the National Institutes of Health (NIH) has been essential in the development of life-saving drugs and effective prevention interventions. Efforts continue at NIH to develop much needed HIV vaccines and Microbicides. 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 Health Resources and Services Administration. 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 HIVAIDS patients under the AIDS Drug Assistance Program (ADAP). Prevention efforts are administered through the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA). These prevention programs, 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 AIDS Initiative, which is funded through several federal agencies, was created in 1998 to address the disproportionate effect HIV/AIDS is having on communities of color.

The Federal commitment to the HIV/AIDS epidemic must include a National AIDS Strategy which will have demonstrable goals and objectives to end the epidemic in our country. This strategy must include continued and improved coordination and accountability across federal public health agencies. The government must also commit the necessary funding for 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 hardest hit by the HIV/AIDS epidemic.

Immunization: The National Institutes of Health (NIH), and private sector pharmaceutical firms, develop the vaccines effective against childhood diseases such as whooping cough and measles. But in the late 1980's and early 1990's national estimates indicated only 55 percent of U.S. two-year olds were fully immunized against these and other diseases. Consequently, outbreaks of whooping cough and measles began to occur around the nation after decades of successful prevention. A commitment in 1994 to fully immunize 90 percent of American two-year olds relied on the Centers for Disease Control and Prevention (CDC) to develop an outreach and delivery strategy, working closely with state and local health departments and relying on many federal programs within its sister agencies the Health Resources and Services Administration (HRSA) and the Indian Health Service (IHS). Today, for some childhood vaccines, such as HIB, measles and polio, coverage rates among pre-school children is at or exceeds 90 percent. However, the viruses and bacteria that cause these diseases still exist and some diseases, such as polio, are just a plane ride away.

Annually, four million children will need to be immunized against 14 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 200,000 hospitalized and between 5,000 and 6,000 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.

Traditionally, adult vaccination has been underemphasized by obstetrician-gynecologists despite the fact that adults are at a higher risk of complications from certain vaccine-preventable diseases. In addition, vaccine-preventable infections continue to contribute to the maternal and neonatal burden of disease. The CDC has funded a program administered through the American College of Obstetricians and Gynecologists (ACOG) to improve the rate of administration of immunizations for women of reproductive age. This includes both the administration of vaccines and provision of advice to patients to remain up to date with recommended immunizations. This program provides information on periodic immunization requirements as well as assistance on office-based immunization protocols and procedures.

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 U.S. infant mortality rates showed no significant improvement in 2005 after increasing in 2002 for the first time in since 1958. In 2003, the infant mortality rate was 6.86 deaths for every 1,000 live births, which was statistically unchanged from the 2002 rate of 7.0. Two-thirds of all infant deaths occurred within the first month of life. Birth defects, as well as prematurity and low birthweight remained the leading causes of infant death. Racial and ethnic disparities in infant mortality also persist. According to the CDC, the rate for black infants was more than double the rate for white infants. 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:

  • The NFIMR Resource Center -- HRSA should continue to fund NFIMR, which provides training and technical assistance to 220+ local fetal and infant mortality review community programs in 40 states. These programs are addressing community issues related to infant health disparities and ensuring a safety net for socially, economically and medically high risk pregnant women.
  • Sudden Infant Death Syndrome - The joint NIH and HRSA "Back to Sleep Campaign" has helped reduce SIDS by 42 percent.
  • Perinatal HIV Transmission - Dramatic reductions in the 1-2,000 infants born annually in the U.S. with HIV infection at the height of the AIDS epidemic have occurred as a direct result of four federal agencies: CDC funds perinatal HIV transmission prevention in 16 states via targeted HIV testing followed by antiretroviral interventions. CDC also supports four national organizations' efforts to implement CDC's Revised Recommendations for HIV Testing of Adults, Adolescents and Pregnant Women in U.S. Health Care Settings. These activities include a pilot program that uses the NFIMR methodology to identify and address missed opportunities in perinatal HIV prevention; FDA has been instrumental in drug development for the prevention of perinatal HIV transmission; the National Institute of Child Health and Development at NIH has funded studies on reducing postnatal transmission through breast milk and has provided small grants on perinatal HIV transmission.
  • Birth Defects --CDC promotes healthy pregnancies through increased folic acid usage and decreased alcohol consumption. CDC monitors the prevalence of alcohol use among women of childbearing age in the U.S. and funds several programs to decrease alcohol use in diverse populations. One such program develops education and service delivery materials for reproductive health care providers to address at-risk drinking for all women of reproductive age and any drinking during pregnancy. CDC also recently created a National Center on Birth Defects and Developmental Disabilities that promotes education and services to help prevent birth defects and developmental disabilities, and to increase access to care for persons with disabilities.
  • Healthy Start -HRSA funds grants that use community-designed and evidence-supported strategies aimed at reducing infant mortality and improving perinatal outcomes in project areas with high annual rates of infant mortality.

Kidney Disease: Kidney disease is serious, harmful, and far more common than people think - and requires early detection for treatments to be most effective and cost-efficient. The National Institutes of Health (NIH)-largely led by the National Institute of Diabetes & Digestive & Kidney Disease (NIDDK)-funds basic and clinical research that assesses the causes of chronic kidney disease (CKD), studies the mechanisms that lead to progression of CKD to end-stage renal disease (ESRD), and discovers new treatments to prevent the long-term negative effects of CKD, ESRD, and other kidney diseases including acute kidney injury (AKI) and polycystic kidney disease. NIH also funds myriad studies that consider the correlation between kidney disease and other diseases and disorders such as cardiovascular disease, hypertension, and diabetes.

In coordination with the Department of Veterans Affairs (VA) Medical and Prosthetic Research Program, NIDDK has also funded large kidney disease clinical trials, as kidney disease disproportionately impacts the veteran population. Recent consideration has been given to whether more frequent dialysis will improve renal function in patients with AKI. The VA research program independently spends approximately three percent of its budget on research that addresses the causes of and treatments for kidney disease.

As research has identified some of the causative factors leading to kidney disease, public health agencies are working to encourage prevention and awareness. Through the National Kidney Disease Education Program (NKDEP), NIDDK educates the public on who is at high risk for kidney disease, encourages advanced screening, and advises patients on how to prevent the progression of the disease to kidney failure.

Meanwhile, in a study funded by NIH and the Agency for Healthcare Research and Quality (AHRQ), investigators discovered a single gene that is significantly associated with kidney diseases that disproportionately impact African-American patients. The identification of the gene is expected to assist researchers in creating personalized medical therapies that target specific causative factors to prevent the progression of the disease. The research also uncovers one reason for the disparity of disease among the African-American population, which has been a focus of research at many public health agencies. The Centers for Disease Control and Prevention and AHRQ both publish extensive reports that assess the state of health and health care among underrepresented minorities, including those with kidney disease.

Medical Therapies: The Agency for Healthcare Research and Quality (AHRQ) works conjunction with the Food and Drug Administration to administer the Centers for Education and Research on Therapeutics (CERTs). Fourteen research centers, housed at many of the nation's premier research institutions, each focus on a particular population or therapeutic area. CERTs conduct research and provide educational outreach to improve information regarding the optimal use of pharmaceuticals, biological products and medical devices. To date, CERTs have completed dozens of groundbreaking studies on therapeutic research ranging from a study determining the role of community pharmacy factors associated with drug interactions to research studying the prevalence of Type II Diabetes in children. In one study, CERTs researchers at Duke University examined the use and effectiveness of aspirin use in 25,000 patients with cardiovascular diseases. They found a substantial increase in the use of aspirin by such patients, reflecting practice improvement. After conclusion of this study, the U.S. Preventive Services Task Force recommended that clinicians discuss aspirin therapy with patients at risk of heart disease.

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. HRSA's Healthy Start Program has funded state and community level initiatives to identify and manage perinatal depression, particularly for low income and minority women, building on partnership teams formed previously through the Provider's Partnership.

Many behavioral factors, such as physical inactivity, obesity, anxiety, traits of anger or hostility, and depression, are now known to increase an individual's risk for disease, physical disability, and early death. 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 and interventions 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, 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 and Prevention 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 26 percent since 1996. This means approximately 1000 more babies are born healthy in the United States each year.

Newborn Screening: Newborn screening is a vital public health activity used to identify and treat genetic, metabolic, hormonal and functional conditions in newborns. Screening detects disorders in newborns that, if left untreated, can cause disability, mental retardation, serious illnesses or even death. Parents are often unaware that while nearly all babies born in the United States undergo newborn screening for genetic birth defects, the number and quality of these tests vary from state to state. In 2005, the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children endorsed a report authored by the American College of Medical Genetics (ACMG) which included proposed nationwide standards for state newborn screening programs. The report lists 29 "core" disorders that should be targeted by newborn screening programs. Unfortunately, many states still do not require screening for all 29 treatable disorders. Current federal support for state newborn screening activities is provided through the Maternal and Child Health Block Grant, Special Projects of Regional and National Significance (SPRANS).

Obesity: Overweight and obesity has increased dramatically among U.S. adults, and now obesity has reached epidemic proportions. Nearly 66 million American adults are overweight or obese. More than 9 million Americans aged 6-19 years are overweight. The effects are catastrophic. The estimated annual cost of overweight and obesity, in 2001 dollars, is $117 billion and the cost of lost productivity related to obesity among Americans ages 17-64 is $3.9 billion: People who are overweight or obese increase their risk for cardiovascular diseases, diabetes, high blood pressure, arthritis-related disabilities, and some cancers. The HHS initiative Steps to a Healthier US and 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.

In June 2005, the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health (NIH) launched a new, national education program called Ways to Enhance Children's Activity & Nutrition (We Can!) to help prevent obesity and overweight in youth ages 8-13. We Can! provides resources and community-based programs for parents, caregivers, and youth to encourage healthy eating, increase physical activity, and reduce screen time. The NHLBI-led We Can! program is supported by several other NIH Institutes including the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), the National Institute of Child Health and Human Development (NICHD), and the National Cancer Institute (NCI). We Can! partners include professional societies, parenting groups, media organizations, trade associations, hospital groups, and Federal organizations such as the President's Council on Physical Fitness and Sports, the White House Initiative on Asian Americans and Pacific Islanders, and the Office of Disease Prevention and Health Promotion of the U.S. Department of Health and Human Services.

Oral Health: Oral health is an essential and integral component of general health and well-being. A strong commitment to oral health research, education, and access is crucial to ensure that all Americans can attain optimal oral health. Advances in oral health depend on biomedical and health services research aimed at understanding prevention, causes, diagnosis, and treatment of diseases and disorders that affect the teeth, mouth, jaws, and face.

Federal policymakers play an important role in addressing oral health disparities, advancing dental research, strengthening the dental health workforce, and supporting the nation's dental public health infrastructure. Several federal programs are catalysts in assisting states and dental institutions in providing access to primary oral heath care to underserved populations, educating and training the future oral health care workforce, and expanding prevention services.

These influential federal programs include: the National Institute of Dental and Craniofacial Research (NIDCR); the Health Resources and Services Administration's (HRSA) Bureau of Clinician Recruitment and Service's loan repayment and scholarship programs, the Bureau of Health Professions' Title VII general dentistry and pediatric dentistry residency training programs, the Maternal and Child Health Bureau's state block grants, the HIV/AIDS Bureau, the Bureau of Primary Health Care's community health centers and state dental infrastructure planning grants, and the Office of Rural Health; the Centers for Disease Control and Prevention's (CDC) Oral Health Program, the Agency for Healthcare Research and Quality (AHRQ) and the Agency for Families and Children.

A strong federal dental public health infrastructure can assist in bridging the gap between the public and private aspects of dental delivery systems. Despite the increased emphasis on the importance of oral health with increased allocations directed towards prevention and access to care efforts, the federal dental infrastructure has not kept pace. Where once there were ten HRSA regional dental consultants providing guidance to federal grantees, there is currently one and he only addresses oral health part-time. An increasing number of federally qualified health center dental programs are managed by new dental graduates with little or no experience in operating community-based programs. Efficiency and productivity are growing concerns as the ranks of the dentally underserved increase and access issues multiply.

Oral health research and community prevention programs have led to community water fluoridation that benefits more than 200 million Americans, which has improved the prevention of dental caries. Great strides in dental education and access to dental care, as well as advances in technology, have led to a decline in the incidence of dental caries and periodontal disease. Advances in oral and pharyngeal cancer research and care have reduced patient mortality rates by 25% over the past 20 years, and new cases have declined by 10%.

Despite federal assistance and advances in oral health, disparities exist across population groups at all ages. Over 100 million Americans do not have access to community water fluoridation. More than 108 million children and adults lack dental insurance, which is over 2.5 times the number lacking medical insurance. The nation's total bill for dental services was estimated by the Centers for Medicare and Medicaid Services to be $81.5 billion in 2004; this figure underestimates the true cost because it does not account for indirect expenses of oral health problems or the cost of services by other health care providers. In addition, dental academic institutions face critical faculty shortages and workforce issues. Funding cuts sustained over the last three fiscal years to HRSA's Bureau of Health Professions training programs, in combination with reduced funding for NIH research and CDC prevention activities, makes closing the gap in oral health disparities increasingly challenging.

Smoking Prevention and Cessation: Every year, 178,000 women in the United States die prematurely from smoking-related diseases. The risks associated with smoking to women of reproductive age and pregnant women are devastating, such as decreased fertility, decreased effectiveness of birth control pills, increased risk of stroke, and increased rate of premature and low-birth weight babies. Infants whose mothers smoked while pregnant or children exposed to second-hand smoke are more likely to suffer from respiratory disease, middle ear infection and reduced growth and function. A necessary response involves a multilayered approach, bringing together creative partnerships and diverse resources and expertise. Since March 2004 with major funding from the Centers for Disease Control and Prevention's Division of Reproductive Health, the Association of Maternal and Child Health Programs (AMCHP), the American College of Gynecologists (ACOG) and the Planned Parenthood Foundation of America (PPFA) have convened the Women and Tobacco Action Learning Lab (ALL) to help multidisciplinary state teams address smoking prevention and cessation among women of reproductive age by: 1) fostering new and effective partnership teams between state maternal and child health programs, ACOG chapters and PPFA affiliates, and 2) helping these partnerships develop, implement and evaluate state action plans for smoking prevention and cessation. Specific projects of the state teams that participated in the ALL process have facilitated provider involvement and training, provider and patient education, and connections to smokers quit-lines. The ALL process strengthened state teams by creating the opportunity for states to accomplish similar goals and learn from each others' successes and challenges. Non-traditional partnerships and non-tobacco focused organizations, both at the national and state levels, have played an important role in implementing, reinforcing and communicating tobacco-focused organizations' strategies and initiatives. These partnerships are not only influential in tobacco prevention and cessation among women of reproductive age in general, but also remain locally connected and able to address individual community concerns and accomplishments.

Likewise, grant support from the National Institutes of Health (NIH) lead to the creation of an interprofessional smoking cessation curriculum aimed at improving the tobacco education skills of students enrolled in our nation's health professions institutions. Rx for Change: Clinician-Assisted Tobacco Cessation (http://rxforchange.ucsf.edu/about.php) draws much of its evidence-base from the clinical guideline for smoking cessation created through the collaboration between the Agency for Healthcare Research and Quality (AHRQ), several institutes with NIH, the Centers for Disease Control (CDC) other public organizations and academic institutions (http://www.ahrq.gov/path/tobacco.htm).

Stroke: Stroke is America's No. 3 killer and a leading cause of permanent disability. Each year about 780,000 Americans suffer a stroke and more than 143,000 of them will die. Approximately 5.8 million Americans live with the consequences of stroke at an estimated cost of $66 billion in medical expenses and lost productivity in 2008. Recurrent stroke accounts for more than 20 percent 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 people 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, in partnership with the Centers for Disease Control and Prevention, the NINDS initiated a public education campaign, "Know Stroke." It includes enlisting the aid of "Stroke Champions" to teach stroke signs and symptoms to people in communities at high risk for stroke, including African Americans, Hispanics and seniors, and to obtain medical help as soon as possible. This campaign has been extended to the General Federation of Women's Clubs to emphasize differences of stroke in women.

Due to budget shortfalls, the National Institute of Neurological Disorders and Stroke must scale back implementation of its Stroke Progress Review Group recommendations. The report serves as a guide for a long-range strategic plan for stroke. In addition, the NINDS has been forced to compress its Specialized Programs of Translational Research in Acute Stroke from the planned 10 centers to eight now funded. SPOTRIAS researchers aid translation of basic research into patient care and identify diagnostics and interventions for the rapid evaluation and treatment of stroke patients by exploring novel therapies, sharing data and conducting early phase clinical trials. Other research initiatives that could be accelerated with more money include, genetic risk factors for stroke and improved treatments for acute neurological emergencies, such as stroke. Specifically, more funding could be used to conduct stroke research in the following areas. Genetic Repository - Researchers are beginning to understand the genetic risk factors for stroke. With additional resources, NINDS could make more progress in understanding the risks for stroke in many different populations by supporting more researchers to make deposits into an NIH-funded repository and study the genetic samples already available in this resource. Neurological Emergencies Treatment Trials Network - The NINDS has established a Neurological Emergencies Treatment Trials Network, a clinical research network of emergency medicine physicians, neurologists and neurosurgeons to develop through clinical trials, more and improved treatments for acute neurological emergencies, such as stroke. The number of trials supported will be subject in part by funding available. Recent research 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 need for rehabilitative services and long-term care for stroke survivors is reduced.

Various federal public health agencies are working under a Memorandum of Understanding (MOU) with the American Heart Association to achieve the Healthy People 2010 goals related to heart disease, stroke and other forms of cardiovascular disease. These include improving cardiovascular health and quality of life through the prevention, detection, and treatment of risk factors; promoting early identification and treatment of heart attacks and strokes; and preventing recurrent cardiovascular events. The Association and agency representatives meet on a monthly basis via conference call to discuss activities of mutual interest and report on progress on collaborative projects. Examples of recent collaborations include a coordinated effort to improve heart disease and stroke outcomes in the Menominee Tribe in Wisconsin through the implementation of a broad range of heart disease and stroke educational and awareness activities, as well as the development and dissemination of "The Community Health Worker's Sourcebook: A Training Manual for Preventing Heart Disease and Stroke." In addition to the American Heart Association, federal agencies under the MOU include Centers for Disease Control and Prevention's National Center for Chronic Disease Prevention and Health Promotion, the National Institutes of Health's National Heart, Lung, and Blood Institute, and the National Institute of Neurological Disorders and Stroke, Office of Disease Prevention and Health Promotion, Office of Public Health and Science; and the Indian Health Service.

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 the Substance Abuse and Mental Health Services Administration (SAMHSA).

The public sector share of treatment expenditures has grown to 64% 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 (DoD), Department of Justice, the Department of Veterans Affairs (VA) 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. Nearly 80% of those in prison have an underlying alcohol or drug problem and many of those have co-occurring mental illness. Moreover, community-based treatment is significantly less expensive to provide than incarceration. 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. It is often the SAMSHA Substance Abuse Prevention and Treatment Block Grant that is the key to stopping the revolving door that cuts recidivism.

SAMHSA, the Health Resources and Services Administration (HRSA) and the Administration for Children and Families have great potential to provide leadership and coordinate services in coordination with the VA and DOD. Treatment providers and communities need to be prepared to assess, intervene, and refer early our returning veterans and their families living within our civilian communities. Returning veterans and their families should have ready access to appropriate substance abuse and co-occurring substance abuse services and not fall through the cracks. The roadmap to services for families and returning veterans can often by-pass both the DOD and VA systems of care. Public policy should anticipate the increase of newly returning at-risk veterans to their communities, many of who will seek out or need substance abuse and/or co-occurring mental health treatment through community public health resources. Client -based early intervention and treatment for veterans and their families based on evidence-based research will be an emerging and significant need in the coming years. 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.

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 which can cause Americans to not reach treatment till its late stages. The blending of Substance Abuse Treatment with primary care has been initiated through a variety of efforts by ONDCP and SAMHSA, introducing substance use screening, brief intervention and treatment protocols into medical education. These efforts have also supported the development of addiction medicine primary care specialty boards. In addition, the AMA has developed specific CPT codes to reimburse health care providers for structured substance use screening and brief intervention The NIAAA has developed an online training program for providers to address both alcohol and other substance abuse during routine primary care encounters. This training includes information on medications that can be used to reduce craving and withdrawal symptoms..

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.

Vision Health: Vision and eye health problems are the second most prevalent chronic health care condition in the United States, affecting more than 120 million Americans. The economic and societal costs of vision impairment and eye disease, recently calculated at $68 billion per year, are continuing to grow. If existing barriers to eye and vision care can successfully be overcome, the early detection and treatment of glaucoma, diabetic retinopathy and a range of disorders of the eye and visual system will safeguard the vision of millions more Americans and lead to greater overall health outcomes.

Ensuring fully expanded and non-discriminatory access to eye and vision care services must be a key element of legislation to reform the health care system in America as well as to reauthorize SCHIP and other vital programs. Too often, visual disorders needlessly prevent children from reaching their full potential in the classroom and hasten the loss of independence of older Americans. To eliminate unjust barriers to medical eye care disproportionately affecting America's underserved populations, doctors of optometry must also be defined as physicians under the Medicaid program as they now are under the Medicare.

The Centers for Disease Control and Prevention (CDC) has supported the Vision Health Initiative, which provides technical assistance to national, state and local organizations oriented to preserving, protecting, and enhancing vision. This initiative addresses early detection, disease disparities, access to care, cost of vision loss, vision disability, eye disease and quality of life. In 2008, at the direction of Congress, the CDC provided funding for the first time for InfantSEE®, a life-saving and sight-saving initiative launched by optometrists in communities across the country to provide no-cost eye and vision assessments to children between six months and one-year of age.

The National Eye Institute's (NEI) National Eye Health Education Program is addressing vision loss due to eye disease through programs of biomedical research, disease prevention, and health promotion. In 1991, NEI established the National Eye Health Education Program (NEHEP), which it coordinates in partnership with a variety of public and private organizations that conduct eye health education programs. The focus of the NEHEP is on public and professional education programs that encourage early detection and timely treatment of glaucoma and diabetic eye disease and the appropriate treatment for low vision.

Despite federal assistance from the CDC and NEI, profound disparities remain and there is still much work to be done. Recent data from the National Health and Nutritional Examination Survey (NHANES) revealed that approximately 14 million individuals in this country have visual impairment; however, more than 11 million could have their vision improved with refractive correction. Those individuals without vision correction are primarily those below the poverty level, racial/ethnic minorities and uninsured. Although this study did not capture only individuals who obtain their health care from community health centers, the demographics of those with the greatest need for vision correction in the NHANES closely mirror the demographics of those individuals who obtain their health care from community health centers.

Today, there remains a pressing and immediate need to fund establishment and expansion of vision clinics in community health facilities. With an unfair exclusion from participation in key National Health Service Corps (NHSC) programs still in place, it is clear that decisive action is necessary to make optometrists eligible for the NHSC student loan repayment and scholarship programs to assist in expanding accessibility of eye and vision care in communities where it is most needed. Moreover, doctors of optometry must be made fully eligible for all federal grant or loan repayment program designed to enhance education, research, training, or access for health professionals.

©2008 Coalition for Health Funding